Time / Date: 12/4/2024 8:42:39
JSP ID: 3163
Scope of Work: Isolate energy source at panel 347A28A circuit 11 for receptacle on 2nd floor ALS building 6 lobby. LOTO, ZVV and remove receptacle faceplate.
Work Order:
Building: 6
Person in Charge: Dave Davis
Lead / Supervisor: Combs, Everett
Logged Email: ddavis@lbl.gov
Division: ALS
QEW Level: QEW 2
Modes of Work: Mode 1 - LOTO & Zero Voltage Verification
Second Person Requirement: Not Required
Second Person Identified:
List Other Participants:
Affected Persons Notified: Yes
Switching: Non-Hazardous Switching
Panel / Equipment ID: 347A28A
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.

Verify circuit and panel, use appropriate ppe for simple LOTO, perform LOTO, attach lock, zvv, remove faceplate

Control of Work Area

Minimum Approach Boundary: 42in
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: 0.13 cal/cm2
Arc Flash Boundary: 5in
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: Al’s building 6 rm2101
Emergency Number to Call: 7911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: Al’s 1st fl lobby
Fire Extinguisher Location: 2nd fl lobby
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: Repetitive actions or monotony
Work Environment: Distractions/interruptions
Individual Capabilities:
Human Nature:
Error Precursor Mitigations:

Maintain focus

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