Time / Date: 2/1/2023 8:08:32
JSP ID: 543
Scope of Work: Repair lights
Work Order: 310909
Building:
Person in Charge: Primo
Lead / Supervisor: Keusch, Justen
Logged Email: pcaliz@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:
List Other Participants:
Affected Persons Notified: Yes
Switching: Non-Hazardous Switching
Panel / Equipment ID: 49A2A6A. CT# 1
System Information Review: Single Line Drawing
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.

ISM

Control of Work Area

Minimum Approach Boundary: 12inches
Barricade Tape / Attendant:

Shock Risk Assessment

System Voltage: 277/480 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: 0.77 cal/cm2
Arc Flash Boundary: 14inches
Working Distance: No Arc Flash Hazard Present
Arc Flash PPE Level: 2
Incident Energy Reduction Measures: 0

Capacitor Hazards

Capacitor Bus Voltage: 277
Capacitor total stored energy (joules): 480
Discharge wait time (minutes):

Emergency Response Plan

Nearest Landline Location: 275J
Emergency Number to Call: 7911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: Entrance
Fire Extinguisher Location: Entrance
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

Safety glasses (ANSI Z87),
Arc-rated clothing (flash suit,
daily wear) including face shield,
balaclava,
hood.,
Hearing protection,
Rubber insulating gloves and leather protectors,
Non-melting footwear that fully covers the feet,
Removal of conductive articles,
Insulated tools,
Multimeter and other electrical test instruments

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