☑ Arc Flash Labels ☑ Pin n sleeve rec and disconnect
Control of Hazardous Energy
LOTO Not Required (Mode 2 or 3 only)
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
Plug in mo box to pin and sleeve receptacle, test receptacle with multi meter
Control of Work Area
Minimum Approach Boundary
Barricade Tape / Attendant
Attendant
Shock Risk Assessment
System Voltage
No Shock Hazard Present
Limited Approach Boundary
None
Restricted Approach Boundary
None
Will the hands enter the RAB
No
Voltage Glove Class
Not Required
Will any other part of the body enter the RAB
No
Arc Flash Risk Assessment
Incident Energy
<1.2 cal/cm2
Arc Flash Boundary
18”
Working Distance
No Arc Flash Hazard Present
Arc Flash PPE Level
Minimum PPE for Electrical Work
Incident Energy Reduction Measures
Not Required
Capacitor Hazards
Capacitor Bus Voltage
Na
Capacitor Total Stored Energy (Joules)
Na
Discharge Wait Time (Minutes)
Na
Emergency Response Plan
Nearest Landline Location
In this room
Emergency Number to Call
911
Sufficient Cell Phone Signal
Yes
Clear Exit Path
Yes
AED Location
In lobby next room over
Fire Extinguisher Location
In room on south outside wall
Contact Release Method Available and Tested
Upstream breaker or switch
Environmental Conditions
Does the environment present additional hazards that should be addressed?
Noisy environment
Error Precursors
Task Demands
Work Environment
Individual Capabilities
Human Nature
Stress (limits attention)
Error Precursor Mitigations
Keep on the task don’t worry about anything else
PPE Inspections
☑ Safety glasses (ANSI Z87) ☑ Arc-rated clothing (flash suit ☑ daily wear) including face shield ☑ balaclava ☑ hood. ☑ Hearing protection ☑ Non-melting footwear that fully covers the feet ☑ Multimeter and other electrical test instruments
Notes / Other
Testing new outlet on mo box for proper voltage
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)
