Time / Date: 9/26/2023 11:12:21
JSP ID: 1599
Scope of Work: ZVV at disc 16A 480vac
Work Order: 1234
Building: 75A
Person in Charge: CWoo
Lead / Supervisor: Other
Logged Email: konecliff@gmail.com
Division: Facilities
QEW Level: QEW 2
Modes of Work: Mode 1 - LOTO & Zero Voltage Verification
Second Person Requirement: Standby Person
Second Person Identified: Derek Mccabe
List Other Participants: Ari Harding - LBNL EHS
Affected Persons Notified: Yes
Switching: No Switching Required
Panel / Equipment ID: 16A
System Information Review: 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.

1. Join RI LOTO. 2. Open 16A panel=our elev control. 3. ZVV 16A Load side. 4. Do repairs. 5. Close 16A panel = our elev control. 6. Remove my lock from RI group lock.

Control of Work Area

Minimum Approach Boundary: Greater the LAB or is 42” vs arc flash 26”
Barricade Tape / Attendant: Attendant

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: 00
Will any other part of the body enter the RAB: No

Arc Flash Risk Assessment

Incident Energy: 2.37 cal/cm2
Arc Flash Boundary: 26
Working Distance: 18 inches
Arc Flash PPE Level: 2
Incident Energy Reduction Measures: 00

Capacitor Hazards

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

Emergency Response Plan

Nearest Landline Location: B75 in hallway
Emergency Number to Call: 7911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: On wall right hand south
Fire Extinguisher Location: Outside west door and is charged
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: Time pressure (in a hurry), High workload (memory requirements)
Work Environment: Distractions/interruptions
Individual Capabilities: Unfamiliar with, or first time performing task, New technique not used before
Human Nature: Stress (limits attention)
Error Precursor Mitigations:

Step by step procedure JSP Job Safety Plan

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

Practical test for QEW 2 level

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