Time / Date: 1/6/2023 8:35:20
JSP ID: 405
Scope of Work: Troubleshoot cause of 06 AHU 16 Bkr trip
Work Order: W0307276
Building:
Person in Charge: J. Pica
Lead / Supervisor: Cameron, Benjamin
Logged Email: josephpica@lbl.gov
Division: Facilities
QEW Level: QEW 2
Modes of Work: Mode 1 - LOTO & Zero Voltage Verification
Second Person Requirement: Safety Watch
Second Person Identified: Ben Cameron
List Other Participants: none
Affected Persons Notified: Yes
Switching: Non-Hazardous Switching
Panel / Equipment ID: MCC 304A7A5A7A Bldg06AHU016 Bkr / VFD
System Information Review: Panel Schedules, 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.

Roof Access Permission from Control Room

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: .4cal cal/cm2
Arc Flash Boundary: 42”
Working Distance: 18 inches
Arc Flash PPE Level: 2
Incident Energy Reduction Measures: 0

Capacitor Hazards

Capacitor Bus Voltage: N/A
Capacitor total stored energy (joules):
Discharge wait time (minutes):

Emergency Response Plan

Nearest Landline Location: Hallway
Emergency Number to Call: 911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: Crew Carry
Fire Extinguisher Location: Stairway
Contact release method available and tested: Upstream breaker or switch, Rescue hook, Voltage gloves

Environmental Conditions

Does the environment present additional hazards that should be addressed?

Roof Access

Error Precursors

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

Second Check Verbatim Repeat Back

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