Time / Date: 1/20/2023 9:32:03
JSP ID: 472
Scope of Work: Preventive maintenance
Work Order: W0299166
Building:
Person in Charge: Juan Juarez Garcia
Lead / Supervisor: Delgado, Alex
Logged Email: juanjuarez37@gmail.com
Division: Facilities
QEW Level: QEW 2
Modes of Work: Mode 0 - Electrically Safe Work Condition, Mode 1 - LOTO & Zero Voltage Verification
Second Person Requirement: Safety Watch
Second Person Identified: Justin walker
List Other Participants:
Affected Persons Notified: Yes
Switching: Hazardous Switching
Panel / Equipment ID: E38A9A/4–50BAHU027
System Information Review: 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.

Implement LOTO PROCEDURE AND ZVV ,maintenance steps found on task, after maintenance power reconnect using proper PPE for voltage and flash hazards.

Control of Work Area

Minimum Approach Boundary: 77
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: 11.7 cal/cm2
Arc Flash Boundary: 72
Working Distance: 18 inches
Arc Flash PPE Level: 4
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: 1237 room
Emergency Number to Call: 7911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: Outside 1237 to the left
Fire Extinguisher Location: Outside 1237 to the right
Contact release method available and tested: Rescue hook

Environmental Conditions

Does the environment present additional hazards that should be addressed?

Insufficient lighting

Error Precursors

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

Missing step climbing ladder—— using 3 points of contact

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