Time / Date: 4/14/2023 10:28:49
JSP ID: 893
Scope of Work: Investigate the cause of the Lights that are OFF.
Work Order: 322502
Building:
Person in Charge: Anthony Pilz
Lead / Supervisor: Ramer, Robert
Logged Email: apilz@lbl.gov
Division: Facilities
QEW Level: QEW 2
Modes of Work: Mode 0 - Electrically Safe Work Condition
Second Person Requirement: Safety Watch
Second Person Identified: Greg Neidiger
List Other Participants:
Affected Persons Notified: Yes
Switching: Non-Hazardous Switching
Panel / Equipment ID: 175A
System Information Review: Panel Schedules, Arc Flash Labels
Control of Hazardous Energy: LOTO Not Required (Mode 2 or 3 only)
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.

Check The label for the circuit and panel. Then see the breakers labeled Overhead lights. Don PPE and switch the 120 single pole breakers ON.

Control of Work Area

Minimum Approach Boundary: 50
Barricade Tape / Attendant: Attendant

Shock Risk Assessment

System Voltage: 120/208 V ac
Limited Approach Boundary: 42 inches
Restricted Approach Boundary: None
Will the hands enter the RAB: No
Voltage Glove Class: 00
Will any other part of the body enter the RAB: No

Arc Flash Risk Assessment

Incident Energy: 7.61 cal/cm2
Arc Flash Boundary: 50
Working Distance: No Arc Flash Hazard Present
Arc Flash PPE Level: 1
Incident Energy Reduction Measures: 00

Capacitor Hazards

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

Emergency Response Plan

Nearest Landline Location: in building 60
Emergency Number to Call:
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: in building 60
Fire Extinguisher Location: in building 60
Contact release method available and tested:

Environmental Conditions

Does the environment present additional hazards that should be addressed?

Insufficient lighting

Error Precursors

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

Being Aware

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