Time / Date: 12/28/2022 7:14:04
JSP ID: 387
Scope of Work: Switch and Troubleshoot cause of Main MCC trip
Work Order: W0307275
Building:
Person in Charge: Joseph Pica (w/ Cameron via phone)
Lead / Supervisor: Cameron, Benjamin
Logged Email: josephpica@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: Justin Solis
List Other Participants: James Harris
Affected Persons Notified: Yes
Switching: Non-Hazardous Switching
Panel / Equipment ID: 304A7A5A7A Main Breaker
System Information Review: Panel Schedules, Arc Flash Labels
Control of Hazardous Energy: LOTO Not Required (Mode 2 or 3 only)
Equipment Condition: Properly installed, Properly maintained, All doors and covers closed and fully latched, No signs of impending failure

Sequence of Job Steps

List basic sequence of steps from start to finish.

Request Permission to Switch Troubleshoot as necessary to isolate potential fault Report Findings Return to Service as applicable

Control of Work Area

Minimum Approach Boundary: 42”
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: .4 calories cal/cm2
Arc Flash Boundary: 9” (>42” for Second Man)
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: Rm 2263 (adjacent)
Emergency Number to Call: 911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: Crew Carry
Fire Extinguisher Location: Hall
Contact release method available and tested: Upstream breaker or switch

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:

Verbatim Repeat Back Second Check Availability of Assistance Standing By

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