Time / Date: 1/26/2023 8:16:08
JSP ID: 510
Scope of Work: Test test
Work Order: Test test
Building:
Person in Charge: test
Lead / Supervisor: Other
Logged Email: mvr@lbl.gov
Division: Facilities
QEW Level: QEW 2
Modes of Work: Mode 1 - LOTO & Zero Voltage Verification, Mode 2 - Energized Diagnostics, Testing and Troubleshooting, Visual Inspection
Second Person Requirement: Standby Person
Second Person Identified: Test test
List Other Participants: Test test
Affected Persons Notified: Yes
Switching: Hazardous Switching
Panel / Equipment ID: Test test
System Information Review: Single Line Drawing
Control of Hazardous Energy: Exclusive Control of Plug
Equipment Condition: Properly maintained

Sequence of Job Steps

List basic sequence of steps from start to finish.

Test test

Control of Work Area

Minimum Approach Boundary: Test test
Barricade Tape / Attendant: Danger - Red

Shock Risk Assessment

System Voltage: 120 Vac
Limited Approach Boundary: 42 inches
Restricted Approach Boundary: 3 inches
Will the hands enter the RAB: No
Voltage Glove Class: Not Required
Will any other part of the body enter the RAB: No

Arc Flash Risk Assessment

Incident Energy: Test test cal/cm2
Arc Flash Boundary: 18
Working Distance: No Arc Flash Hazard Present
Arc Flash PPE Level: Minimum PPE for Electrical Work
Incident Energy Reduction Measures: Not Required

Capacitor Hazards

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

Emergency Response Plan

Nearest Landline Location: Test test
Emergency Number to Call: Test test
Sufficient cell phone signal? No
Clear exit path? Yes
AED Location: Test test
Fire Extinguisher Location: Test test
Contact release method available and tested:

Environmental Conditions

Does the environment present additional hazards that should be addressed?

Wet location

Error Precursors

Task Demands: Time pressure (in a hurry)
Work Environment: Obscure electrical supplies or configurations
Individual Capabilities: Unsafe attitudes for critical task
Human Nature: Habit patterns
Error Precursor Mitigations:

Test test

PPE Inspections

Notes / Other

Test test

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