Time / Date: 7/3/2024 8:15:48
JSP ID: 2725
Scope of Work: Repair damaged wall power receptacle.
Work Order: 389043
Building: 50B
Person in Charge: Alejandro Lopez
Lead / Supervisor: Ramer, Robert
Logged Email: Alopez2@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: n/a
List Other Participants: none
Affected Persons Notified: Yes
Switching: Non-Hazardous Switching
Panel / Equipment ID: 38A4A2A
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

Sequence of Job Steps

List basic sequence of steps from start to finish.

Apply simple LOTO, ZVV, remove damaged receptacle, install new power receptacle, remove simple LOTO, test power outlet and clean work area.

Control of Work Area

Minimum Approach Boundary: 3 inches
Barricade Tape / Attendant: Danger - Red

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: No
Voltage Glove Class: 00
Will any other part of the body enter the RAB: No

Arc Flash Risk Assessment

Incident Energy: 0.41 cals cal/cm2
Arc Flash Boundary: 9 inches
Working Distance: 18 inches
Arc Flash PPE Level: Minimum PPE for Electrical Work
Incident Energy Reduction Measures: 00

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: 5th floor main corridor
Emergency Number to Call: 911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: main corridor 5th floor
Fire Extinguisher Location: main corridor 5th floor
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

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,
Multimeter and other electrical test instruments

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