Time / Date: 1/23/2023 11:09:21
JSP ID: 488
Scope of Work: Reset breaker
Work Order: WO307186
Building:
Person in Charge: Balbino
Lead / Supervisor: Keusch, Justen
Logged Email: bmmercadal@lbl.gov
Division: Facilities
QEW Level: QEW 2
Modes of Work: Mode 1 - LOTO & Zero Voltage Verification
Second Person Requirement: Not Required
Second Person Identified: None
List Other Participants: N/A
Affected Persons Notified: Yes
Switching: Non-Hazardous Switching
Panel / Equipment ID: 90A1A
System Information Review: Panel Schedules
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.

Find the right panel, check the schedule panel, bring out pocket guide follow procedure.use PPE for switching safety glasses and leather gloves, non melting clothing.etc. Reset circuit breaker 21 it close but it slowly trip. Am requesting for Fatse 1 to replace defective circuit breaker for corridor emergency lighting in 2 nd floor.

Control of Work Area

Minimum Approach Boundary: 12 in
Barricade Tape / Attendant: Notice - Blue

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

Arc Flash Risk Assessment

Incident Energy: 0.14 cal/cm2
Arc Flash Boundary: 5 in
Working Distance: 18 inches
Arc Flash PPE Level: Minimum PPE for Electrical Work
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: Cell phone
Emergency Number to Call: 510-486-7111
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: Main lobby 1st floor
Fire Extinguisher Location: 1sr floor main lobby
Contact release method available and tested: 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:

N/A

PPE Inspections

Notes / Other

None

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