Time / Date: 10/3/2022 9:15:18
JSP ID: 48
Scope of Work: Perform switching and loto of panel to 252A10A-1,3. Preform zvv on branch circuits in junction box. remove furniture whip from junction box on wall. Put furniture whip in a electrically safe condition.
Work Order: 296493
Building:
Person in Charge: Jared Tissot
Lead / Supervisor: Ramer, Robert
Logged Email: jtissot@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: Not Required
Second Person Identified:
List Other Participants:
Affected Persons Notified:
Switching: Non-Hazardous Switching
Panel / Equipment ID: 25210A
System Information Review: Panel Schedules, Arc Flash Labels
Control of Hazardous Energy: Complex LOTO (requires LP, CLP, FLP)
Equipment Condition:

Sequence of Job Steps

List basic sequence of steps from start to finish.

Control of Work Area

Minimum Approach Boundary:
Barricade Tape / Attendant:

Shock Risk Assessment

System Voltage: 120/208 V ac
Limited Approach Boundary: 42 inches
Restricted Approach Boundary: Avoid contact
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: 9.74 cal/cm2
Arc Flash Boundary: 59”
Working Distance: 18 inches
Arc Flash PPE Level: 1
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: B26
Emergency Number to Call: 9-911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: B26
Fire Extinguisher Location: B26
Contact release method available and tested: Upstream breaker or switch, 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:

Reviewed and no mitigations needed

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