Time / Date: 10/5/2022 8:32:33
JSP ID: 57
Scope of Work: Electrical troubleshooting
Work Order: 297148
Building:
Person in Charge: Michael Capeto
Lead / Supervisor: Delgado, Alex
Logged Email: mcapeto@lbl.gov
Division: Facilities
QEW Level: QEW 2
Modes of Work: Mode 0 - Electrically Safe Work Condition, Mode 2 - Energized Diagnostics, Testing and Troubleshooting, Visual Inspection
Second Person Requirement: Safety Watch
Second Person Identified: Larry Antles
List Other Participants:
Affected Persons Notified:
Switching: Hazardous Switching
Panel / Equipment ID: 46 AC 041
System Information Review: Arc Flash Labels
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, 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: 74 inches
Barricade Tape / Attendant: 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: 21 calories cal/cm2
Arc Flash Boundary: 74 inches
Working Distance: 18 inches
Arc Flash PPE Level: 4
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: Room 175 F
Emergency Number to Call: X6999
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: 2nd floor 275C
Fire Extinguisher Location: Ground level truck
Contact release method available and tested: Upstream breaker or switch, Rescue hook, Voltage gloves

Environmental Conditions

Does the environment present additional hazards that should be addressed?

Wet location, Fall hazard, Lookalike equipment

Error Precursors

Task Demands: Critical steps or irreversible acts
Work Environment:
Individual Capabilities:
Human Nature:
Error Precursor Mitigations:

Not wearing fall gear correctly. Slipping on roof.

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