Time / Date: 10/13/2022 8:32:42
JSP ID: 86
Scope of Work: Contractor relocating receptacle
Work Order: W0291750
Building:
Person in Charge: Joe Colmenares
Lead / Supervisor: Cameron, Benjamin
Logged Email: jcolmenares@lbl.gov
Division: Facilities
QEW Level: QEW 2
Modes of Work: Mode 1 - LOTO & Zero Voltage Verification
Second Person Requirement: Standby Person
Second Person Identified: Pica
List Other Participants: Pica. Reynolds Cameron Alexi
Affected Persons Notified:
Switching: Hazardous Switching
Panel / Equipment ID: PNL 126-02. /. 243A21A
System Information Review: Panel Schedules, Arc Flash Labels
Control of Hazardous Energy: Complex LOTO (requires LP, CLP, FLP)
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.

JSP BRIEF DAWN FOOT PROTECTION LOTO ZVV

Control of Work Area

Minimum Approach Boundary: 42 inch
Barricade Tape / Attendant: Attendant

Shock Risk Assessment

System Voltage: 120/208 V ac
Limited Approach Boundary: 42 inches
Restricted Approach Boundary: Avoid contact
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: 0.17 cal cal/cm2
Arc Flash Boundary: 5 inch
Working Distance: 18 inches
Arc Flash PPE Level: 1
Incident Energy Reduction Measures: 0

Capacitor Hazards

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

Emergency Response Plan

Nearest Landline Location: By rm 147
Emergency Number to Call: 7911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: Main lobby room 102
Fire Extinguisher Location: Main lobby room 102
Contact release method available and tested: Voltage gloves

Environmental Conditions

Does the environment present additional hazards that should be addressed?

Noisy environment, Yellow lights

Error Precursors

Task Demands:
Work Environment:
Individual Capabilities:
Human Nature:
Error Precursor Mitigations:

Yellow light casting shadows

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