Time / Date: 1/23/2023 14:16:06
JSP ID: 490
Scope of Work: Loto lighting circuit in to a safe work
Work Order: 309866
Building:
Person in Charge: Beau Erwin
Lead / Supervisor: Secheck, Stephen
Logged Email: beauerwin81@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: Alex Lopez
List Other Participants:
Affected Persons Notified: Yes
Switching: Hazardous Switching
Panel / Equipment ID: 566A16A/7
System Information Review: 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.

Loto,ZVV,removed light fixture . Put conductors in a j-box and safety off. Turned lighting circuit back on.. ready for fmcs to do there work..

Control of Work Area

Minimum Approach Boundary:
Barricade Tape / Attendant: Caution - Yellow

Shock Risk Assessment

System Voltage: 277/480 V ac
Limited Approach Boundary: 42 inches
Restricted Approach Boundary: 12 inches
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: 15.1 cal/cm2
Arc Flash Boundary: 73”
Working Distance: 24 inches
Arc Flash PPE Level: 2
Incident Energy Reduction Measures: 0

Capacitor Hazards

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

Emergency Response Plan

Nearest Landline Location: Hallway
Emergency Number to Call:
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: 6th flr hallway
Fire Extinguisher Location: 6th flr hallway
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:

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