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Gas Distribution Incident or Accident Supplementary Details Form


If you would like to report a notifiable gas accident, you should complete the Event Notification Formwhich will go directly into the Energy Safety Intelligence database. This form below has been provided to allow notifiers to provide additional accident details as required by regulation 33 of the Gas Regulations 1993. This can be done online or by printing it out and posting or faxing it to us.

If you wish to retain a copy, print the form first (use "Save as PDF") and then to send it to Energy Safety (by pressing "Submit"). Submitting the form blanks the fields.

* indicates a mandatory field

Incident Details
(dd/mm/yyyy)
 
(e.g. 22:00)
 
 
Gas type

 
Incident type

 
Environment

 
Losses involved?

 
Notifiable? (Under Gas Act)
 
Equipment type




 
 
Equipment details (Complete as appropriate)
 
Pipes
Material
 
Pressure
 
 
Jointing
 
 
Regulators and Meters
 
 
 
 
Summary of events surrounding incident or accident *
 
Actions to ensure safety at scene
(E.g. Emergency services callout, isolation, odorant check)
 
Description of loss (E.g. Injuries, extent of damage, costs) *
 
Casual factor(s)
(Tick any applicable)












 
Suspected cause(s) and or significant factors *
 
Remedial Action Taken or Recommended
(To minimize the chance of recurrence elsewhere)
 
Person(s) involved and/or reporting incident *
(Names, contacts details and occupations)
 
 
 
Notifier to Energy Safety
 
(dd/mm/yyyy)
 
Other informant(s)
(Names, contact details and occupations of witnesses, investigators, etc) *
 
Other report(s)
(Names and contact details)

Caution: Submitting the form blanks the fields. If you wish to print the form (from "Save as PDF") and submit it on-line you should print it first.

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