Time / Date: 12/16/2022 8:07:32
JSP ID: 358
Scope of Work: Troubleshoot sump pump MANHOLE 133
Work Order:
Building:
Person in Charge: Colmenares
Lead / Supervisor: Cameron, Benjamin
Logged Email: jcolmenares@lbl.gov
Division: Facilities
QEW Level: QEW 3
Modes of Work: Mode 1 - LOTO & Zero Voltage Verification, Mode 2 - Energized Diagnostics, Testing and Troubleshooting, Visual Inspection
Second Person Requirement: Safety Watch
Second Person Identified: Turner, Cameron
List Other Participants: PMT Fellman
Affected Persons Notified: N/A
Switching: Hazardous Switching
Panel / Equipment ID: 306A switchboard
System Information Review: Single Line Drawing, 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.

Brief, loto, confined space testing, ZVV , troubleshoot sump pump

Control of Work Area

Minimum Approach Boundary: 115 inch
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: Yes

Arc Flash Risk Assessment

Incident Energy: 23.2 cal cal/cm2
Arc Flash Boundary: 115 inch
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: Fire house
Emergency Number to Call: 7911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: On site
Fire Extinguisher Location: N/A
Contact release method available and tested: Voltage gloves

Environmental Conditions

Does the environment present additional hazards that should be addressed?

Insufficient lighting, Wet location, Confined space, Insufficient/cramped/awkward space, Fall hazard

Error Precursors

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

None

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