Time / Date: 1/11/2023 8:06:51
JSP ID: 430
Scope of Work: Air gap furniture whip so water damage repairs can take place.
Work Order: 309021
Building:
Person in Charge: Shane Miller
Lead / Supervisor: Secheck, Stephen
Logged Email: spmiller@lbl.gov
Division: Facilities
QEW Level: QEW 2
Modes of Work: Mode 1 - LOTO & Zero Voltage Verification
Second Person Requirement: Standby Person
Second Person Identified: Shane Miller
List Other Participants: Nick Gripe
Affected Persons Notified: Yes
Switching: Non-Hazardous Switching
Panel / Equipment ID: E65A16A
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, Not energizing equipment for the first time, or after electrical repair

Sequence of Job Steps

List basic sequence of steps from start to finish.

Dawn the proper PPE and Switch circuit #4 in panel E65A16A, ZVV and disconnect furniture whip and leave in an electrically safe state.

Control of Work Area

Minimum Approach Boundary: 68"
Barricade Tape / Attendant: Attendant

Shock Risk Assessment

System Voltage: 120 Vac
Limited Approach Boundary: 42 inches
Restricted Approach Boundary: 12 inches
Will the hands enter the RAB: No
Voltage Glove Class: 00
Will any other part of the body enter the RAB: No

Arc Flash Risk Assessment

Incident Energy: 13.1 cal/cm2 cal/cm2
Arc Flash Boundary: 68"
Working Distance: No Arc Flash Hazard Present
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: B65B
Emergency Number to Call: X6999
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: B65
Fire Extinguisher Location: B65
Contact release method available and tested: Voltage gloves

Environmental Conditions

Does the environment present additional hazards that should be addressed?

Wet location

Error Precursors

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

none

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