Time / Date: 1/13/2023 8:52:32
JSP ID: 443
Scope of Work: Replace modulating, high limit and low fire modules
Work Order: 291838
Building:
Person in Charge: Larry Antles
Lead / Supervisor: Delgado, Alex
Logged Email: leantles@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: Not Required
Second Person Identified: Gerald Fowler
List Other Participants:
Affected Persons Notified: Yes
Switching: Non-Hazardous Switching
Panel / Equipment ID: 25A1A10A/B50 BR007
System Information Review: Panel Schedules, Arc Flash Labels
Control of Hazardous Energy: Complex LOTO (requires LP, CLP, FLP)
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.

LOTO 25A1A10A CKT 6

Control of Work Area

Minimum Approach Boundary: 42”
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: <1.2 cal/cm^2 cal/cm2
Arc Flash Boundary: 18’
Working Distance: 18 inches
Arc Flash PPE Level: 2
Incident Energy Reduction Measures: 0

Capacitor Hazards

Capacitor Bus Voltage: None
Capacitor total stored energy (joules): None
Discharge wait time (minutes): None

Emergency Response Plan

Nearest Landline Location: Halfway near 4th Floor Elevator
Emergency Number to Call: 6999
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: Next B50 Auditorium
Fire Extinguisher Location: Halfway next to 4008
Contact release method available and tested: Upstream breaker or switch

Environmental Conditions

Does the environment present additional hazards that should be addressed?

Lookalike equipment

Error Precursors

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

Slips, trips and falls, sharp edges

PPE Inspections

Notes / Other

N/A

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