Time / Date: 5/7/2024 9:18:23
JSP ID: 2544
Scope of Work: PM 74A AC001
Work Order: 371977
Building: 74a
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: Juan Garcia
List Other Participants:
Affected Persons Notified: N/A
Switching: Non-Hazardous Switching
Panel / Equipment ID: 47a5a9a4a
System Information Review: Panel Schedules, Arc Flash Labels
Control of Hazardous Energy: Simple LOTO
Equipment Condition: Properly installed, All doors and covers closed and fully latched, Not energizing equipment for the first time, or after electrical repair

Sequence of Job Steps

List basic sequence of steps from start to finish.

Loto zvv equipment 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: Less than 1.2 cal/cm2
Arc Flash Boundary: N/A
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: In hallway of 74a
Emergency Number to Call: 6999
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: At unit
Fire Extinguisher Location: On service truck
Contact release method available and tested: Voltage gloves

Environmental Conditions

Does the environment present additional hazards that should be addressed?

Fall hazard

Error Precursors

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

Electrical, falls slips trips and falls

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

No signs of impending failure box would not check for some reason

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