Time / Date: 7/12/2024 13:13:13
JSP ID: 2752
Scope of Work: Replace convenience wall power receptacle.
Work Order: 388997
Building: 55
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: n/a
Affected Persons Notified: N/A
Switching: Non-Hazardous Switching
Panel / Equipment ID: 29A15A1A
System Information Review: Panel Schedules,
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.

LOTO circuit 29A15A1A-23, ZVV and replace wall power receptacle, remove LOTO and test power receptacle.

Control of Work Area

Minimum Approach Boundary: 42 inches
Barricade Tape / Attendant: Danger - Red

Shock Risk Assessment

System Voltage: 120 Vac
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: 4.23 cal/cm2
Arc Flash Boundary: 40 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: main corridor
Emergency Number to Call: 911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: main corridor
Fire Extinguisher Location: main corridor
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