Information
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Contractor
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Foreman:
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Conducted on
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Prepared by
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Location
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Crew Members:
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Client
- CPA-North 2231 Rochester
- CPA- North 2232 Emlenton
- CPA-North 2234 New Bethlehem
- CPA-North 2238 Bradford
- CPA-North 2239 Warren
- CPA-South 2321 Uniontown
- CPA-Central 2221 Bridgeville
- CPA- Central 2391 Washignton
- CPA-East 2171 Greencastle
- CPA-East 2421 York
- CPA-East 2451 State College
- Peoples Natural Gas
Utility Damage Investigation
Information
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Damage Date:
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What utility line was damaged?
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Was the Emergency One Call System Notified?
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Original One Call #
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Damage One Call #
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Was 911 Called?
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Did the emergency responders arive on the jobsite?
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Utility Company Contacted
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Name of Utility Representative
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Utility Representative Phone Number
Damage Investigation
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Damage Caused By:
- excavator
- air tool
- hand tool
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Damage to:
- Gas Service Line
- Gas Main Line
- Water Main Line
- Water Service Line
- Electric Line
- CATV
- Telephone Line
- Sewer Line
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Line Characteristics:
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Number of lines in pair:
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Depth of utility cover:
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Distance from gas line:
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Distance from markings:
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Line Characteristics:
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Depth of Cover:
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Distance from gas line:
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Distance from markings:
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Line Characteristics:
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Line Voltage:
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Depth of Cover:
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Distance from gas line:
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DIstance from markings:
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Material Type:
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Line Pressure:
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Line Size:
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Depth of Utility Cover:
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Distance from nearest markings:
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Distance from nearest gas utility line or curb valve:
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Distance from nearest sidewalk or street:
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Distance from nearest shut off valve:
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If applicable, did the crew follow proper Emergency Respose Protol (911 notification), Contact Gas Company Personnel, protect life, evacuate the work area, stop all digging, remain upwind, eliminate ll ignition sources, move people away from the area, and never enter into the excavation without proper Stop Work Authority program implementation, and PPE?
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What Could the crew have done differently:
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Were Pre Job Pictures taken?
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Describe events leading up to damage:
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What conditions of the work area contributed to the damages?
- Paint not visible
- Flags not accurate
- Line was miss marked
- Line was not marked
- Paint was not accurate
- Offsets not accurate
- Flags altered or moved
- Lack of visible sign in utility area
- Faded paint
- Flags not present
- Other
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What job factors contributed to the damage?
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What Actions or Indirect Causes and Root Causes lead to the damages?
- Failed to use prudent and due care techniques while excavating
- Hand tools not used around utility
- Used equipment improprely
- Operating Procedures not followed
- Complacency, horseplay, and/or distracted work practices
- 18 inch tolerance zone not utilized or established
- Failed to notify PA One Call
- One Call Ticket Out of Date
- Improper excavation techniques
- Unauthorized actions
- Failed to work within the scope of the PA One Call Ticket
- One Call center error
- Improper excavation methods
- Failure to support exposed utility
- Improper backfilling
- Notification not sufficient
- Facility could not be found or located
- Failed to maintain clearances
- Failed to properly expose utility
- Previous damage
- Wrong information submitted to one call
- Markings not sufficient
- Deteriorated facility
- Failed to maintain marks
- Failed to place spot holes at appropriate distances
- Data not collected
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Recommended Corrective Actions for Prevention:
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Pictures of Damage (Take at least 10 pictures from all angles)
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Provide a sketch of the damage location:
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Signature: