Time / Date: 3/19/2025 9:46:15
JSP ID: 3522
Scope of Work: Replace damaged receptacle
Work Order: 429658
Building: B50
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: Not Required
Second Person Identified:
List Other Participants:
Affected Persons Notified: Yes
Switching: Non-Hazardous Switching
Panel / Equipment ID: 25A18A10A-4 and 13
System Information Review: Single Line Drawing, Panel Schedules, Arc Flash Labels
Control of Hazardous Energy: Complex LOTO (requires LP, CLP, FLP)
Equipment Condition: Properly installed, 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) LOTO 25A18A10A-4 and 13 in Rm 6035 2) ZVV at receptacle behind Rockwell drill press 3) Attempt to start drill press fed by circuit 4 4) Replace receptacle 5) Release LOTO 6) Verify voltage and correct wiring with plug tester

Control of Work Area

Minimum Approach Boundary: 68in
Barricade Tape / Attendant:

Shock Risk Assessment

System Voltage: 120/208 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: 9.94 cal/cm2
Arc Flash Boundary: 68in
Working Distance: No Arc Flash Hazard Present
Arc Flash PPE Level: Minimum PPE for Electrical Work
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: Other side of room
Emergency Number to Call: 911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: 4th floor lobby by trash cans
Fire Extinguisher Location: In corridor just outside room
Contact release method available and tested:

Environmental Conditions

Does the environment present additional hazards that should be addressed?

Insufficient/cramped/awkward space

Error Precursors

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

Cramped work area has been cleared

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

Two upstream OCPDs make the switching non-hazardous. Minimum PPE will be used for switching. Voltage rated gloves will be used for ZVV and removing receptacle.

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