JFL.OSH.057F Strike Investigation Form

• Conducted on

  Date

• Prepared by

• Location
  Address

• Supervisor controlling work for Contractor

• Names of other members of site team

• Subcontractor Involved

  Yes

  No

• Company Name

• Date and time of incident

  Date

• Details of work being undertaken

• Weather at time of incident

  Select Dry Wet Raining Cold Warm Hot Freezing Still Breezy Windy Clear Misty Foggy

  • Dry
  • Wet
  • Raining
  • Cold
  • Warm
  • Hot
  • Freezing
  • Still
  • Breezy
  • Windy
  • Clear
  • Misty
  • Foggy

• Was the work planned or emergency work

  Planned

  Emergency

Strike involved in Excavation

• Was the utility damaged during an excavation activity

  Yes

  No

• Type of carriageway

  Select Footway Footpath Garden Field Public Space Verge Carriageway (Road) Other

  • Footway
  • Footpath
  • Garden
  • Field
  • Public Space
  • Verge
  • Carriageway (Road)
  • Other

• State other and photo

• Service position

  Buried Services

  Overhead

• Surface type

  Select Earth-soft ground Tarmac Concrete Paviors Slabs other

  • Earth-soft ground
  • Tarmac
  • Concrete
  • Paviors
  • Slabs
  • other

• State other and photo

• Ground Type

  Select Gravel Clay Sand Silt Rocky Topsoil Loam/worked agricultural other

  • Gravel
  • Clay
  • Sand
  • Silt
  • Rocky
  • Topsoil
  • Loam/worked agricultural
  • other

• State type and photo

• Plant and Equipment involved in the strike

  Select Insulated hand tools Excavator (including 360 digger) Mole Plough Chain Trencher Cut Saw Road Saw Mechanical Pecker Mechanical Breaker Directional drill Moling equipment Auger Other

  • Insulated hand tools
  • Excavator (including 360 digger)
  • Mole Plough
  • Chain Trencher
  • Cut Saw
  • Road Saw
  • Mechanical Pecker
  • Mechanical Breaker
  • Directional drill
  • Moling equipment
  • Auger
  • Other

• State equipment involved in damage

Strike involved in a Cabling Activity

• Was the utility damaged during a Cabling Activity

  Yes

  No

• Details of work

• Photos

  Media

• Was the utility damaged during tree works

  Select Yes - Work Managed by Construction Yes - Work Managed by Service Delivery No

  • Yes - Work Managed by Construction
  • Yes - Work Managed by Service Delivery
  • No

Utility Damaged

• Type of service damaged

  Select HV Electric LV Electric Street Light High pressure gas Medium pressure gas Gas service Intermediate gas Water mains water service Mains Sewer Rising Main sewer Fibre optic Telecommunication trunk Telecommunication services Media cable Oil pipeline other

  • HV Electric
  • LV Electric
  • Street Light
  • High pressure gas
  • Medium pressure gas
  • Gas service
  • Intermediate gas
  • Water mains
  • water service
  • Mains Sewer
  • Rising Main sewer
  • Fibre optic
  • Telecommunication trunk
  • Telecommunication services
  • Media cable
  • Oil pipeline
  • other

• State type and photo

• Diameter of service damaged (mm)

• Depth of service damaged (mm)

• Expected depth of service type (mm)

• Type of utility service material

  Select Vitrified clay Concrete Cast iron Ductile iron Pitch iron Asbestos UPVC Steel Brick or masonary other

  • Vitrified clay
  • Concrete
  • Cast iron
  • Ductile iron
  • Pitch iron
  • Asbestos
  • UPVC
  • Steel
  • Brick or masonary
  • other

• Type and photos

• Was the service protected by ducting

  Yes

  No

• Utility Status

  Live

  Redundant

  other

• Provide details and photos if other to explain.

Management of Risk

• Point of work completed - include photo or identify number

  Yes

  No

• Permit to dig completed - include photo or identify number

  Yes

  No

  N/A

• Permit to climb completed - include photo or identify number

  Yes

  No

  N/A

• Digging controls used - if no digging tick N/A

  Yes

  N/A

• identify all controls demonstrated by the site team - provide photos to demonstrate.

  Select All utility plans were avaible and to a scale of 1:500 an with 3 months of issue. Some utility plans were avaible and to a scale of 1:500 an with 3 months of issue Plans were in colour CAT and Genny on site CAT and Genny in calibration There is clear evidence of use of the CAT and Genny Site team have been trained and demonstrated competency in using the CAT and Genny Services have been marked up to indicate location within and close to excavation Different coloured paints or flags have been used (correct colours identify appropriate services Safe place to dig located before digging Damaged service had not been identified before damage Protection boards were used to protect exposed service CAT and Genny has been used at 150mm intervals or more frequently as digging occurs Trial pits have been done to locate services prior to digging Exposed services were supported to protect them None of the above were undertaken other

  • All utility plans were avaible and to a scale of 1:500 an with 3 months of issue.
  • Some utility plans were avaible and to a scale of 1:500 an with 3 months of issue
  • Plans were in colour
  • CAT and Genny on site
  • CAT and Genny in calibration
  • There is clear evidence of use of the CAT and Genny
  • Site team have been trained and demonstrated competency in using the CAT and Genny
  • Services have been marked up to indicate location within and close to excavation
  • Different coloured paints or flags have been used (correct colours identify appropriate services
  • Safe place to dig located before digging
  • Damaged service had not been identified before damage
  • Protection boards were used to protect exposed service
  • CAT and Genny has been used at 150mm intervals or more frequently as digging occurs
  • Trial pits have been done to locate services prior to digging
  • Exposed services were supported to protect them
  • None of the above were undertaken
  • other

• Provide any other supporting information - photos and explanation