Time / Date: 1/24/2023 14:00:51
JSP ID: 499
Scope of Work: Replace GCFI outlet for GEM charger
Work Order: W0309556
Building:
Person in Charge: Greg Neidiger
Lead / Supervisor: Secheck, Stephen
Logged Email: gcn@lbl.gov
Division: Facilities
QEW Level: QEW 2
Modes of Work: Mode 1 - LOTO & Zero Voltage Verification
Second Person Requirement: Standby Person
Second Person Identified: AlejandroLopez
List Other Participants:
Affected Persons Notified: N/A
Switching: Hazardous Switching
Panel / Equipment ID: 172A-3
System Information Review: Panel Schedules, Arc Flash Labels
Control of Hazardous Energy: Simple LOTO
Equipment Condition:

Sequence of Job Steps

List basic sequence of steps from start to finish.

Identify circuit. LOTO and ZVV. Replace receptacle. Energize and test.

Control of Work Area

Minimum Approach Boundary:
Barricade Tape / Attendant: Attendant

Shock Risk Assessment

System Voltage: 120 Vac
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: 19 cal/cm2
Arc Flash Boundary: 83in
Working Distance: 36 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:
Emergency Number to Call:
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: 71J
Fire Extinguisher Location: wallkway neasrby
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:

no mitogations

PPE Inspections

Notes / Other

panel is not properly maintained, does not meet normal operating conditions

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