Time / Date: 9/29/2022 15:05:44
JSP ID: 38
Scope of Work: Shut off disconnect. LOTO. ZVV in unit panel. Perform PM. Restore power. Check operations.
Work Order: 0273798
Building:
Person in Charge: Justin S
Lead / Supervisor: Delgado, Alex
Logged Email: jrsolis@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: Mike Capeto
List Other Participants:
Affected Persons Notified:
Switching: Hazardous Switching
Panel / Equipment ID: 90-AC-48
System Information Review: Arc Flash Labels
Control of Hazardous Energy: Simple LOTO
Equipment Condition:

Sequence of Job Steps

List basic sequence of steps from start to finish.

Control of Work Area

Minimum Approach Boundary:
Barricade Tape / Attendant: Warning

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: 39.6 cal/cm2
Arc Flash Boundary: 101
Working Distance: 101
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: Fourth floor room 4129
Emergency Number to Call: 510-486-6911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: Fourth floor outside room 4035
Fire Extinguisher Location: Fourth floor outside room 4035
Contact release method available and tested: Rescue hook, Voltage gloves

Environmental Conditions

Does the environment present additional hazards that should be addressed?

None

Error Precursors

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

N/A

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