Time / Date: 10/17/2022 7:48:41
JSP ID: 98
Scope of Work: Switch tripped Breaker caused by space heater
Work Order: 299618
Building:
Person in Charge: Christopher Nelson
Lead / Supervisor: Secheck, Stephen
Logged Email: cnelson@lbl.gov
Division: Facilities
QEW Level: QEW 2
Modes of Work: Mode 0 - Electrically Safe Work Condition
Second Person Requirement: Not Required
Second Person Identified:
List Other Participants: Alex Lopez
Affected Persons Notified:
Switching: Non-Hazardous Switching
Panel / Equipment ID: 25A17A40A
System Information Review: Panel Schedules, Arc Flash Labels
Control of Hazardous Energy: Exclusive Control of Plug
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.

Switch Tripped Breaker test receptacles for 120V power

Control of Work Area

Minimum Approach Boundary: 42
Barricade Tape / Attendant:

Shock Risk Assessment

System Voltage: 120/208 V ac
Limited Approach Boundary: 42 inches
Restricted Approach Boundary: 12 inches
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: 11.6 cal/cm2 cal/cm2
Arc Flash Boundary: 76
Working Distance: 18 inches
Arc Flash PPE Level: 2
Incident Energy Reduction Measures: 0

Capacitor Hazards

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

Emergency Response Plan

Nearest Landline Location:
Emergency Number to Call: 911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location:
Fire Extinguisher Location:
Contact release method available and tested: NA

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:

NA

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