Time / Date: 8/22/2023 8:01:54
JSP ID: 1438
Scope of Work: LOTO and ZVV receptacles and start stop station
Work Order: 336021
Building: ALS
Person in Charge: Chis Nelson
Lead / Supervisor: Combs, Everett
Logged Email: cnelson@lbl.gov
Division: ALS
QEW Level: QEW 2
Modes of Work: Mode 1 - LOTO & Zero Voltage Verification
Second Person Requirement: Standby Person
Second Person Identified: Robert Ralph
List Other Participants: Everet Combs also ALS personnel we are LOTO and ZVV for
Affected Persons Notified: Yes
Switching: Non-Hazardous Switching
Panel / Equipment ID: 277A
System Information Review: Panel Schedules, Arc Flash Labels
Control of Hazardous Energy: Complex LOTO w/ RI
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.

Control of Work Area

Minimum Approach Boundary: 42”
Barricade Tape / Attendant: Warning - Orange

Shock Risk Assessment

System Voltage: 120/208 V ac
Limited Approach Boundary: 42 inches
Restricted Approach Boundary: Avoid contact
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/cm2
Arc Flash Boundary: 18 inches
Working Distance: 18 inches
Arc Flash PPE Level: Minimum PPE for Electrical Work
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: Around corner from panel
Emergency Number to Call: 911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: Building 15 lobby
Fire Extinguisher Location:
Contact release method available and tested: Upstream breaker or switch, Voltage gloves

Environmental Conditions

Does the environment present additional hazards that should be addressed?

Heavy traffic, Lookalike equipment, Noisy environment

Error Precursors

Task Demands: Time pressure (in a hurry), Simultaneous or multiple tasks, Repetitive actions or monotony
Work Environment: Distractions/interruptions
Individual Capabilities:
Human Nature: Stress (limits attention), Mind-set
Error Precursor Mitigations:

Keep on the task a hand don’t stress

PPE Inspections

Safety glasses (ANSI Z87),
Arc-rated clothing (flash suit,
daily wear) including face shield,
balaclava,
hood.,
Hearing protection,
Rubber insulating gloves and leather protectors,
Non-melting footwear that fully covers the feet,
Removal of conductive articles,
Insulated tools,
Multimeter and other electrical test instruments

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