Title Page
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Project Number
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Client / Site name
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Conducted on
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Prepared by
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Location
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Date and time incident took place
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Operator name
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Were pictures taken
Location of Event
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Street address of strike
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What is the nearest intersection
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Right of way where event occurred
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Public:
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Private:
- Private Business
- Pipeline
- Federal Land
- Private Land Owner
- Power / Transmission Line
- Railroad
- Private Easement
- Ddicated Public Utility Easement
- Unknow/ Other
- Data not collected
Affected Facility Information
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What type of facility operation was affected?
- Cable Television
- Electric
- Natural Gas
- Sewer
- Storm
- Steam
- Fiber
- Telecommunications
- Water
- Unknown/ Other
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What type of facility was affected?
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Was the facility part of a joint trench?
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Was the facility owner a member of One-Call Center?
Excavation Information
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Type of Excavation Equipment Used?
- Backhoe/Trackhoe
- Grader/Scraper
- Hand Tools
- Auger
- Explosives
- Probing Divice
- Farm quipment
- Trencher
- Boring
- Vacuum Equipment
- Drilling
- Directional Drilling
- Unknown/Other
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Type of Work Being Performed?
- Curb/Sidewalk
- Survey
- Liquid Pipeline
- Site Development
- Traffic Sign
- Bldg. Construction
- Fencing
- Bldg. Demolition
- Grading
- Storm Drain/ Culvert
- Waterway Improv.
- Driveway
- Irrigation
- Road Work
- Street Light
- Landscaping
- Sewer
- Traffic Signal
- Water Main/ Service
- JUT
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Was the facility pot-holed before excavation?
Notification
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Was the One-Call Center Notified?
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If yes, please provide the ticket number
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Were facility marks visible in the area of the excavation?
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Were Facilities marked correctly?
Excavator Downtime
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Did the excavator incur downtime?
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If Yes, how much time?
- Unknown
- Less than1 hour
- 1 hour
- 2 hours
- 3 or more hours
- Exact Value
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Estimated cost of downtime?
- Unknown
- $0
- $1-500
- $501-1,000
- 1,001-2,500
- Exact Value
Description of Damage
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Was there damage to a facility?
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Did the damage cause an interruption in service?
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If yes, how long was service interrupted?
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Approximately how many customers were affected?
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Estimated cost of damage / repair/ restoration?
- Unknown
- $0
- $1-1,000
- 1,001-5,000
- 5,001-10,000
- Over 10,000
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Number of people injured?
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Number of fatalities?
Description of the Root Cause
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One-Call Notification Practices Not Sufficient
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Locating Practices Not Sufficient
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Excavation Practices Not Sufficient
- Failure to maintain marks
- Failure to support exposed facilities
- Failure to use hand tools when required
- failure to test-hole (pot-hole)
- Improper backfilling practices
- Failure to maintain clearance
- Other insufficient excavation practices
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Miscellaneous Root Causes
- One-Call Center error
- Abandoned facility
- Deteriorated facility
- Previous damage
- Data Not Collected
- Other
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Additional Comments:
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Please add detailed photos:
