☑ Mode 0 - Electrically Safe Work Condition ☑ Mode 1 - LOTO & Zero Voltage Verification
QEW Level
QEW 2
Second Person Requirement
Standby Person
Second Person Identified
Juan
Other Participants
None
Affected Persons Notified
N/A
System / Equipment
Switching
Hazardous Switching
Panel / Equipment ID
420A6A1A11A/ 72 AH 001
System Information Review
☑ Arc Flash Labels
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
Stop VFD, switch at CB, LOTO, ZVV,PM, release LOTO, switch, start at VFD, verify ops
Control of Work Area
Minimum Approach Boundary
42”
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
19.5 cal cal/cm2
Arc Flash Boundary
71”
Working Distance
24 inches
Arc Flash PPE Level
4
Incident Energy Reduction Measures
0
Capacitor Hazards
Capacitor Bus Voltage
NA
Capacitor Total Stored Energy (Joules)
NA
Discharge Wait Time (Minutes)
NA
Emergency Response Plan
Nearest Landline Location
At entrance
Emergency Number to Call
911
Sufficient Cell Phone Signal
Yes
Clear Exit Path
Yes
AED Location
Portable
Fire Extinguisher Location
At entrance
Contact Release Method Available and Tested
Voltage gloves
Environmental Conditions
Does the environment present additional hazards that should be addressed?
Confined space
Error Precursors
Task Demands
Work Environment
Individual Capabilities
Human Nature
Error Precursor Mitigations
Reviewed
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 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)
