Time / Date: 9/26/2025 9:07:21
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JSP ID: 4144
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Scope of Work: Install new 208V 20A receptacle in room 110
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Work Order: 445308
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Building: 62
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Person in Charge: Greg Neidiger
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Lead / Supervisor: Ramer, Robert
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Logged Email: gcn@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: Beau Erwin
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List Other Participants:
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Affected Persons Notified: Yes
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Switching: Hazardous Switching
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Panel / Equipment ID: 67A18A
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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
List basic sequence of steps from start to finish.
1) Switch and LOTO at panel 67A-18 2) ZVV at 67A18A 3) perform work 4) inspection 5) release LOTO |
Control of Work Area
Minimum Approach Boundary: 76”
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Barricade Tape / Attendant:
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Shock Risk Assessment
System Voltage: 120/208 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
Incident Energy: Switching - 24.4 ZVV - 16.1 cal/cm2
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Arc Flash Boundary: 76 inches
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Working Distance: 18 inches
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Arc Flash PPE Level: 4
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Incident Energy Reduction Measures: 0
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Capacitor Hazards
Capacitor Bus Voltage:
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Capacitor total stored energy (joules):
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Discharge wait time (minutes):
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Emergency Response Plan
Nearest Landline Location: Rm111
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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: Elevator lobby
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Fire Extinguisher Location: Corridor near rm 115
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Contact release method available and tested: Upstream breaker or switch
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Environmental Conditions
Does the environment present additional hazards that should be addressed?
None |
Error Precursors
Task Demands:
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Work Environment:
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Individual Capabilities:
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Human Nature: Assumptions
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Error Precursor Mitigations:
We are assuming labeling is correct. In the case that labeling is not correct, standby is prepared to take the entire bank in the case of emergency. Care will be taken presume breaker could be mislabeled and the panel will still be energized after switching. |
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
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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:
Rev 2023.08.22.1 Form Content and Feedback Contact: Michael Rose -- mvr@lbl.gov |