Time / Date: 1/29/2024 8:59:57
JSP ID: 2144
Scope of Work: Preform simple loto on a single pole switch to re-land 120 volt control voltage to a chilled water actuator.
Work Order: W0361037
Building: 91U
Person in Charge: Sean Legan
Lead / Supervisor: Alford, Steve
Logged Email: slegan@lbl.gov
Division: Facilities
QEW Level: QEW 2
Modes of Work: Mode 1 - LOTO & Zero Voltage Verification
Second Person Requirement: Not Required
Second Person Identified: N/A
List Other Participants: Mike Rose
Affected Persons Notified: Yes
Switching: Non-Hazardous Switching
Panel / Equipment ID: TBD
System Information Review: Site Review
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.

1- Inspect tools and PPE. 2- Verify multimeter is operational and meets requirements. 3- Preform non-hazardous switching and point of loto. 4- Apply lock and challenge. 5- Preform ZVV at actuator location after verification that meter can read a presence of voltage. 6- Begin task of re-wiring field device. 7- Replace cover and bolt closed. 8- Release loto. 9- Test device for operation.

Control of Work Area

Minimum Approach Boundary: 36
Barricade Tape / Attendant: Attendant

Shock Risk Assessment

System Voltage: 120 Vac
Limited Approach Boundary: None
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: 0 cal/cm2
Arc Flash Boundary: N/A
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: 91
Emergency Number to Call: 15104866999
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: 91U
Fire Extinguisher Location: 91U
Contact release method available and tested: Upstream breaker or switch

Environmental Conditions

Does the environment present additional hazards that should be addressed?

Insufficient lighting, Insufficient/cramped/awkward space, Noisy environment

Error Precursors

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

Have not preformed simple loto in quite some 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,
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