Time / Date: 9/29/2022 13:34:44
JSP ID: 37
Scope of Work: PM- check operations, inspect electrical, inspect for possible leaks
Work Order: 273752
Building:
Person in Charge: Capeto
Lead / Supervisor: Delgado, Alex
Logged Email: mcapeto@lbl.gov
Division: Facilities
QEW Level: QEW 2
Modes of Work: Mode 0 - Electrically Safe Work Condition, Mode 1 - LOTO & Zero Voltage Verification
Second Person Requirement: Safety Watch
Second Person Identified:
List Other Participants: Justin Solis
Affected Persons Notified:
Switching: Hazardous Switching
Panel / Equipment ID: 55 AC 024
System Information Review: Arc Flash Labels
Control of Hazardous Energy: Simple LOTO
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.

Control of Work Area

Minimum Approach Boundary: 42
Barricade Tape / Attendant: Warning

Shock Risk Assessment

System Voltage: 277/480 V ac
Limited Approach Boundary: 42 inches
Restricted Approach Boundary: 12 inches
Will the hands enter the RAB: Yes
Voltage Glove Class: 0
Will any other part of the body enter the RAB: No

Arc Flash Risk Assessment

Incident Energy: 29.1 cal/cm2
Arc Flash Boundary: 105 inches
Working Distance: 18 inches
Arc Flash PPE Level: 4
Incident Energy Reduction Measures: 0

Capacitor Hazards

Capacitor Bus Voltage: No
Capacitor total stored energy (joules):
Discharge wait time (minutes):

Emergency Response Plan

Nearest Landline Location: Office
Emergency Number to Call: 911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: 1st floor
Fire Extinguisher Location: At entrance
Contact release method available and tested: Rescue hook

Environmental Conditions

Does the environment present additional hazards that should be addressed?

None

Error Precursors

Task Demands:
Work Environment:
Individual Capabilities:
Human Nature:
Error Precursor Mitigations:

Hot inside suite. Using fan

PPE Inspections

Notes / Other

Perform Job Breifing

PIC Conducts the Job Briefing. Cover all the contents of the Job Safety Plan.

A Job Briefing at a minimum must include:
  1. Detailed Scope of Work
  2. Shock and arc flash hazards for each task
  3. Controls to mitigate the hazards (procedures, precautions, energy source controls, PPE requirements)
  4. Work area controls (barricades, signs, attendants)
  5. Emergency Response Plan

Rev 2023.08.22.1
Form Content and Feedback Contact: Michael Rose -- mvr@lbl.gov