Wildanet Service Strike Investigation

• Document No.

• Location
  Address

• Conducted on

  Date

• Prepared by

• Contractor

Incident details

• Date and time of incident;

  Date

• Type of service encountered.

  Select GAS WATER LV HV BT/FIBER OTHER

  • GAS
  • WATER
  • LV
  • HV
  • BT/FIBER
  • OTHER

• Plant type involved.

• Name of Principal Contractor

  Trench Cut

  Jagger Utilities

  Pioneer Utilities

• Site Address that the incident took place.

• Detailed description of location of incident (please be specific, plot numbers, chainage ref etc).

• Service drawings

  Media

• Photos of various aspects of the location of the incident. Do not approach any damaged service in such a way that you may sustain Injury doing so.

  Media

• Weather conditions.

  Select Clear Overcast Fog Snow Rain High Winds Extremely warm day Extremely cold day Dark (Low visibility) Below 0 degrees Celcius

  • Clear
  • Overcast
  • Fog
  • Snow
  • Rain
  • High Winds
  • Extremely warm day
  • Extremely cold day
  • Dark (Low visibility)
  • Below 0 degrees Celcius

Personnel

• Supervisor name

• Banksman name

• Machine operator name

Procedure (HSG 47 Compliance)

• Was a Permit in place for the works?

  Yes

  No

• Where operative briefed on the permit and briefed on any existing services?

  Yes

  No

• Was the area scanned with a CAT & Genny?

  Yes

  No

• CAT Serial Number

• Calibration Date

  Date

• Where trial holes dug to determine depths and direction of services?

  Yes

  No

• Where insulated tools used to hand dig?

  Yes

  No

Plant Used During the Works

• Plant type and serial number

• Are daily plant inspections being completed and recorded?

  Yes

  No

• Is a copy of the thorough examination certificate available?

  Yes

  No

• Do all operatives involved have relevant qualifications to operate plant?

  Yes

  No

Who has been contacted, by who, and when?

• Service Provider informed (Service Strike)

  Yes

  No

  N/A

• Internal H&S Manager / Advisor?

  Yes

  No

  N/A

• Principal Contractor?

  Yes

  No

  N/A

• Client Informed?

  Yes

  No

  N/A

• HSE Informed?

  Yes

  No

  N/A

Witness statements

• Witnesses 1

• Name and signature of the witness 1

• Witnesses 2

• Name and signature of the witness 2

• Witnesses 3

• Name and signature of the witness 3

Action: Short Term

• Contributing causes of the Incident: (Inadequate training, Inadequate supervision. Employee not following correct safety procedures and instructions)

• What was the immediate action taken to correct the issue (how was this done):

• Who was the responsible party for correcting the issue:

Moving forwards

• Lessons Learned:

• What is the long term action needed to correct the issue:

Investigation Conclusions

• Where does the fault fall, and why did this happen?

Person Completing Form (please sign below)

• The above report a true reflection of the Incident to the best of my knowledge.

  Sign