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QEW 1 / 2 / 3 Job Safety Plan

Electrical Safety
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Time / Date: 1/16/2026 11:02:03
JSP ID: 4467
Scope of Work: Turn off circuit 1 in panel 727A. Perform ZVV on circuit 1 receptacle. Change from one gang to two gang. Turn circuit 1 back on.

General Information

Work Order
105904
Building
6
Person in Charge
Jevon Mattiassi
Lead / Supervisor
Keusch, Justen
Logged Email
jmmattiassi@gmail.com
Division
ALS

Work Planning

Modes of Work
☑ Mode 1 - LOTO & Zero Voltage Verification
QEW Level
QEW 2
Second Person Requirement
Not Required
Second Person Identified
None
Other Participants
Ems
Affected Persons Notified
Yes

System / Equipment

Switching
Non-Hazardous Switching
Panel / Equipment ID
727A
System Information Review
☑ Panel Schedules
☑ Arc Flash Labels
Control of Hazardous Energy
Complex LOTO (requires LP, CLP, FLP)
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
Set up limited approach boundaries. Check all ppe. Check proving unit. Check meter. Notify EMs. Wear all ppe for switching. Turn off breaker. Perform ZVV. Change out plug. Notify EMs that power will be coming back on. Turn on circuit breaker 1.

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

Arc Flash Risk Assessment

Incident Energy
3.61 cal/cm2
Arc Flash Boundary
33”
Working Distance
18 inches
Arc Flash PPE Level
2
Incident Energy Reduction Measures
00

Capacitor Hazards

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

Emergency Response Plan

Nearest Landline Location
BR3 entrance
Emergency Number to Call
911
Sufficient Cell Phone Signal
Yes
Clear Exit Path
Yes
AED Location
Linac rack 123
Fire Extinguisher Location
Bottom of stairs
Contact Release Method Available and Tested
Upstream breaker or switch, Voltage gloves

Environmental Conditions

Does the environment present additional hazards that should be addressed?
Insufficient lighting, Lookalike equipment, Noisy environment

Error Precursors

Task Demands
Work Environment
Individual Capabilities
Human Nature
Stress (limits attention)
Error Precursor Mitigations
Calm down and exercise the well thought out plan.

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