Utility Strike Investigation

Utility Strike Investigation
Initial Details
Client: *
Workstream:*
Map Group Incident Number:
Client Incident Number (If applicable):
Utility Provider Reference Number:
Company Name:*
Lead Operative:

First NameLast Name
Operative 2:

First NameLast Name
Operative 3:

First NameLast Name
Operative 4:

First NameLast Name
Name of operative who scanned point of work with service location device:*
Name of operative operating excavator/plant (If applicable):*
Name of operative with NRSWA card:*
Contractor Supervisor (If applicable):

First NameLast Name
Map Group UK Supervisor:*

First NameLast Name
Location:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you or have you been on the Map Group UK Permit to Dig Register?*
What task was being conducted?*
Location type:*
Date of strike:*

DayMonthYear
Date
Approximate time of strike:*

Hour Minutes
Was anyone injured as a result of the strike?*
IF STRIKE HAS RESULTED IN AN INJURY, PLEASE CONTACT HSQE DEPARTMENT IMMEDIATLEY.
What utility was damaged?*
Ground conditions:*
Depth of damaged service (mm):*
Equipment being utilised at time of strike:*
Other equipment utilised at time of strike:*

SLG - Full Site Set Up.

Cancelof
Comments:
Service Identification (Spray Markings).

Cancelof
Comments:
Trial Hole(s) - Was a trial hole excavated prior to excavation?

Cancelof
Comments:
Damaged Service - Including warning tape or other service indicators.

Cancelof
Comments:
Depth Of Service - NOTE: DO NOT USE A METALLIC MEASURING DEVICE TO MEASURE ELECTRIC

Cancelof
Comments:
Street Furniture - Joint boxes, street lighting etc.

Cancelof
Comments:
Visual Indicators - HPP (High Pressure Pipeline) markers, demarcation (Toby) boxes, electric sockets etc. If a GAS service has been damaged that is servicing a domestic property, it is vital that photographic evidence is captured of the gas meter housing (if fitted externally) & route of the service to the property.

Cancelof
Comments:

Equipment Involved - Excavator, floor saw, hydraulic breaker, insulated hand tool, drill etc. (include service due dates).

Cancelof
Comments:
Cable Avoidance Tool (CAT) - Include calibration due date.

Cancelof
CAT ID Number (If applicable):*
Comments:
Signal Generator (Genny) - Include calibration due date.

Cancelof
Genny ID Number (If applicable):*
Comments:
Gas Detection Unit (GDU) - Incude days remaining/calibration due date

Cancelof
Comments:
Multi Detector (Pipe/Stud Locator) - Domestic strike only - Photo of detector over the damaged service/area.

Cancelof
Comments:

SWQR/NRSWA (Front & Back)- Minimum of one holder per site

Cancelof
Comments:
Plant Accreditations (Front & Back) - NPORS, CPCS etc.

Cancelof
Comments:
Other Accreditations (Front & Back) - Plant operator, NOPS, CSCS, EUSR, IPAF, PASMA etc

Cancelof
Comments:
POWRA/RA (Front & Back).

Cancelof
Comments:
Utility Plans - All utility plans for the area of works, include date of issue in comments section.

Cancelof
Comments:

Has the site been made safe?
Has the service provider been notified?
Has the service been repaired/restored?
Please provide DNO ref number in comments section.
Comments:
What time was service restored?

Hour Minutes
Comments:
Lead operative description of HOW & WHY the incident occurred.*
I blanks* declare that the above information, evidence & statements are correct & to the best of my knowledge.
Lead Operative Name:*

First NameLast Name
Lead Operative Signature:*

Clear
Investigators closing comments: HOW & WHY the incident occurred, avoidable or unavoidable.*
Name of Investigator:*

First NameLast Name
Signature of Investigator: *

Clear

Corrective Actions

Rows	Actions required	By Whom	Target close out date	Actual close out date
Toolbox talk - HSG47
Toolbox talk - Service location avoidance
Permit to Dig
Re-induction required
Equipment replacement
Yellow/Red cards issued
Retraining
Suspended upon further investigation
Lessons Learned
Other

Initial Details