Time / Date: 10/11/2022 9:25:05
JSP ID: 74
Scope of Work: Shut off disconnect. LOTO. ZVV in unit panel. Perform Repairs. Restore power. Check operations.
Work Order: 0296344
Building:
Person in Charge: Justin S
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: Larry A
List Other Participants:
Affected Persons Notified:
Switching: Non-Hazardous Switching
Panel / Equipment ID: 55a ac 003
System Information Review: Arc Flash Labels
Control of Hazardous Energy: Simple LOTO
Equipment Condition: Properly installed, All doors and covers closed and fully latched, No signs of impending failure

Sequence of Job Steps

List basic sequence of steps from start to finish.

Control of Work Area

Minimum Approach Boundary:
Barricade Tape / Attendant:

Shock Risk Assessment

System Voltage: 120/208 V ac
Limited Approach Boundary: 42 inches
Restricted Approach Boundary: Avoid
Will the hands enter the RAB: Yes
Voltage Glove Class: 0
Will any other part of the body enter the RAB: Yes

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: Bldg 55 room 143
Emergency Number to Call: 5104866911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: Bldg 55 outside room 143
Fire Extinguisher Location: Bldg 55 outside room 135
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:

None

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