Time / Date: 1/24/2023 13:43:59
JSP ID: 502
Scope of Work: Remove furniture whip in room 157C at building 46 and install two new electrical plugs.
Work Order: W0309488.
Building:
Person in Charge: Jarred Tissot
Lead / Supervisor: Secheck, Stephen
Logged Email: Alopez2@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: Standby Person
Second Person Identified: Alejandro Lopez
List Other Participants: None
Affected Persons Notified: Yes
Switching: Non-Hazardous Switching
Panel / Equipment ID: 253B1A33A39A
System Information Review: Panel Schedules
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

Sequence of Job Steps

List basic sequence of steps from start to finish.

Simple LOTO, ZVV, remove furniture whip and install two new power plugs.

Control of Work Area

Minimum Approach Boundary: 42
Barricade Tape / Attendant: Attendant

Shock Risk Assessment

System Voltage: 120/208 V ac
Limited Approach Boundary: 42 inches
Restricted Approach Boundary: 3 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: 7.63 cal/cm2
Arc Flash Boundary: 57
Working Distance: 18 inches
Arc Flash PPE Level: Minimum PPE for Electrical Work
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: Room 157
Emergency Number to Call: 911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: Main corridor
Fire Extinguisher Location: Main corridor
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

None

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