Time / Date: 1/27/2023 8:54:25
JSP ID: 519
Scope of Work: Performing monthly PM on emergency lighting. Replace battery as needed.
Work Order: W0307115
Building:
Person in Charge: Balbino Mercadal
Lead / Supervisor: Keusch, Justen
Logged Email: bmmercadal@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: N/A
List Other Participants: N/A
Affected Persons Notified: Yes
Switching: Non-Hazardous Switching
Panel / Equipment ID: 119A
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.

Follow electrical safety QEW 2 pocket guide and LOTO lock out/ tag out…follow ISM for every job including PPE inspection.

Control of Work Area

Minimum Approach Boundary: 12
Barricade Tape / 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: Yes
Voltage Glove Class: 0
Will any other part of the body enter the RAB: No

Arc Flash Risk Assessment

Incident Energy: 1.2 cal/cm2
Arc Flash Boundary: N/A
Working Distance: No Arc Flash Hazard Present
Arc Flash PPE Level: 2
Incident Energy Reduction Measures: 0

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: Cell phone
Emergency Number to Call: 510-486-7111 or 911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: Room 105
Fire Extinguisher Location: Room 105
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:

Yes

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