Time / Date: 11/3/2022 9:22:55
JSP ID: 181
Scope of Work: PM AC 25
Work Order: 284297
Building:
Person in Charge: Larry Antles
Lead / Supervisor: Delgado, Alex
Logged Email: leantles@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: Not Required
Second Person Identified: Justin Solis
List Other Participants:
Affected Persons Notified: Yes
Switching: Non-Hazardous Switching
Panel / Equipment ID: 253B1A3A21A/B46 AC025
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, No signs of impending failure

Sequence of Job Steps

List basic sequence of steps from start to finish.

LOTO ZVV, check and tighten electrical, inspect unit, check operations

Control of Work Area

Minimum Approach Boundary: 42
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: 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/sm^2 cal/cm2
Arc Flash Boundary: 18”
Working Distance: No Arc Flash Hazard Present
Arc Flash PPE Level: 2
Incident Energy Reduction Measures: 0

Capacitor Hazards

Capacitor Bus Voltage: None
Capacitor total stored energy (joules): None
Discharge wait time (minutes): None

Emergency Response Plan

Nearest Landline Location: 175f
Emergency Number to Call: 6999
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: Near 275C
Fire Extinguisher Location: Near 170
Contact release method available and tested: Voltage gloves

Environmental Conditions

Does the environment present additional hazards that should be addressed?

Cold

Error Precursors

Task Demands:
Work Environment:
Individual Capabilities:
Human Nature:
Error Precursor Mitigations:

Not being aware of surroundings

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