Time / Date: 1/20/2023 9:04:50
JSP ID: 471
Scope of Work: Perform scheduled maintenance on 50B Ahu 030
Work Order: W0299168
Building:
Person in Charge: Juan Garcia
Lead / Supervisor: Delgado, Alex
Logged Email: jwwalker@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: None
Affected Persons Notified: Yes
Switching: Non-Hazardous Switching
Panel / Equipment ID: 38A1A/ breaker #1
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.

Go over safety briefing and job scope with HVAC lead. Identify panels and switching requirements. Perform AHA and SHA. Fill out JSP form. Contact affected persons. Perform loto and verify ZVV. Perform maintenance. Release loto. Verify unit operations.

Control of Work Area

Minimum Approach Boundary: 42 inches
Barricade Tape / Attendant: Warning - Orange

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: .85 cal/cm^2 cal/cm2
Arc Flash Boundary: 15 inches
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): N/A
Discharge wait time (minutes): N/A

Emergency Response Plan

Nearest Landline Location: 50B 1237
Emergency Number to Call: 911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: In hall outside room 1221
Fire Extinguisher Location: In hall outside room 1237
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?

Fall hazard, Will be working on a ladder. Air handler above ceiling

Error Precursors

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

No current error precursors. Technicians alert and comfortable with job task

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