Time / Date: 4/21/2023 10:17:13
JSP ID: 922
Scope of Work: Air gap the diamond blade saw in building 77 so they can move the equipment safely.
Work Order: 323288
Building:
Person in Charge: Anthony Polz
Lead / Supervisor: Secheck, Stephen
Logged Email: apilz@gmail.com
Division: Facilities
QEW Level: QEW 2
Modes of Work: Mode 1 - LOTO & Zero Voltage Verification
Second Person Requirement: Standby Person
Second Person Identified: Steve Sechak
List Other Participants: Shane Miller
Affected Persons Notified: Yes
Switching: Non-Hazardous Switching
Panel / Equipment ID: 83D
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.

LOTO and ZVV the equipment. Pull line wires out of the disconnect and jam them in a 4 square box with wire nuts safely in the box. Keep an admin lock on the breaker for when the new equipment is put in the same area.

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: 3 inches
Will the hands enter the RAB: Yes
Voltage Glove Class: 00
Will any other part of the body enter the RAB: No

Arc Flash Risk Assessment

Incident Energy: 3.53 cal/cm2
Arc Flash Boundary: 33 inches
Working Distance: 18 inches
Arc Flash PPE Level: 2
Incident Energy Reduction Measures: 00

Capacitor Hazards

Capacitor Bus Voltage:
Capacitor total stored energy (joules):
Discharge wait time (minutes):

Emergency Response Plan

Nearest Landline Location: In immediate work area
Emergency Number to Call:
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: In immediate area
Fire Extinguisher Location: In immediate area
Contact release method available and tested: Voltage gloves

Environmental Conditions

Does the environment present additional hazards that should be addressed?

Noisy environment

Error Precursors

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

Be aware

PPE Inspections

Safety glasses (ANSI Z87),
Arc-rated clothing (flash suit,
daily wear) including face shield,
balaclava,
hood.,
Hearing protection,
Rubber insulating gloves and leather protectors,
Non-melting footwear that fully covers the feet,
Removal of conductive articles,
Insulated tools,
Multimeter and other electrical test instruments

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