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Time / Date: 10/7/2025 7:52:17
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JSP ID: 4166
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Scope of Work: Preventive maintenance
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Work Order: W0307247
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Building: 91
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Person in Charge: Larry antles
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Lead / Supervisor: Delgado, Alex
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Logged Email: juanjuarez37@lbl.gov
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Division: Facilities
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QEW Level: QEW 2
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Modes of Work: Mode 0 - Electrically Safe Work Condition, Mode 1 - LOTO & Zero Voltage Verification
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Second Person Requirement: Safety Watch
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Second Person Identified: Juan Juárez
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List Other Participants: Justin solis ,Antonio collado
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Affected Persons Notified: Yes
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Switching: Hazardous Switching
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Panel / Equipment ID: DP671A9A11A/1-2-4 91AHU002
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System Information Review: Arc Flash Labels
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Control of Hazardous Energy: Complex LOTO (requires LP, CLP, FLP)
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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
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Sequence of Job Steps
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List basic sequence of steps from start to finish.
After the safety briefing we will established LOTO AND ZVV ,removed the access panel to perform visual inspection , thigh in screws and check electrical components, replaced air filters , checked indoor blower components, clean surfaces ,reconnected power supply and performed a system test. |
Control of Work Area
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Minimum Approach Boundary: 42”
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Barricade Tape / Attendant: Attendant
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Shock Risk Assessment
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System Voltage: 277/480 V ac
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Limited Approach Boundary: 42 inches
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Restricted Approach Boundary: 12 inches
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Will the hands enter the RAB: Yes
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Voltage Glove Class: 0
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Will any other part of the body enter the RAB: No
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Arc Flash Risk Assessment
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Incident Energy: 1.45 cal cal/cm2
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Arc Flash Boundary: 20
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Working Distance: 18 inches
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Arc Flash PPE Level: 2+
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Incident Energy Reduction Measures: 0
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Capacitor Hazards
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Capacitor Bus Voltage:
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Capacitor total stored energy (joules):
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Discharge wait time (minutes):
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Emergency Response Plan
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Nearest Landline Location: Building 91 room 424 conference room 4th floor
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Emergency Number to Call: 7911
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Sufficient cell phone signal? Yes
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Clear exit path? Yes
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AED Location: Portable next to us at unit 91AHU002
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Fire Extinguisher Location: 4th floor in front of elevators
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Contact release method available and tested: Rescue hook, Voltage gloves
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Environmental Conditions
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Does the environment present additional hazards that should be addressed?
Fall hazard |
Error Precursors
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Task Demands:
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Work Environment:
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Individual Capabilities:
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Human Nature:
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Error Precursor Mitigations:
Fall hazard- wear fall protection |
PPE Inspections
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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
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Perform Job Breifing
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PIC Conducts the Job Briefing. Cover all the contents of the Job Safety Plan.
A Job Briefing at a minimum must include:
Rev 2023.08.22.1 Form Content and Feedback Contact: Michael Rose -- mvr@lbl.gov |