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Time / Date: 4/8/2025 7:02:08
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JSP ID: 3588
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Scope of Work: Investigate old receptacle in room 011A so we can LOTO it to change it to a quad receptacle
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Work Order: 415067
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Building: 80
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Person in Charge: Christopher Nelson
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Lead / Supervisor: Combs, Everett
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Logged Email: cnelson@lbl.gov
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Division: Facilities
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QEW Level: QEW 2
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Modes of Work: Mode 1 - LOTO & Zero Voltage Verification
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Second Person Requirement: Standby Person
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Second Person Identified: David Davis
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List Other Participants:
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Affected Persons Notified: Yes
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Switching: Non-Hazardous Switching
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Panel / Equipment ID: 342A1A19A
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System Information Review: Panel Schedules, Arc Flash Labels
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Control of Hazardous Energy: Simple LOTO
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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.
Use circuit tracer to find panel and circuit. Once verified switch LOTO ZVV and change out receptacle to a 4plex. |
Control of Work Area
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Minimum Approach Boundary: 42
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Barricade Tape / Attendant: Warning - Orange
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Shock Risk Assessment
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System Voltage: 120/240 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: 11 cal/cm2
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Arc Flash Boundary: 72
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Working Distance: 18 inches
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Arc Flash PPE Level: 1
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Incident Energy Reduction Measures: 0
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Capacitor Hazards
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Capacitor Bus Voltage: Na
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Capacitor total stored energy (joules): Na
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Discharge wait time (minutes): Na
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Emergency Response Plan
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Nearest Landline Location: Across the room
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Emergency Number to Call: 911
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Sufficient cell phone signal? Yes
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Clear exit path? Yes
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AED Location: In 15 lobby
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Fire Extinguisher Location:
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Contact release method available and tested: Voltage gloves
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Environmental Conditions
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Does the environment present additional hazards that should be addressed?
Noisy environment |
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: Stress (limits attention)
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Error Precursor Mitigations:
Be alert and keep focused on the task |
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 |