Scope of Work:Demo a few receptacles and remove wire mold
General Information
Work Order
None
Building
67
Person in Charge
Beau Erwin
Lead / Supervisor
Ramer, Robert
Logged Email
jgerwin@lbl.gov
Division
Facilities
Work Planning
Modes of Work
☑ Mode 1 - LOTO & Zero Voltage Verification
QEW Level
QEW 2
Second Person Requirement
Not Required
Second Person Identified
Other Participants
Affected Persons Notified
System / Equipment
Switching
Non-Hazardous Switching
Panel / Equipment ID
559A3A
System Information Review
☑ Panel Schedules ☑ Arc Flash Labels
Control of Hazardous Energy
Complex LOTO (requires LP, CLP, FLP)
Equipment Condition
☑ Properly installed ☑ Properly maintained ☑ All doors and covers closed and fully latched ☑ No signs of impending failure ☑ Not energizing equipment for the first time ☑ or after electrical repair
Sequence of Job Steps
List basic sequence of steps from start to finish
Loto,verify,
Control of Work Area
Minimum Approach Boundary
Barricade Tape / Attendant
Attendant
Shock Risk Assessment
System Voltage
120/208 V ac
Limited Approach Boundary
42 inches
Restricted Approach Boundary
12 inches
Will the hands enter the RAB
No
Voltage Glove Class
0
Will any other part of the body enter the RAB
No
Arc Flash Risk Assessment
Incident Energy
5.12 cal/cm2
Arc Flash Boundary
42in
Working Distance
18 inches
Arc Flash PPE Level
2
Incident Energy Reduction Measures
0
Capacitor Hazards
Capacitor Bus Voltage
Capacitor Total Stored Energy (Joules)
Discharge Wait Time (Minutes)
Emergency Response Plan
Nearest Landline Location
Office near break room
Emergency Number to Call
Sufficient Cell Phone Signal
Yes
Clear Exit Path
Yes
AED Location
Hallway 4th flr
Fire Extinguisher Location
Hallway 4th flr
Contact Release Method Available and Tested
Voltage gloves
Environmental Conditions
Does the environment present additional hazards that should be addressed?
Heavy traffic
Error Precursors
Task Demands
Work Environment
Individual Capabilities
Human Nature
Error Precursor Mitigations
None
PPE Inspections
☑ Safety glasses (ANSI Z87) ☑ Arc-rated clothing (flash suit ☑ daily wear) including face shield ☑ balaclava ☑ hood. ☑ Hearing protection ☑ Rubber insulating gloves and leather protectors
Notes / Other
Perform Job Briefing
PIC Conducts the Job Briefing. Cover all the contents of the Job Safety Plan.
A Job Briefing at a minimum must include:
Detailed Scope of Work
Shock and arc flash hazards for each task
Controls to mitigate the hazards (procedures, precautions, energy source controls, PPE requirements)
Work area controls (barricades, signs, attendants)
