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QEW 1 / 2 / 3 Job Safety Plan

Electrical Safety
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Time / Date: 10/3/2025 10:04:07
JSP ID: 4160
Scope of Work: Swap phases on a receptacle attached to MO box.

General Information

Work Order
415067
Building
B6
Person in Charge
Robert Ralph
Lead / Supervisor
Combs, Everett
Logged Email
RobertRalph@lbl.gov
Division
Facilities

Work Planning

Modes of Work
☑ Mode 0 - Electrically Safe Work Condition
☑ Mode 1 - LOTO & Zero Voltage Verification
☑ Mode 2 - Energized Diagnostics
☑ Testing and Troubleshooting
☑ Visual Inspection
QEW Level
QEW 2
Second Person Requirement
Standby Person
Second Person Identified
Mayumi Taylor
Other Participants
Affected Persons Notified
Yes

System / Equipment

Switching
No Switching Required
Panel / Equipment ID
287A
System Information Review
☑ Panel Schedules
Control of Hazardous Energy
Exclusive Control of Plug
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
1. Unplug cord feeding MO box 2.) verify unplugged and de-energized 3.)swap phases at outlet 4.) plug in and verify working correctly. 5.) May need to perform switching to troubleshoot.

Control of Work Area

Minimum Approach Boundary
42”
Barricade Tape / Attendant
Warning - Orange

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
Yes
Voltage Glove Class
00
Will any other part of the body enter the RAB
No

Arc Flash Risk Assessment

Incident Energy
1.2 cal/cm2
Arc Flash Boundary
18”
Working Distance
18 inches
Arc Flash PPE Level
2
Incident Energy Reduction Measures
00

Capacitor Hazards

Capacitor Bus Voltage
Capacitor Total Stored Energy (Joules)
Discharge Wait Time (Minutes)

Emergency Response Plan

Nearest Landline Location
On desk nearby
Emergency Number to Call
911
Sufficient Cell Phone Signal
Yes
Clear Exit Path
Yes
AED Location
Lobby B6
Fire Extinguisher Location
Just outside user floor
Contact Release Method Available and Tested
Voltage gloves

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
Everything is good

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
☑ Non-melting footwear that fully covers the feet
☑ Removal of conductive articles
☑ Insulated tools
☑ Multimeter and other electrical test instruments

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:
  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 2026.03.17.1
Form Content and Feedback Contact: Michael Rose -- mvr@lbl.gov