Utility Strike Report - DDS Companies

• Customer/Client Name

• Project Site Address

• Map Location
  Address

• DDS Reporting Office

  Select

• DDS Division

  Select

• Incident Severity Low: minimal impact and can be handled within work hours. (Example: employee requires minor first aid and returns to work). Medium: business impact (either internal or external) but doesn't significantly impact normal operations. (Example: Utility Strike with no injuries). High: impact warrants immediate response and may disrupt normal operations, these are high priority. (Example: Employee is injured and requires offsite medical attention).

  Select

• Conducted on

  Date

• Prepared by

• Document Number

• What was the date and time of the utility strike?

  Date
• What is the location of the utility Strike?
  Address

• Do we have active and updated location tickets?

  Yes

  No

  N/A

• Please document the ticket number

• What Utility has been damaged?

  Select Electric Natural Gas Sewer Water Telephone Cable Other

  • Electric
  • Natural Gas
  • Sewer
  • Water
  • Telephone
  • Cable
  • Other

• What type of service?

  Service Drop

  Main

  Fiber Optic

• Was a sub-contractor involved?

  Yes

  No

  N/A

• Name of sub-contracted company, including foreman's name and phone number.

• Was the One Call Center Notified?

  Yes

  No

  N/A

• Were the markings visible at the time of the strike?

  Yes

  No

  N/A

• Were the markings accurate?

  Yes

  No

  N/A

• How Deep was the utility at the time of strike?

• What were the utilities marked with?

  Paint

  Flags

  Paint and Flags

  Line was NOT Marked

• What type of markings were present?

  Select Duct Bank (Diamond Pattern) Single Line (With Buffer) Single Line (Without Buffer) Line was NOT Marked

  • Duct Bank (Diamond Pattern)
  • Single Line (With Buffer)
  • Single Line (Without Buffer)
  • Line was NOT Marked

• Add all photos of the strike (Mandatory)

  Media

• What type of digging equipment was being used at the time of the strike?

  Select Back Hoe Track Hoe Boring Equipment Auger Trencher Directional Drill Drilling Hand Tools Skid Steer Dozer Pan Roller Loader Mini-Excavator Other

  • Back Hoe
  • Track Hoe
  • Boring Equipment
  • Auger
  • Trencher
  • Directional Drill
  • Drilling
  • Hand Tools
  • Skid Steer
  • Dozer
  • Pan
  • Roller
  • Loader
  • Mini-Excavator
  • Other

• If you checked "OTHER" Please specify.

• What type of work was being performed?

  Grading

  Utility

  Concrete

  Transportation

• Describe the Incident in Detail.

• Were there any injuries as a result of the utility strike?

  Yes

  No

  N/A

• Did the employee leave the job site to seek medical attention?

  Yes

  No

  N/A

• Eye witness statements

Corrective Actions

• Are corrective/further actions required with regard to this incident?

  Yes

  No

  N/A

• Please add any corrective actions to the appropriate questions above before completing this incident investigation

• Have all required corrective actions been added as Actions to this inspection?

  Yes

  No

  N/A

Root Cause Analysis / Contributing Factors

• What were the contributing factors to this incident occurring? (select all that apply)

  Select Equipment Defects Unauthorized Equipment Use Improper Equipment Use Lack of protective safety devices Employee operating at inappropriate speed Equipment used outside rated capacity Lack of PPE Inappropriate PPE Untidy Conditions (Poor Housekeeping) Safety procedures not followed Inadequate ventilation Drugs or Alcohol Improper Body Position Other

  • Equipment Defects
  • Unauthorized Equipment Use
  • Improper Equipment Use
  • Lack of protective safety devices
  • Employee operating at inappropriate speed
  • Equipment used outside rated capacity
  • Lack of PPE
  • Inappropriate PPE
  • Untidy Conditions (Poor Housekeeping)
  • Safety procedures not followed
  • Inadequate ventilation
  • Drugs or Alcohol
  • Improper Body Position
  • Other

• What other contributing factors?

• A Root Cause Analysis (RCA) is the process of determining the cause of an incident. It requires consideration of all the factors that may have contributed to this incident occurring and deeply understanding the underlying cause. One tactic to determine this is through asking "Why?" five times, to uncover the core of a problem.

• Has the root cause of this issue been able to be identified?

  Yes

  No

  N/A

• Why is the root cause for this issue unable to be identified at this time?

• How likely is this incident to reoccur in future?

  Select Certain Very Likely Likely Unlikely Very Unlikely Never Unclear / Not Determinable

  • Certain
  • Very Likely
  • Likely
  • Unlikely
  • Very Unlikely
  • Never
  • Unclear / Not Determinable

• What is the root cause of this incident? Please consider and include all contributing factors

• Has the root cause of this issue been rectified or eliminated?

  Yes

  No

• How was the root cause rectified or eliminated?

• Please attach any relevant photos or media

  Media

• Please provide any relevant further details

• How likely is this incident to reoccur in future?

  Select Certain Very Likely Likely Unlikely Very Unlikely Never Unclear / Not Determinable

  • Certain
  • Very Likely
  • Likely
  • Unlikely
  • Very Unlikely
  • Never
  • Unclear / Not Determinable

• DDS Foreman name

• DDS Foreman Phone Number

• Name all involved crew members

• Signature of investigator.

  Sign