Time / Date: 7/21/2023 9:33:38
JSP ID: 1292
Scope of Work: Install new GFI
Work Order:
Building: 71T
Person in Charge: Armand Uribe
Lead / Supervisor: Ramer, Robert
Logged Email: Auribe@lb.gov
Division: Facilities
QEW Level: QEW 1
Modes of Work: Mode 1 - LOTO & Zero Voltage Verification
Second Person Requirement: Standby Person
Second Person Identified: Alex lopez
List Other Participants: N/A
Affected Persons Notified: N/A
Switching: Non-Hazardous Switching
Panel / Equipment ID: 354a1a1a1a
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.

JSP. Inspect PPE. Lotto breaker. ZVV receptacle. Install new GFI. Restore power.

Control of Work Area

Minimum Approach Boundary: 18”
Barricade Tape / Attendant: Attendant

Shock Risk Assessment

System Voltage: No Shock Hazard Present
Limited Approach Boundary: 42 inches
Restricted Approach Boundary: Avoid contact
Will the hands enter the RAB: No
Voltage Glove Class: 00
Will any other part of the body enter the RAB: No

Arc Flash Risk Assessment

Incident Energy: 4.6 cal cal/cm2
Arc Flash Boundary: 42”
Working Distance: 18 inches
Arc Flash PPE Level: Minimum PPE for Electrical Work
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: Inside building 71T
Emergency Number to Call: 925-724-3900
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: Inside 71 t
Fire Extinguisher Location: Inside 71T
Contact release method available and tested: Upstream breaker or switch, 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

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