Time / Date: 10/19/2022 7:53:02
JSP ID: 112
Scope of Work: Establish LOTO LP4712 contractor support Switch panel 72C2A ZVV 3 LOTO points at Disconnects
Work Order: 299210
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 1 - LOTO & Zero Voltage Verification
Second Person Requirement: Standby Person
Second Person Identified: Alex lopez
List Other Participants: Alex Lopez
Affected Persons Notified: Yes
Switching: Hazardous Switching
Panel / Equipment ID: 72C2A
System Information Review: LOTO Permit/procedure 4712
Control of Hazardous Energy: Complex LOTO (requires LP, CLP, FLP)
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.

Follow/review LP 4712 sign please Switch LOTO ZVV

Control of Work Area

Minimum Approach Boundary: 42 inches
Barricade Tape / Attendant: Caution

Shock Risk Assessment

System Voltage: 277/480 V ac
Limited Approach Boundary: 42 inches
Restricted Approach Boundary: 12 inches
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: .55 cal/cm2 cal/cm2
Arc Flash Boundary: 12 Inches
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: Room 105A
Emergency Number to Call: 911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: Other end of bul
Fire Extinguisher Location: 15ft away next to roll up door
Contact release method available and tested: Upstream breaker or switch

Environmental Conditions

Does the environment present additional hazards that should be addressed?

Insufficient lighting

Error Precursors

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

Use light stands for more lights open roll up door

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