Utility Damage Report

• Site conducted

  Select

• Conducted on

  Date
• Location
  Address

• Contract Director

  Select

• Contracts Manager

  Select

• Site Foreman

  Select

• Date of Investigation:

  Date

• Investigation by:

• Incident Day and Date:

  Date

• Incident Time:

  Date

• Supervisor:

• Type of Work:

• Incident Address:

Utility Information (Damaged Utility)

• What utility was damaged?

  Select Gas Water Electric BT Virgin Sewer Other

  • Gas
  • Water
  • Electric
  • BT
  • Virgin
  • Sewer
  • Other

• Shown on drawings?

  Yes

  No

• Pressure / Voltage?

  High

  Low

  N/A

• Size of the utility?

• Service / Main

  Main

  Service

• Where is the utility

  Select Overhead Footpath Carriageway Other

  • Overhead
  • Footpath
  • Carriageway
  • Other

• Depth of utility

• Measured or estimated

  Estimated

  Measured

• What caused the damage?

• Ground Conditions

• Operatives Involved

• Qualifications of Operator

  Select CPCS Red CPCS Blue NPORS

  • CPCS Red
  • CPCS Blue
  • NPORS

Event Description (giving details of precautions observed, unsafe acts, location of apparatus/ operative in trench,):

• undefined

Plan Information

• Were plans on site (Attach Photo)

  Yes

  No

• Plans clear and accurate (Attach Photo)

  Yes

  No

• Suitable Risk Assessment (Attach Photo)

  Yes

  No

• Permit to Break Ground (Attach Photo)

  Yes

  No

Location Equipment Information

• Was C.A.T available?

  Yes

  No

• Serial Number

• CAT calibration due

  Date

• Was Genny available?

  Yes

  No

• Genny Serial Number

• Genny calibration due

  Date

• Was C.A.T functioning correctly

  Yes

  No

• Was Genny functioning correctly

  Yes

  No

• C.A.T data available? (Data checked and downloaded)

  Yes

  No

Survey- Prior and During Operations

• Was C.A.T survey completed prior to works commencing?

  Yes

  No

• Was C.A.T used in conjunction with Genny?

  Yes

  No

• Were all located utilities marked prior to excavation?

  Yes

  No

• Which operative completed the C.A.T /Genny Survey?

• What modes were utilised during survey e.g Radio?

  Select Power Radio Genny

  • Power
  • Radio
  • Genny

Operation / Excavation

• Was all underground plant located and marked as required?

  Yes

  No

• Was plant located within 500mm of known services?

  Yes

  No

• Was mechanical excavation used?

  Yes

  No

• If mechanical plant was used, who was the operator

• If hand excavation, what tools were used and by whom

• Was all relevant PPE worn as per the risk assessment?

  Yes

  No

• Was the utility damage avoidable?

  Yes

  No

  N/A

• Any further comments including previous damage history to the same location or different locations?

  Yes

  No

  N/A

Witness Statements

• Witness Statement One

• Witness Statement Two

• Witness Statement Three

• Witness Statement Four

Cause Analysis

• Immediate Cause

• Contributory Causes

• Root Cause(s)

• Action Taken- Corrective Action and Preventative Measures

Check List- The form must not be accepted without the following (list documents attached by reference)

• Utility plans attached

  Yes

  No

• Risk assessment attached

  Yes

  No

• Photographs of damaged utility

  Yes

  No

• Photographs of mark up

  Yes

  No

Completed

• Site Foreman:

  Sign

• Completing Investigation:

  Sign

• Witness Statement One:

  Sign

• Witness Statement Two:

  Sign

• Witness Statement Three:

  Sign

• Witness Statement Four:

  Sign