Time / Date: 10/28/2025 7:32:29
JSP ID: 4248
Scope of Work: Preventive maintenance
Work Order: W0451595
Building: 67
Person in Charge: Juan juarez
Lead / Supervisor: Delgado, Alex
Logged Email: juanjuarez37@lbl.gov
Division: Facilities
QEW Level: QEW 2
Modes of Work: Mode 0 - Electrically Safe Work Condition, Mode 1 - LOTO & Zero Voltage Verification
Second Person Requirement: Safety Watch
Second Person Identified: Larry antles
List Other Participants:
Affected Persons Notified: Yes
Switching: Hazardous Switching
Panel / Equipment ID: EM551A4A1A4A4A — 67AHU003
System Information Review: 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.

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 ,reconnected power supply and performed a system test.

Control of Work Area

Minimum Approach Boundary:
Barricade Tape / Attendant: Attendant

Shock Risk Assessment

System Voltage: 277/480 V ac
Limited Approach Boundary: 42 inches
Restricted Approach Boundary: 12 inches
Will the hands enter the RAB: Yes
Voltage Glove Class: 0
Will any other part of the body enter the RAB: No

Arc Flash Risk Assessment

Incident Energy: 14.2 cal/cm2
Arc Flash Boundary: 72”
Working Distance: 18 inches
Arc Flash PPE Level: 4
Incident Energy Reduction Measures: 0

Capacitor Hazards

Capacitor Bus Voltage:
Capacitor total stored energy (joules):
Discharge wait time (minutes):

Emergency Response Plan

Nearest Landline Location: Building 66 side entrance hallway ,first floor
Emergency Number to Call: 7911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: Portable , next to us building 67
Fire Extinguisher Location: Entrance building 67
Contact release method available and tested: Rescue hook, Voltage gloves

Environmental Conditions

Does the environment present additional hazards that should be addressed?

Heavy traffic

Error Precursors

Task Demands:
Work Environment:
Individual Capabilities:
Human Nature:
Error Precursor Mitigations:

Trip hazard, watch our step

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,
Insulated tools,
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