Time / Date: 4/5/2023 9:42:57
JSP ID: 849
Scope of Work: Replace light fixtures
Work Order: 313837
Building:
Person in Charge: Primitivo CALIZ. 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: Standby Person
Second Person Identified: Balbino
List Other Participants: None
Affected Persons Notified: Yes
Switching: Non-Hazardous Switching
Panel / Equipment ID: 33A4A34A
System Information Review: Panel Schedules
Control of Hazardous Energy: Simple LOTO
Equipment Condition:

Sequence of Job Steps

List basic sequence of steps from start to finish.

ISM

Control of Work Area

Minimum Approach Boundary: 7in
Barricade Tape / Attendant:

Shock Risk Assessment

System Voltage: No Shock Hazard Present
Limited Approach Boundary: 42 inches
Restricted Approach Boundary: Avoid contact
Will the hands enter the RAB: No
Voltage Glove Class: 0
Will any other part of the body enter the RAB: No

Arc Flash Risk Assessment

Incident Energy: 0.2 cal/cm2
Arc Flash Boundary: 7in
Working Distance: 18 inches
Arc Flash PPE Level: 2
Incident Energy Reduction Measures: 0

Capacitor Hazards

Capacitor Bus Voltage:
Capacitor total stored energy (joules):
Discharge wait time (minutes): None

Emergency Response Plan

Nearest Landline Location: Hallway
Emergency Number to Call: 911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: Hallway
Fire Extinguisher Location: Hallway
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:

No e

PPE Inspections

Safety glasses (ANSI Z87)

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