Utility Damage report form

• Site conducted

• Conducted on

  Date

• Prepared by

  Alan Milford

  Paul Sainsbury

  Aaron Hitchen
• Location
  Address

• Incidental details

• Date of Incident and time

  Date

• Depot/Office

• Reported Date and time

  Date

• Individuals Involved

• Reported By

• Contact number

• Team Manager

• Senior Manager

• Safety Rep Included in the Investigation

• Other person(s) Involved

• Location (address details, including post code)

Investigation details

• undefined

Incident details

• Site Specific Risk Assessment Carried out?

  Yes

  No

  N/A

• Details of work activity being undertaken

• Did the Manager attend site on the day?

  Yes

  No

  N/A

• Other Utility Informed?

  Yes

  No

  N/A

• Name of Other Utility

• Who damaged the cable/utility?

• Description of Incident

• What occurred when the cable/utility was struck?

• - Fire

  Yes

  No

  N/A

• - Flash

  Yes

  No

  N/A

• - Explosion

  Yes

  No

  N/A

• - Bang

  Yes

  No

  N/A

• Details of any injury or medical treatment received (if applicable)

• Did this have any impact on the environment?

  Yes

  No

  N/A

• What type of utility was damaged (LV, HV, service, main etc)?

• What was it damaged by?

• Was the utility in footpath, carriageway or private?

• Were Utility Plans available, read and understood?

  Yes

  No

  N/A

• Was the Cat and Genny used in all three modes?

  Yes

  No

  N/A

• Was Cat 4 used?

  Yes

  No

  N/A

• If so has embedded information been interrogated by a responsible Manager?

  Yes

  No

  N/A

• Were rechecks carried out with the Cat at different levels? (If so, rechecking with the Cat was carried out every mm)

  Yes

  No

  N/A

• Has the Cat and Genny been tested on site?

  Yes

  No

  N/A

• Was an air lance available?

  Yes

  No

  N/A

• Was an air lance used?

  Yes

  No

  N/A

• If an air lance wasn't used, please detail why not

• Were conditions / ground type suitable for the air lance to be used?

  Yes

  No

  N/A

• Did the Team rely on other people's markings?

  Yes

  No

  N/A

• Was the cable/utility located and marked?

  Yes

  No

  N/A

• Was ground penetrated within 250mm of marked indication?

  Yes

  No

  N/A

• Were Safe Digging Practices being used near known plant?

  Yes

  No

  N/A

• Was Mechanical Plant used within 500mm?

  Yes

  No

  N/A

• Was Plant used as a step to exit hole?

  Yes

  No

  N/A

• Were Trial Holes used to physically locate cable?

  Yes

  No

  N/A

• EQUIPMENT LIST:

• CAT (Locator)

  Yes

  No

  N/A

• GENNY (Transmitter)

  Yes

  No

  N/A

• Connection Cable (Clip/Magnet)

  Yes

  No

  N/A

• Ground Cable Reel

  Yes

  No

  N/A

• Ground Stake

  Yes

  No

  N/A

• Signal Clamp

  Yes

  No

  N/A

• Plug Connector

  Yes

  No

  N/A

• Has the Plant & Equipment Monthly Checks Sheet been completed? *If required, team manager to order

  Yes

  No

  N/A

Investigation findings

• undefined

Cause and conclusion

• IMMEDIATE CAUSE: (simply what caused the Incident/Injury) e.g. cable struck with shovel, graft, fork or falling object whilst hand digging

• undefined

• CONCLUSION:

• undefined

• Include whether the damage was due to Site Conditions/Plant & Equipment/Procedural or Human Behaviour

• What procedures were used/supposed to be used In this activity?

• Appendix

  Media

Appendix

• Is a risk assessment included?

  Yes

  No

  N/A

• Is there additional information not covered in the investigation?

• Is the information in the document purely factual?

  Yes

  No

  N/A