Time / Date: 10/4/2022 7:34:22
JSP ID: 52
Scope of Work: Install data logger in panel 30A3A5B27A ckt 27
Work Order: W0296596
Building:
Person in Charge: Andrew Southward
Lead / Supervisor: Hendrick, Jeffery
Logged Email: amsouthward@lbl.gov
Division: Facilities
QEW Level: QEW 2
Modes of Work: Mode 2 - Energized Diagnostics, Testing and Troubleshooting, Visual Inspection
Second Person Requirement: Safety Watch
Second Person Identified: Jarrod Tissot
List Other Participants: Jarrod Tissot
Affected Persons Notified:
Switching: No Switching Required
Panel / Equipment ID: 30A3A5B
System Information Review: Panel Schedules, Arc Flash Labels
Control of Hazardous Energy: Complex LOTO w/ RIN/A (Mode 2 or Mode 3 only)
Equipment Condition: Properly installed, 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.

Control of Work Area

Minimum Approach Boundary: 67 inches
Barricade Tape / Attendant: Danger

Shock Risk Assessment

System Voltage: 120/208 V ac
Limited Approach Boundary: 42 inches
Restricted Approach Boundary: 12 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: 12.7 cal/cm2
Arc Flash Boundary: 67 inches
Working Distance: 18 inches
Arc Flash PPE Level: 3
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: Lab 157
Emergency Number to Call: 911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: On hand
Fire Extinguisher Location: Hallway outside of lab 157
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