Time / Date: 9/19/2023 11:16:48
JSP ID: 1569
Scope of Work: Install new AC power disconnect
Work Order: 319402
Building: 71C
Person in Charge: Alex Lopez
Lead / Supervisor: Secheck, Stephen
Logged Email: Alopez2@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: Greg Neidiger
List Other Participants: None
Affected Persons Notified: Yes
Switching: Non-Hazardous Switching
Panel / Equipment ID: 172A12A
System Information Review: Panel Schedules, Arc Flash Labels
Control of Hazardous Energy: Simple LOTO
Equipment Condition: Properly installed, Properly maintained, All doors and covers closed and fully latched

Sequence of Job Steps

List basic sequence of steps from start to finish.

Establish LOTO, ZVV, install power disconnect, make necessary wire connections and re-energize power disconnect.

Control of Work Area

Minimum Approach Boundary: 3 inches
Barricade Tape / Attendant: Attendant

Shock Risk Assessment

System Voltage: 120/208 V ac
Limited Approach Boundary: 42 inches
Restricted Approach Boundary: 12 inches
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: 0.12 cals cal/cm2
Arc Flash Boundary: 18 inches
Working Distance: No Arc Flash Hazard Present
Arc Flash PPE Level: Minimum PPE for Electrical Work
Incident Energy Reduction Measures: 0

Capacitor Hazards

Capacitor Bus Voltage: N/A
Capacitor total stored energy (joules): N\A
Discharge wait time (minutes): N/A

Emergency Response Plan

Nearest Landline Location: Cell phone
Emergency Number to Call: 911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: In vehicle
Fire Extinguisher Location: 71P building
Contact release method available and tested: Upstream breaker or switch, Voltage gloves

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 at this time

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

Notes / Other

None

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