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Run: Pipeline Damage Investigation and Reporting Form

A pipeline damage investigation and reporting form for documenting third-party strikes, excavation damage, locate ticket status, impacts, notifications, and ...

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Submission Notice

Submission type (required)

Brief incident summary (required)

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.

Yes No N/A

Incident Overview

Date of incident (required)

Approximate time of incident

Incident location (required)

Enter the site address, nearest intersection, or GPS coordinates if available.

Facility type affected (required)

Incident type (required)

Detailed description of what happened (required)

Locate and Excavation Details

Was a one-call / locate ticket used? (required)

Locate / ticket number

Were locate marks visible at the time of excavation?

Excavation method (required)

Third-party activity at the time of damage (required)

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 (required)

Did anyone get injured? (required)

Injury details

Describe the nature of the injury and any immediate medical response. Do not include unnecessary medical details.

Was there a product release? (required)

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? (required)

Notifications made (required)

Response actions taken (required)

Summarize actions taken to secure the site, stop work, isolate the area, or mitigate the impact.

Root Cause and Follow-Up

Probable cause (required)

Contributing factors

Corrective actions and prevention measures (required)

Describe actions to prevent recurrence, such as retraining, process changes, locate improvements, or contractor follow-up.

Is regulatory reporting required? (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. (required)

Yes No N/A

Signature

Optional signature if your organization requires sign-off for audit trail purposes.

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Email (required)

Your name (optional)

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