Time / Date: 1/6/2023 12:45:31
JSP ID: 411
Scope of Work: Shut off disconnect. LOTO. ZVV in unit panel. Perform PM. Restore power. Check operations
Work Order: 304162
Building:
Person in Charge: Justin Solis
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: Justin Walker
List Other Participants:
Affected Persons Notified: Yes
Switching: Non-Hazardous Switching
Panel / Equipment ID: 212a/ac-3-55a
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.

Contact user. Shut off disconnect. LOTO. ZVV in unit panel. Perform PM. Restore power. Check operations. Give feed back

Control of Work Area

Minimum Approach Boundary:
Barricade Tape / Attendant: Attendant

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

Arc Flash Risk Assessment

Incident Energy: 0.16 cal/cm2
Arc Flash Boundary: 5”
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: Room 100
Emergency Number to Call: 7911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: Room 100
Fire Extinguisher Location: Room 100
Contact release method available and tested: Upstream breaker or switch, 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:

NA

PPE Inspections

Notes / Other

NA

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