Time / Date: 12/12/2022 13:17:07
JSP ID: 344
Scope of Work: LOTO and ZVV DI Water Chiller to separate motor terminations to replace motor
Work Order: W0304680
Building:
Person in Charge: Joseph Colmenares
Lead / Supervisor: Cameron, Benjamin
Logged Email: jcolmenares@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: Pica
List Other Participants: PMTs enroute
Affected Persons Notified: Yes
Switching: Hazardous Switching
Panel / Equipment ID: 72A7A4A breaker34 Local Disconnect
System Information Review: Panel Schedules, Local Labeling
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.

Switch Panel 72A7A4A bkr 34 Disconnect Lock on ZVV Simple LOTO For DI Water Chiller separate motor terminations replace motor Confirm Operation Restore to Service

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: 3 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: 5.6cal 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: 2nd floor Rear Entrance (20’)
Emergency Number to Call: 911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: Wall Mount in Hall & Crew Carry
Fire Extinguisher Location: Wall Mount
Contact release method available and tested: Upstream breaker or switch

Environmental Conditions

Does the environment present additional hazards that should be addressed?

Wet location

Error Precursors

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

Second Checks

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