☑ Mode 0 - Electrically Safe Work Condition ☑ Mode 1 - LOTO & Zero Voltage Verification
QEW Level
QEW 2
Second Person Requirement
Standby Person
Second Person Identified
Mauricio Hercules
Other Participants
Luis Martinez
Affected Persons Notified
N/A
System / Equipment
Switching
Hazardous Switching
Panel / Equipment ID
E238A1A16A34 CT. 3
System Information Review
☑ Arc Flash Labels
Control of Hazardous Energy
Simple LOTO
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
Verify equipment to be worked on (already admin locked out), add LOTO, ZVV, air gap old motor, wire in replacement motor, remove LOTO, re-energize.
Control of Work Area
Minimum Approach Boundary
48”
Barricade Tape / Attendant
Attendant
Shock Risk Assessment
System Voltage
277/480 V ac
Limited Approach Boundary
42 inches
Restricted Approach Boundary
12 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
6 cal/cm2
Arc Flash Boundary
48”
Working Distance
18 inches
Arc Flash PPE Level
2+
Incident Energy Reduction Measures
0
Capacitor Hazards
Capacitor Bus Voltage
None
Capacitor Total Stored Energy (Joules)
None
Discharge Wait Time (Minutes)
None
Emergency Response Plan
Nearest Landline Location
Cell phone
Emergency Number to Call
5104867911
Sufficient Cell Phone Signal
Yes
Clear Exit Path
Yes
AED Location
On hand
Fire Extinguisher Location
Outside 4th floor staircase
Contact Release Method Available and Tested
Voltage gloves
Environmental Conditions
Does the environment present additional hazards that should be addressed?
Lookalike equipment, Noisy environment
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
Notes / Other
Perform Job Briefing
PIC Conducts the Job Briefing. Cover all the contents of the Job Safety Plan.
A Job Briefing at a minimum must include:
Detailed Scope of Work
Shock and arc flash hazards for each task
Controls to mitigate the hazards (procedures, precautions, energy source controls, PPE requirements)
Work area controls (barricades, signs, attendants)
