Time / Date: 5/16/2025 7:37:34
JSP ID: 3743
Scope of Work: Troubleshooting unit ac
Work Order: W0441062
Building: 55
Person in Charge: Justin solis
Lead / Supervisor: Delgado, Alex
Logged Email: juanjuarez37@lbl.gov
Division: Facilities
QEW Level: QEW 2
Modes of Work: Mode 0 - Electrically Safe Work Condition, Mode 1 - LOTO & Zero Voltage Verification
Second Person Requirement: Safety Watch
Second Person Identified: Juan juarez
List Other Participants:
Affected Persons Notified: Yes
Switching: Hazardous Switching
Panel / Equipment ID: 513A7A11B1B/55AC043
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.

Wait for safety briefing, implement loto and ZVV protocols, troubleshoot unit ,get parts if necessary, test unit after service.

Control of Work Area

Minimum Approach Boundary: 46
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: No

Arc Flash Risk Assessment

Incident Energy: 7.99 cal/cm2
Arc Flash Boundary: 46”
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: Second floor 55 building front room 230
Emergency Number to Call: 7911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: First floor building 55 at the corner of room 136
Fire Extinguisher Location: Second floor building 55 front of room 226
Contact release method available and tested: Voltage gloves

Environmental Conditions

Does the environment present additional hazards that should be addressed?

Fall hazard

Error Precursors

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

High voltage , performance ZVV accurately

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

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