Pipeline Damage Investigation and Reporting Form

Captures details of a third-party strike or excavation damage to buried facilities, including incident facts, locate/ticket status, response actions, root cause, and regulatory reporting follow-up.

Submission Notice

• Submission type
• Brief incident summary
  One to three sentences describing what was struck, where it occurred, and the immediate outcome.
• Submit anonymously
  Select this if you do not want your identity attached to the submission. Anonymous submission may limit follow-up questions.

Incident Overview

• Date of incident
• Approximate time of incident
• Incident location
  Enter the site address, nearest intersection, or GPS coordinates if available.
• Facility type affected
• Incident type
• Detailed description of what happened

Locate and Excavation Details

• Was a one-call / locate ticket used?
• Locate / ticket number
• Were locate marks visible at the time of excavation?
• Excavation method
• Third-party activity at the time of damage
• Approximate excavation depth at time of strike
  Enter depth in feet or meters using the unit noted in the incident record.

Damage and Impact Assessment

• Observed damage
• Did anyone get injured?
• Injury details
  Describe the nature of the injury and any immediate medical response. Do not include unnecessary medical details.
• Was there a product release?
• Estimated release quantity
  Enter the estimated quantity released using the unit noted in the incident record.
• Immediate public safety actions taken

Response and Notifications

• Reported by
  Name or role of the person submitting the report. Leave blank if submitting anonymously.
• Contact email
  Optional contact information for follow-up questions.
• Were emergency responders notified?
• Notifications made
• Response actions taken
  Summarize actions taken to secure the site, stop work, isolate the area, or mitigate the impact.

Root Cause and Follow-Up

• Probable cause
• Contributing factors
• Corrective actions and prevention measures
  Describe actions to prevent recurrence, such as retraining, process changes, locate improvements, or contractor follow-up.
• Is regulatory reporting required?
• Regulatory reference or report number
  Enter the applicable report number, agency reference, or internal compliance tracking ID.

Attachments and Acknowledgment

• Photos, sketches, and supporting documents
  Upload photos of the damage, locate marks, site conditions, sketches, or related documents.
• I confirm the information provided is accurate to the best of my knowledge.
• Signature
  Optional signature if your organization requires sign-off for audit trail purposes.