Time / Date: 11/14/2022 8:28:53
JSP ID: 226
Scope of Work: Replace burner on 70-BR-013
Work Order: 296774
Building:
Person in Charge: Gerald Fowler
Lead / Supervisor: Delgado, Alex
Logged Email: gdfowler@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: Standby Person
Second Person Identified: Jack Fellman
List Other Participants: Na
Affected Persons Notified: Yes
Switching: Non-Hazardous Switching
Panel / Equipment ID: E30A5A7A1A/70-BR-013
System Information Review: Arc Flash Labels
Control of Hazardous Energy: Complex LOTO (requires LP, CLP, FLP)
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 out 115v breaker and gas valve then replace burner

Control of Work Area

Minimum Approach Boundary: 46 inches
Barricade Tape / Attendant: Warning - Orange

Shock Risk Assessment

System Voltage: 120 Vac
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: 4.14 cal cm2 cal/cm2
Arc Flash Boundary: 36 inches
Working Distance: 18 inches
Arc Flash PPE Level: 2
Incident Energy Reduction Measures: 0

Capacitor Hazards

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

Emergency Response Plan

Nearest Landline Location: Room 177 next door
Emergency Number to Call: 510-486-6999 / 7911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: Main lobby outside of room we are working in
Fire Extinguisher Location: In the room we are in
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:
Work Environment:
Individual Capabilities:
Human Nature: Complacency/overconfidence
Error Precursor Mitigations:

Complacency due to repeated tasks

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