Time / Date: 1/20/2023 8:37:20
JSP ID: 470
Scope of Work: Replace existing twist-lock receptacle with new Hubbell 5461 style.
Work Order: W0292066
Building:
Person in Charge: Greg Neidiger
Lead / Supervisor: Ramer, Robert
Logged Email: gcn@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:
List Other Participants:
Affected Persons Notified:
Switching: Non-Hazardous Switching
Panel / Equipment ID: 67A18A
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.

1) Switch and LOTO circuit 2) Perform ZVV 3) Replace receptacle 4) Release LOTO, energize and test voltage at outlet.

Control of Work Area

Minimum Approach Boundary: n/a
Barricade Tape / Attendant:

Shock Risk Assessment

System Voltage: No Shock Hazard Present
Limited Approach Boundary: 42 inches
Restricted Approach Boundary: 12 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: 16.1 cal/cm2
Arc Flash Boundary: 76in.
Working Distance: No Arc Flash Hazard Present
Arc Flash PPE Level: Minimum PPE for Electrical Work
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:
Emergency Number to Call:
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: elevator lobby
Fire Extinguisher Location: in corridor outside room
Contact release method available and tested:

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:

I am of sound mind and body and I am ready to safely complete my task after reviewing potential error precursors.

PPE Inspections

Notes / Other

At least two upstream OCPDs before 208V equipment. No AF hazard present.

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