Time / Date: 9/26/2025 7:52:45
JSP ID: 4143
Scope of Work: Perform annual test of the emergency fixtures
Work Order: Turn off breakers then reenergize
Building: 90
Person in Charge: Egon Hampton
Lead / Supervisor: Keusch, Justen
Logged Email: efhampton@lbl.gov
Division: Facilities
QEW Level: QEW 2
Modes of Work: Mode 0 - Electrically Safe Work Condition
Second Person Requirement: Not Required
Second Person Identified: Na
List Other Participants: Na
Affected Persons Notified: Yes
Switching: Non-Hazardous Switching
Panel / Equipment ID: E90A4A9A3A
System Information Review: Panel Schedules
Control of Hazardous Energy: Cord & Plug 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.

Turn off breakers for the units

Control of Work Area

Minimum Approach Boundary: Signs designating outage time contacts
Barricade Tape / Attendant: Attendant

Shock Risk Assessment

System Voltage: No Shock Hazard Present
Limited Approach Boundary: None
Restricted Approach Boundary: None
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: 4.7 cal/cm2
Arc Flash Boundary: 42”
Working Distance: No Arc Flash Hazard Present
Arc Flash PPE Level: 2
Incident Energy Reduction Measures: 0

Capacitor Hazards

Capacitor Bus Voltage: Na
Capacitor total stored energy (joules): Na
Discharge wait time (minutes): Na

Emergency Response Plan

Nearest Landline Location: Lobby
Emergency Number to Call: 699
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: Lobby
Fire Extinguisher Location: Lobby
Contact release method available and tested: Non electrical work

Environmental Conditions

Does the environment present additional hazards that should be addressed?

Na

Error Precursors

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

Na

PPE Inspections

Safety glasses (ANSI Z87),
Hearing protection,
Rubber insulating gloves and leather protectors,
Na

Notes / Other

Test of emergency fixtures

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