Time / Date: 12/8/2022 7:47:13
JSP ID: 324
Scope of Work: 1. Remove admin lock from M31A15/70A-GP-50 2. Apply LOTO lock/hasp to M31A15A/70A-GP-50 3. With arc rated ppe & shock protection, perform ZW at 70A-GP-50 DISC and adjacent j-box. 4. ESWC / LOTO Safe Zone established at 70A-GP-50 DISC and adjacent j-box. Perform electrical installation work as required. 5. Remove LOTO from M31A15A/70A-GP-50 6. Replace admin lock on M31A15A/70A-GP-50
Work Order: 294555
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: No Switching Required
Panel / Equipment ID: M31A15A/70A-GP-50
System Information Review: Panel Schedules, Arc Flash Labels
Control of Hazardous Energy: Simple LOTO
Equipment Condition: Not energizing equipment for the first time, or after electrical repair

Sequence of Job Steps

List basic sequence of steps from start to finish.

1. Remove admin lock from M31A15/70A-GP-50 2. Apply LOTO lock/hasp to M31A15A/70A-GP-50 3. With arc rated ppe & shock protection, perform ZW at 70A-GP-50 DISC and adjacent j-box. 4. ESWC / LOTO Safe Zone established at 70A-GP-50 DISC and adjacent j-box. Perform electrical installation work as required. 5. Remove LOTO from M31A15A/70A-GP-50 6. Replace admin lock on M31A15A/70A-GP-50

Control of Work Area

Minimum Approach Boundary: 120
Barricade Tape / Attendant: Danger - Red

Shock Risk Assessment

System Voltage: 120/208 V ac
Limited Approach Boundary: None
Restricted Approach Boundary: 12 inches
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: 9.2 cal/cm2
Arc Flash Boundary: 49 inches
Working Distance: 18 inches
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: Upstairs in main e room
Emergency Number to Call: 510 6314372
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: Upstairs in elevator lobby
Fire Extinguisher Location: In area
Contact release method available and tested:

Environmental Conditions

Does the environment present additional hazards that should be addressed?

Wet location, Insufficient/cramped/awkward space, Noisy environment

Error Precursors

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

All errors are mitigated.

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