Time / Date: 11/14/2022 13:07:06
JSP ID: 230
Scope of Work: PM B46 AC 34
Work Order: 284303
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: Standby Person
Second Person Identified: Mike Capeto
List Other Participants:
Affected Persons Notified: Yes
Switching: Non-Hazardous Switching
Panel / Equipment ID: 253A1A/B46 AC 34
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

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/cm^2 cal/cm2
Arc Flash Boundary: 18”
Working Distance: 18 inches
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: 275C
Emergency Number to Call: 6999
Sufficient cell phone signal? Yes
Clear exit path?
AED Location: Outside 275C
Fire Extinguisher Location: Outside 275C
Contact release method available and tested: Rescue hook

Environmental Conditions

Does the environment present additional hazards that should be addressed?

Fall hazard

Error Precursors

Task Demands: Time pressure (in a hurry), Critical steps or irreversible acts
Work Environment:
Individual Capabilities:
Human Nature:
Error Precursor Mitigations:

Slips, trips and falls

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