Time / Date: 9/30/2025 7:07:57
JSP ID: 4151
Scope of Work: Terminate and install a low voltage cable in a terminal block box.
Work Order:
Building: 88
Person in Charge: Brendan Ford
Lead / Supervisor: Other
Logged Email: bpford@lbl.gov
Division: Other
QEW Level: QEW 1
Modes of Work: Mode 0 - Electrically Safe Work Condition, Mode 1 - LOTO & Zero Voltage Verification
Second Person Requirement: Not Required
Second Person Identified:
List Other Participants:
Affected Persons Notified: Yes
Switching: Hazardous Switching
Panel / Equipment ID: EJ0
System Information Review: Single Line Drawing
Control of Hazardous Energy: Complex LOTO w/ RI
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.

Open box, cover exposed terminal blocks that are 120VAC with rubber sheeting, terminate low voltage cable on terminals, remove sheeting and close box up.

Control of Work Area

Minimum Approach Boundary: 42
Barricade Tape / Attendant: Notice - Blue, 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: 0
Will any other part of the body enter the RAB: Yes

Arc Flash Risk Assessment

Incident Energy: none cal/cm2
Arc Flash Boundary: none
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: 0 volts
Capacitor total stored energy (joules): none
Discharge wait time (minutes): 0

Emergency Response Plan

Nearest Landline Location: North side of room.
Emergency Number to Call: 911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: In Control Room.
Fire Extinguisher Location: North side of Room by door.
Contact release method available and tested: Rescue hook, Voltage gloves

Environmental Conditions

Does the environment present additional hazards that should be addressed?

Noisy environment

Error Precursors

Task Demands: Critical steps or irreversible acts
Work Environment:
Individual Capabilities:
Human Nature:
Error Precursor Mitigations:

Have attendant verbally verify installation steps.

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

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