Time / Date: 10/9/2025 6:53:37
JSP ID: 4174
Scope of Work: E642A9A ckt 40,41 - Finish conduit tie in and wire pull. Land wire on new breaker. E642A4A ckts 33, 35 - Replace breaker with two single pole breakers and finish landing wire. Install hasps. E642A15A ckts 33, 35, 36 finish tie in of conduit and wire. Add new breakers and land wires. For all equipment above, SOW to include: Test per NETA. Inspect per LBL IOR. Receive authorization per EVAP. Execute JSP upon partial release of LOTO.
Work Order: W0459542
Building: 33
Person in Charge: Ben Cameron
Lead / Supervisor: Hendrick, Jeffery
Logged Email: bccameron@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: Andrew Southward
List Other Participants:
Affected Persons Notified: Yes
Switching: Hazardous Switching
Panel / Equipment ID: E642A
System Information Review: Single Line Drawing, Panel Schedules, Arc Flash Labels
Control of Hazardous Energy: Complex LOTO w/ RI
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.

Control of Work Area

Minimum Approach Boundary: 104”
Barricade Tape / Attendant: Attendant

Shock Risk Assessment

System Voltage: 120/208 V ac
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: No

Arc Flash Risk Assessment

Incident Energy: 14.6 cal/cm2
Arc Flash Boundary: 104”
Working Distance: 18 inches
Arc Flash PPE Level: 4
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: Building 33
Emergency Number to Call: 911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: In Van
Fire Extinguisher Location: In hallway
Contact release method available and tested: Upstream breaker or switch, Voltage gloves

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:

None

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