Time / Date: 10/19/2022 7:52:31
JSP ID: 111
Scope of Work: Switching support for PMT’s to perform maintenance
Work Order: W0298854
Building:
Person in Charge: Andrew Southward
Lead / Supervisor: Cameron, Benjamin
Logged Email: amsouthward@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: Ben Cameron
List Other Participants: Ben Cameron
Affected Persons Notified: Yes
Switching: Hazardous Switching
Panel / Equipment ID: 350A10A
System Information Review: Panel Schedules, Arc Flash Labels
Control of Hazardous Energy: Simple LOTO
Equipment Condition: Properly installed, All doors and covers closed and fully latched, Not energizing equipment for the first time, or after electrical repair

Sequence of Job Steps

List basic sequence of steps from start to finish.

Located breaker for equipment needing maintenance, switch off breaker, attempt to start equipment. Re-energize when work is complete. This is deranged electrical equipment so full PPE will be worn while switching.

Control of Work Area

Minimum Approach Boundary: 62 inches
Barricade Tape / Attendant:

Shock Risk Assessment

System Voltage: No Shock Hazard Present
Limited Approach Boundary: None
Restricted Approach Boundary: None
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: 8.67 cal/cm2
Arc Flash Boundary: 62 inches
Working Distance: 18 inches
Arc Flash PPE Level: 4
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: Offices outside of mechanical room
Emergency Number to Call: 911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: On hand
Fire Extinguisher Location: In mechanical room
Contact release method available and tested: Upstream breaker or switch, Voltage gloves

Environmental Conditions

Does the environment present additional hazards that should be addressed?

Noisy environment

Error Precursors

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

None

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