Time / Date: 1/6/2023 9:23:24
JSP ID: 408
Scope of Work: Replace ballast in light fixture 3
Work Order:
Building:
Person in Charge: Sayee Chea
Lead / Supervisor: Keusch, Justen
Logged Email: SChea@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: Standby Person
Second Person Identified: Frank
List Other Participants: None
Affected Persons Notified: Yes
Switching: Non-Hazardous Switching
Panel / Equipment ID: BB-2
System Information Review: Panel Schedules, 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

Sequence of Job Steps

List basic sequence of steps from start to finish.

Turn off breaker, perform zvv

Control of Work Area

Minimum Approach Boundary: 3 inches
Barricade Tape / Attendant: Attendant

Shock Risk Assessment

System Voltage: 120 Vac
Limited Approach Boundary: 42 inches
Restricted Approach Boundary: 3 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: 1.2 cal/cm2
Arc Flash Boundary: NA
Working Distance: No Arc Flash Hazard Present
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: Yes
Emergency Number to Call: 5104867911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: 75A 101
Fire Extinguisher Location: Outside back door of 75A 101
Contact release method available and tested: Rescue hook, Voltage gloves

Environmental Conditions

Does the environment present additional hazards that should be addressed?

None

Error Precursors

Task Demands: Repetitive actions or monotony
Work Environment: Unexpected equipment conditions
Individual Capabilities:
Human Nature:
Error Precursor Mitigations:

Review procedures of my task

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