☑ Mode 0 - Electrically Safe Work Condition ☑ Mode 1 - LOTO & Zero Voltage Verification
QEW Level
QEW 1
Second Person Requirement
Not Required
Second Person Identified
Other Participants
Affected Persons Notified
Yes
System / Equipment
Switching
Non-Hazardous Switching
Panel / Equipment ID
A2432
System Information Review
☑ LOTO procedure E3-10 hazard analysis
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
Perform LOTO procedure E3-10, remove A2432 alarm chassis and replace with a new chassis, remove LOTO
Control of Work Area
Minimum Approach Boundary
3 inches
Barricade Tape / Attendant
Warning - Orange
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
No
Arc Flash Risk Assessment
Incident Energy
N/A cal/cm2
Arc Flash Boundary
N/A
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
Capacitor Total Stored Energy (Joules)
Discharge Wait Time (Minutes)
Emergency Response Plan
Nearest Landline Location
Control room
Emergency Number to Call
Sufficient Cell Phone Signal
Yes
Clear Exit Path
Yes
AED Location
Control room
Fire Extinguisher Location
Control room
Contact Release Method Available and Tested
Environmental Conditions
Does the environment present additional hazards that should be addressed?
None
Error Precursors
Task Demands
Work Environment
Individual Capabilities
Unfamiliar with, or first time performing task
Human Nature
Error Precursor Mitigations
Carefully follow JSP and LOTO procedure
PPE Inspections
☑ Safety glasses (ANSI Z87) ☑ Rubber insulating gloves and leather protectors ☑ Non-melting footwear that fully covers the feet ☑ Removal of conductive articles ☑ Multimeter and other electrical test instruments
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)
