Time / Date: 4/14/2025 12:22:43
JSP ID: 3628
Scope of Work: Loto and zvv
Work Order: WO415062
Building: Bldg. 6 ALS
Person in Charge: Mayumi Taylor
Lead / Supervisor: Keusch, Justen
Logged Email: mjtaylor@lbl.gov
Division: ALS
QEW Level: QEW 2
Modes of Work: Mode 1 - LOTO & Zero Voltage Verification
Second Person Requirement: Standby Person
Second Person Identified: Robert Ralph
List Other Participants: N/A
Affected Persons Notified: Yes
Switching: Hazardous Switching
Panel / Equipment ID: Pnl 319A
System Information Review: Panel Schedules, Arc Flash Labels
Control of Hazardous Energy: Complex LOTO w/ RI
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.

Wear appropriate ppe, turn off breakers, Loto and zvv

Control of Work Area

Minimum Approach Boundary: 113inches
Barricade Tape / Attendant: Warning - Orange

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: No
Voltage Glove Class: 0
Will any other part of the body enter the RAB: No

Arc Flash Risk Assessment

Incident Energy: 22.5cal/cm2 cal/cm2
Arc Flash Boundary: 113
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: Inner pit office
Emergency Number to Call: 911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: Lobby
Fire Extinguisher Location: Sector 8
Contact release method available and tested: Voltage gloves

Environmental Conditions

Does the environment present additional hazards that should be addressed?

Confined space, Heavy traffic, Lookalike equipment, Noisy environment

Error Precursors

Task Demands: Simultaneous or multiple tasks
Work Environment: Distractions/interruptions, Changes/departures from routine
Individual Capabilities:
Human Nature: Stress (limits attention), Habit patterns, Assumptions
Error Precursor Mitigations:

N/A

PPE Inspections

Safety glasses (ANSI Z87),
Arc-rated clothing (flash suit,
daily wear) including face shield,
balaclava,
hood.,
Hearing protection,
Rubber insulating gloves and leather protectors,
Non-melting footwear that fully covers the feet,
Removal of conductive articles,
Insulated tools,
Multimeter and other electrical test instruments

Notes / Other

None

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