Time / Date: 9/28/2022 10:48:50
JSP ID: 31
Scope of Work: Maintenance on ac unit 69 ac 009
Work Order: 28509
Building:
Person in Charge: Antonio collado
Lead / Supervisor: Delgado, Alex
Logged Email: acollado@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:
List Other Participants: Larry antles
Affected Persons Notified:
Switching: Non-Hazardous Switching
Panel / Equipment ID: 185a, 69 ac 009
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.

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: 2.9 cal/cm2
Arc Flash Boundary: 28 inches
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):
Discharge wait time (minutes):

Emergency Response Plan

Nearest Landline Location: 125
Emergency Number to Call: 6999
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: 123
Fire Extinguisher Location: 123
Contact release method available and tested: Upstream breaker or switch, Voltage gloves

Environmental Conditions

Does the environment present additional hazards that should be addressed?

None

Error Precursors

Task Demands: Time pressure (in a hurry), Critical steps or irreversible acts
Work Environment: Distractions/interruptions
Individual Capabilities: Unfamiliar with, or first time performing task
Human Nature: Stress (limits attention), Mental shortcuts (biases)
Error Precursor Mitigations:

Ladder , make sure to keep 3 point contact.

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