Time / Date: 9/23/2024 13:49:10
JSP ID: 2954
Scope of Work: Add 30 A two pole twist lock receptacle to existing circuits and jbox in ceiling.
Work Order: 396425
Building: 15
Person in Charge: Robert Ralph
Lead / Supervisor: Keusch, Justen
Logged Email: RobertRalph@lbl.gov
Division: ALS
QEW Level: QEW 2
Modes of Work: Mode 1 - LOTO & Zero Voltage Verification
Second Person Requirement: Standby Person
Second Person Identified: Jared Tissot
List Other Participants:
Affected Persons Notified: Yes
Switching: No Switching Required
Panel / Equipment ID: E362A1A
System Information Review: Panel Schedules
Control of Hazardous Energy: Simple LOTO
Equipment Condition: Not energizing equipment for the first time, or after electrical repair

Sequence of Job Steps

List basic sequence of steps from start to finish.

1. Join LOTO 2. Perform ZVV on conductors at existing jbox. 3. Begin installing conduit 4. Pull conductors 5 install receptacle 6. Make up jbox and remove personal locks.

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: 12 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: 9.84 cal cal/cm2
Arc Flash Boundary: 58”
Working Distance: No Arc Flash Hazard Present
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: Inside this room
Emergency Number to Call: 911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: 15 lobby
Fire Extinguisher Location: In this room
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),
Rubber insulating gloves and leather protectors,
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