Time / Date: 12/5/2022 9:21:39
JSP ID: 304
Scope of Work: Replace breaker in panel E490A1B1A ctkb 7. Switch manual transfer switch and LOTO at that point for ZVV.
Work Order: 304248
Building:
Person in Charge: Anthony Pilz
Lead / Supervisor: Secheck, Stephen
Logged Email: apilz@lbl.gov
Division: Facilities
QEW Level: QEW 2
Modes of Work: Mode 1 - LOTO & Zero Voltage Verification
Second Person Requirement: Standby Person
Second Person Identified: Armand Uribe
List Other Participants:
Affected Persons Notified: Yes
Switching: Hazardous Switching
Panel / Equipment ID: E490A1B1A
System Information 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, Not energizing equipment for the first time, or after electrical repair

Sequence of Job Steps

List basic sequence of steps from start to finish.

Don PPE, Establish boundaries and safety watch. AED and phone located in same room. We will switch the transfer switch to the OFF position and Lock out there. We will ZVV the panel and establish electrically safe condition. Then perform work. And close up panel. Don PPE and switch power back at the manual transfer switch.

Control of Work Area

Minimum Approach Boundary: 8 feet
Barricade Tape / Attendant: Danger - Red

Shock Risk Assessment

System Voltage: 120/208 V ac
Limited Approach Boundary: 42 inches
Restricted Approach Boundary: Avoid contact
Will the hands enter the RAB: No
Voltage Glove Class: 00
Will any other part of the body enter the RAB: No

Arc Flash Risk Assessment

Incident Energy: 11.1 cal/cm2
Arc Flash Boundary: 62 inches
Working Distance: No Arc Flash Hazard Present
Arc Flash PPE Level: 4
Incident Energy Reduction Measures: 00

Capacitor Hazards

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

Emergency Response Plan

Nearest Landline Location: Same room 135
Emergency Number to Call: 510 6314372
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: Across hall in mech room
Fire Extinguisher Location: In hallway outside of room
Contact release method available and tested:

Environmental Conditions

Does the environment present additional hazards that should be addressed?

Insufficient lighting

Error Precursors

Task Demands:
Work Environment: Distractions/interruptions, Unexpected equipment conditions
Individual Capabilities:
Human Nature:
Error Precursor Mitigations:

Brought a light stand for the lighting issue.

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