☑ Mode 0 - Electrically Safe Work Condition ☑ Mode 1 - LOTO & Zero Voltage Verification
QEW Level
QEW 2
Second Person Requirement
Standby Person
Second Person Identified
Andrew S
Other Participants
Affected Persons Notified
Yes
System / Equipment
Switching
Hazardous Switching
Panel / Equipment ID
596A1A1A39A breaker 1, 3, 5
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 is ready to be de-energized, don appropriate PPE, switch, loto, ZVV, perform PM, return to normal operation when work is complete.
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
2.09 cal/cm2
Arc Flash Boundary
24”
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
In room outside elevator
Contact Release Method Available and Tested
Voltage gloves
Environmental Conditions
Does the environment present additional hazards that should be addressed?
Lookalike equipment
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 ☑ 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)
