Time / Date: 10/12/2023 14:35:10
JSP ID: 1696
Scope of Work: Swapping a bad door holder on the 4th floor
Work Order: 451599
Building: 67
Person in Charge: Ed Bekheet
Lead / Supervisor: Lee, Michael
Logged Email: edbekheet@lbl.gov
Division: Facilities
QEW Level: QEW 1
Modes of Work: Mode 0 - Electrically Safe Work Condition, Mode 1 - LOTO & Zero Voltage Verification
Second Person Requirement: Safety Watch
Second Person Identified: Travis Ray
List Other Participants:
Affected Persons Notified: Yes
Switching: Non-Hazardous Switching
Panel / Equipment ID: 559A21A-24
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.

1. Let FAM know about work 2. Perform LOTO 3. Perform ZVV 4. Once ZVV is verified, swap door holder 5. Put power back on 6. Test the door holder

Control of Work Area

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

Shock Risk Assessment

System Voltage: 120 Vac
Limited Approach Boundary: 42 inches
Restricted Approach Boundary: 3 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: 4.25 cal/cm2
Arc Flash Boundary: 42
Working Distance: No Arc Flash Hazard Present
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: Rm 4108
Emergency Number to Call: 911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: 3rd floor entrance lobby
Fire Extinguisher Location: 4th floor by Rm 4204
Contact release method available and tested: 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:

Just need to follow QEW procedure

PPE Inspections

Safety glasses (ANSI Z87),
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