ELECTRICAL INCIDENT REPORT
SCHEDULE 2
Return to: info@esv.vic.gov.au or
PO Box 262
COLLINS STREET WEST VIC 8007
Attn: Electrical Incidents
Network Infrastructure
1.
Installation (customer side)
Reporting person and business details
Company name:
Title:
2.
Office location:
First name:
Surname:
Phone no.
Incident - Address, Date and Time
Address:
Suburb:
Postcode:
Incident date:
Incident time:
Reported date:
Reported time:
3.
Date attended:
Incident location Type (please tick all relevant boxes)
a)
d)
Agricultural
Commercial
b)
e)
g)
Construction
h)
j)
Other, specify
Industrial
Elec. Supply Substation
or Switch-yard
Public space
c))
f))
Residential
Roadway
i)
Traction asset
4.
Description of the Incident
5.
Cause of incident (if unknown, specify actions taken to come to that conclusion)
6.
Action taken to resolve the incident (and by whom)
7. Work related incident
Did the incident occur during the course of work?
Employer name:
Employer address:
Phone no:
Yes
(provide detail below)
No
8.
Personal details of injured person
First name:
Surname:
Phone number:
Email address:
Residential address:
9.
Injuries and treatment details (please tick all relevant boxes)
Electric shock – no injury
Treatment received:
Electric shock – injury
Burns (flash/electrical)
Medical treatment
Hospitalised
Other (Specify details):
10. Witness details
Name of first witness:
Residential address:
Phone number:
Name of second witness:
Residential address:
Phone number:
11. Investigators details (if different from persons reporting)
Name:
Position Title:
Phone number:
Employed/engaged by:
12. Voltage involved (please tick all relevant boxes)
AC Voltage:
a)
d)
g)
j)
Low Voltage (≤1000V)
11 kV
66 kV
500 kV
b)
e)
h)
k)
2200 V
22 kV
132 kV
Other (specify)
c)
f)
i)
m)
1500 V
n)
6600 V
SWER (12.7 kV)
220 kV
DC Voltage:
l)
o)
600 V
Other (specify)
400 kV
13. Type of contact/fault (please tick all relevant boxes)
a)
d)
Phase to Earth
Phase to Neutral
b)
Phase to Phase
c)
Voltage between points of contact:
3 Phase
14. Network type (please tick all relevant boxes)
a)
Distribution
b)
Transmission
c)
Generation
d)
Train Network
e)
Tram Network
f)
Other (specify)
15. Specify the name of Network Company:
Network Company:
16. Consequence of incidents
If more than one person was affected, please number each accordingly; for example, if a MEC worker caused
a fire and a general public sustained injury, write in the rectangular box: 16Av and 16Bvii
Person affected/involved:
a)
MEC Worker
Incident resulted in:
Environmental
i)
issues
iv)
Fatality- wilful act
vii)
Injury medical
attention
No Go Zone
contact
Other (specify)
x)
xiii)
xvi)
b)
A person other than MEC Worker
ii)
Fatality
(electrocution)
iii)
v)
Fires- due to contact
with assets
vi)
Injury - No medical
attention
Property damagegreater than $50k
Significant
disruption to the
community
ix)
viii)
xi)
xiv)
xii)
xv)
Fatality (indirectly caused
by or involving
electricity)
Fires - electricity related
(other than fires -contact
above)
Loss of supply
Property damage-less
than $50k
Vehicle Impact
Serious risk to public safety
Eg. live conductor on ground or live asset accessible to unauthorised persons
17. Causal Summary (please tick all relevant boxes)
a)
Aircraft/balloon
b)
Asset/equipment failure
c)
Tree
d)
Animals
e)
Neutral fault
f)
Vehicle impact
g)
Building/structure
h)
No Go Zone- O/H
i)
Wilful act/Interference
Electricity supply work
k)
No Go Zone- U/G
l)
Other (specify)
j)
m)
Environment storm/wind/Fire/Flood/Rain/lightning
18. Causal Factor (please tick all relevant boxes)
a)
d)
g)
j)
m)
p)
s)
v)
y)
ab)
ae)
ah)
ak)
Conductor clashing
b)
HV injection
c)
Reverse polarity
Corrosion
e)
f)
Tree falling/blown
Environment lightning
Environment wind/storm
Environment - fire
h)
i)
Tree pruning/clearing
k)
Inadequate
communication
Ignoring established
work practice
Induction
l)
Tree within clearances
n)
Interference- Public
o)
Vandalism
Environment rain/water
q)
InterferenceUnauthorised work
r)
Vehicle collide
pole/tower
Failure-electrical
breakdown
Failure - electrical
overload
Failure mechanical
breakdown
Failure mechanical
overload
Failure mechanical
vibration
Failure insulator
t)
Inadequate training
u)
Vehicle contact conductor
w)
Inadequate PPE
x)
Voltage - Over/Under
z)
Inadequate
Procedures/Process
Incorrect connection
aa)
Wildlife - birds
ad)
Wildlife - insect termite
Inadequate
workmanship
Investigation
inconclusive
Out of balance load
ag)
Wildlife - Other animals
Human error
ac)
af)
ai)
al)
aj)
Other (Specify):
19. Failed Assets (please tick all relevant boxes)
a)
d)
g)
j)
m)
p)
s)
v)
y)
ab)
ae)
ah)
ak)
an)
aq)
ACR (OCR)
b)
Communication
cable/equipment
e)
Connection
(connector/terminatio
n)
Connection box
h)
Earth/ Earthing
n)
Fuse - Boric acid
q)
Fuse - EDO fuse
t)
k)
LV pillar
c)
Metering equipment
f)
OH cable (ABC,
covered conductor)
i)
OH conductor (bare)
11/22/66kV
OH conductor LV
(bare)
OH services
l)
o)
Substation-pole
mounted
Substation- terminal/
zone/ switchyard
Surge diverter
SWER conductor
Switch - Circuit Breaker
r)
Switch - Earth
u)
Switch - (any other type)
x)
Tower
Fuse - Powder filled
w)
OH transmission
conductor
Pole
Fuse- (any other type)
z)
Pole top/cross arm
aa)
Transformer
ad)
UG cable 11/22/66 kV
ag)
UG cable LV
aj)
Fused mains box
ac)
Generator
af)
Protective relays &
associated equipment
Public lighting
Insulators
ai)
Substation equipment
Insulator tie
wires/connections
Isolator
al)
Substation - indoor
am)
ao)
Substation - kiosk
ap)
Other (specify):
20. Any additional information
e.g: additional drawings, photographs, images, reports, etc.
ar)
UG services cable
UG services pit
UG transmission
Voltage Regulator