Time / Date: 12/7/2022 6:53:57
JSP ID: 312
Scope of Work: Repair Switch/ Disconnect
Work Order: W0300711
Building:
Person in Charge: Joseph Colmenares
Lead / Supervisor: Cameron, Benjamin
Logged Email: josephpica@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: J Pica
List Other Participants: Ben Cameron
Affected Persons Notified: Yes
Switching: No Switching Required
Panel / Equipment ID: E671A11A1A9A27 Disconnect BankE773A
System Information Review: New Layout
Control of Hazardous Energy: Simple LOTO
Equipment Condition: Properly installed

Sequence of Job Steps

List basic sequence of steps from start to finish.

Isolate at Disconnect Perform ZVV

Control of Work Area

Minimum Approach Boundary: 42
Barricade Tape / Attendant: Attendant

Shock Risk Assessment

System Voltage: 277/480 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: 3.62cal cal/cm2
Arc Flash Boundary: 42
Working Distance: 18 inches
Arc Flash PPE Level: 2
Incident Energy Reduction Measures: 0

Capacitor Hazards

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

Emergency Response Plan

Nearest Landline Location: N/A
Emergency Number to Call: 911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: Crew Carry
Fire Extinguisher Location: N/A
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:
Error Precursor Mitigations:

Verbatim Repeat Back

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