Time / Date: 10/25/2022 9:39:11
JSP ID: 142
Scope of Work: Replace Ckt brkr #4 in 208v panel
Work Order:
Building:
Person in Charge: Jeff Grounds
Lead / Supervisor: Other
Logged Email: jtgrounds@lbl.gov
Division: Facilities
QEW Level: QEW 2
Modes of Work: Mode 0 - Electrically Safe Work Condition, Mode 1 - LOTO & Zero Voltage Verification
Second Person Requirement: Standby Person
Second Person Identified: Mike Rose
List Other Participants:
Affected Persons Notified: Yes
Switching: Hazardous Switching
Panel / Equipment ID: Panel 2
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, Not energizing equipment for the first time, or after electrical repair

Sequence of Job Steps

List basic sequence of steps from start to finish.

Notify affected people of shutdown Set up safety parameters Assign safety watch Perform job safety briefing Open 480v disconnect Apply LOTO to 480v disconnect Perform ZVV at 480v disconnect Open 208v panel Perform ZVV at 208v panel Replace Ckt brkr #4 Close 208v panel Notify affected people that equipment to be Re energized Remove LOTO from 480v disconnect Close disconnect and Re energize circuit Remove safety parameters Collect feedback Task complete

Control of Work Area

Minimum Approach Boundary: 46”
Barricade Tape / Attendant: Warning

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: 5.39 cal cal/cm2
Arc Flash Boundary: 46”
Working Distance: 18 inches
Arc Flash PPE Level: 2
Incident Energy Reduction Measures: 0

Capacitor Hazards

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

Emergency Response Plan

Nearest Landline Location: Cellphone
Emergency Number to Call: 911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: Wall
Fire Extinguisher Location: Outside roll up door
Contact release method available and tested: Upstream breaker or switch, Rescue hook

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:

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