Time / Date: 10/14/2025 10:52:48
JSP ID: 4195
Scope of Work: Demo feed for wire mold receptacles
Work Order: 451868
Building: 2
Person in Charge: Armand uribe
Lead / Supervisor: Secheck, Stephen
Logged Email: AUribe@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: Shane Miller
List Other Participants:
Affected Persons Notified: N/A
Switching: Non-Hazardous Switching
Panel / Equipment ID: 247A4A4A
System Information Review: Panel Schedules
Control of Hazardous Energy: Simple LOTO
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.

We are going to shutdown the panel and demo the feed that powers up the receptacles.

Control of Work Area

Minimum Approach Boundary: 18”
Barricade Tape / Attendant: 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: No
Voltage Glove Class: 00
Will any other part of the body enter the RAB: No

Arc Flash Risk Assessment

Incident Energy: 15.2 cal/cm2
Arc Flash Boundary: 88”
Working Distance: 18 inches
Arc Flash PPE Level: Minimum PPE for Electrical Work
Incident Energy Reduction Measures: 00

Capacitor Hazards

Capacitor Bus Voltage:
Capacitor total stored energy (joules):
Discharge wait time (minutes):

Emergency Response Plan

Nearest Landline Location: Hallway
Emergency Number to Call: 911
Sufficient cell phone signal? Yes
Clear exit path? Yes
AED Location: Hallway
Fire Extinguisher Location: Hallway
Contact release method available and tested: 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),
Rubber insulating gloves and leather protectors

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