Utility Damage Report

• Contractor

• Foreman:

• Conducted on

  Date

• Prepared by

• Location
  Address

• Crew Members:

• Client

  Select 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

  • 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

Information

• Damage Date:

  Date

• What utility line was damaged?

• Was the Emergency One Call System Notified?

  Yes

  No

  N/A

• One Call #

• Was 911 Called?

  Yes

  No

• Did the emergency responders arive on the jobsite?

  Yes

  No

• Utility Company Contacted

• Name of Utility Representative

• Utility Representative Phone Number

Damage Investigation

• Damage Caused By:

  Select excavator air tool hand tool HDD

  • excavator
  • air tool
  • hand tool
  • HDD

• Damage to:

  Select Gas Service Line Gas Main Line Water Main Line Water Service Line Electric Line Communication Telephone Line Sewer Line

  • Gas Service Line
  • Gas Main Line
  • Water Main Line
  • Water Service Line
  • Electric Line
  • Communication
  • Telephone Line
  • Sewer Line

• Line Characteristics:

  Fiberoptic Line

  Conduit

• Number of lines in pair:

• Depth of utility cover:

• Distance from gas line:

• Distance from markings:

• Line Characteristics:

  750 CATV

  500 CATV

  Drop(s)

  Fiberoptic CATV

• Depth of Cover:

• Distance from gas line:

• Distance from markings:

• Line Characteristics:

  primary jacketed line

  primary bare concentric line

  secondary line

  street light line

• Line Voltage:

• Depth of Cover:

• Distance from gas line:

• DIstance from markings:

• Material Type:

• Line Pressure:

• Line Size:

• Depth of Utility Cover:

• Distance from nearest markings:

• Distance from nearest gas utility line or curb valve:

• Distance from nearest sidewalk or street:

• Distance from nearest shut off valve:

• 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?

  Yes

  No

• What Could the crew have done differently:

• Were Pre Job Pictures taken?

  Yes

  No

• Describe events leading up to damage:

• What conditions of the work area contributed to the damages?

  Select 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

  • 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

• What job factors contributed to the damage?

• What Actions or Indirect Causes and Root Causes lead to the damages?

  Select 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

  • 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

• Recommended Corrective Actions for Prevention:

• undefined

• undefined

• Pictures of Damage (Take at least 10 pictures from all angles)

  Media

• Provide a sketch of the damage location:

  Sign

• Foreman Signature:

  Sign

• Supervisor Signature:

  Sign

• Safety Manager Signature:

  Sign

• Manager Signature:

  Sign