Time / Date: 1/30/2023 7:13:49
JSP ID: 527
Scope of Work: test
Work Order: Testing
Building:
Person in Charge: Test
Lead / Supervisor: Other
Logged Email: mvr@lbl.gov
Division: Facilities
QEW Level: QEW 2
Modes of Work: Mode 0 - Electrically Safe Work Condition
Second Person Requirement: Not Required
Second Person Identified: test
List Other Participants: test
Affected Persons Notified: N/A
Switching: No Switching Required
Panel / Equipment ID: test
System Information Review: test
Control of Hazardous Energy: Simple LOTO
Equipment Condition: Not energizing equipment for the first time, or after electrical repair

Sequence of Job Steps

List basic sequence of steps from start to finish.

test

Control of Work Area

Minimum Approach Boundary: 0
Barricade Tape / Attendant: Attendant

Shock Risk Assessment

System Voltage: No Shock Hazard Present
Limited Approach Boundary: None
Restricted Approach Boundary: None
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: 0 cal/cm2
Arc Flash Boundary: 0
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
Emergency Number to Call: test
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: test
Fire Extinguisher Location: test
Contact release method available and tested:

Environmental Conditions

Does the environment present additional hazards that should be addressed?

None

Error Precursors

Task Demands: Lack of or unclear standards
Work Environment: Personality conflicts
Individual Capabilities: Inappropriate values
Human Nature: Mental shortcuts (biases)
Error Precursor Mitigations:

test

PPE Inspections

Notes / Other

Test 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