Time / Date: 12/13/2022 13:10:41
JSP ID: 351
Scope of Work: Preventive maintenance
Work Order: W0299080
Building:
Person in Charge: Darren krans
Lead / Supervisor: Delgado, Alex
Logged Email: juanjuarez37@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: Juan garcia
List Other Participants:
Affected Persons Notified: Yes
Switching: Hazardous Switching
Panel / Equipment ID: E35B15A1A
System Information Review: 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, Not energizing equipment for the first time, or after electrical repair

Sequence of Job Steps

List basic sequence of steps from start to finish.

Id power source , implement LOTO procedures ZVV , perform visual inspection ,tight in screws,check air blower belt, replace air filters, clear condenser drain pipe, reconnect power source to unit, ensure proper performance and temperatures after service.

Control of Work Area

Minimum Approach Boundary: 106
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: 29.5 cal/cm2
Arc Flash Boundary: 106
Working Distance: 18 inches
Arc Flash PPE Level: 4
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: 1st floor
Emergency Number to Call: 7911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: 1st floor
Fire Extinguisher Location: Next to Ac
Contact release method available and tested: Rescue hook

Environmental Conditions

Does the environment present additional hazards that should be addressed?

Insufficient lighting, Fall hazard, Lookalike equipment

Error Precursors

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

Falling off ladder — 2nd person will hold ladder

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