Time / Date: 10/19/2022 10:47:38
JSP ID: 115
Scope of Work: Troubleshoot 85- Br-001
Work Order: 299879
Building:
Person in Charge: Gerald fowler
Lead / Supervisor: Delgado, Alex
Logged Email: gdfowler@lbl.gov
Division: Facilities
QEW Level: QEW 2
Modes of Work: Mode 0 - Electrically Safe Work Condition, Mode 1 - LOTO & Zero Voltage Verification, Mode 2 - Energized Diagnostics, Testing and Troubleshooting, Visual Inspection
Second Person Requirement: Not Required
Second Person Identified: Na
List Other Participants: Na
Affected Persons Notified: Yes
Switching: Non-Hazardous Switching
Panel / Equipment ID: Pnl # 358A/85-BR-001
System Information Review: Arc Flash Labels
Control of Hazardous Energy: Simple LOTO
Equipment Condition: Properly installed, Properly maintained, All doors and covers closed and fully latched, No signs of impending failure

Sequence of Job Steps

List basic sequence of steps from start to finish.

Troubleshoot unit to determine why it will not stay running

Control of Work Area

Minimum Approach Boundary: 42
Barricade Tape / Attendant: Notice

Shock Risk Assessment

System Voltage: 120 Vac
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: 1.2 cal cm 2 cal/cm2
Arc Flash Boundary: 18 inches
Working Distance: 18 inches
Arc Flash PPE Level: 1
Incident Energy Reduction Measures: 0

Capacitor Hazards

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

Emergency Response Plan

Nearest Landline Location: Building 85B lobby
Emergency Number to Call: 6999
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: Building 85B lobby
Fire Extinguisher Location: Just outside of boiler room
Contact release method available and tested: Upstream breaker or switch

Environmental Conditions

Does the environment present additional hazards that should be addressed?

None

Error Precursors

Task Demands:
Work Environment: Distractions/interruptions, Confusing displays or controls
Individual Capabilities: Lack of knowledge (faulty mental model)
Human Nature: Stress (limits attention), Assumptions, Complacency/overconfidence, Inaccurate risk perception
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