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gSPA-(qqg-y?57-!y5
Form Approved
OMB No 2137-0522
NOTICE This report is required by 49 CFR Part 191 Failure to report can result in a civl penalty not to exceed $25 000 for each violation
for each day that such violation persists except that the maximum civil penalty shall not qxceed $500 000 as provided in 49 USC 1678
@
INCIDENT REPORT - GAS TFANSMISSION AND
GATHERING SYSTEMS
U S Department of Transportation
P pel ne and Hazardous Materials Safety
Repod Date
No
Adm nistration
(DOT Use Only)
I
INSTRUCTIONS
Important: Please read the separate instructions for completing this form before you begm They clarify the
information requested and provide spechc exarrples If you do not have a copy of the instrucfions, you
can obtain one from the Ofice Of Pipeline Safety Web Page at htlp. j)ps_tic>?&t,l
PART A
- GENERAL REPORT INFORMATION I Check one 0 Original Report
0 Supplemental Report
Final Report
Operator Name and Address
a Operator's 5-digit Identification Number (when known) I
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1
b
If Operator does not own the pipeline enter Owners 5-digit ldentificatim Number (when known) I
c
Name of Operator
d
Operator street address
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1
1
e. Operator address
City, County or Parrish, State and Zip Code
2. Time and date of the incident
1
1
1
1
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1
hr
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month
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0 Fatality
a.
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day
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Total number of people: I
Employees. I
year
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3. Location of incident
Nearest street or road
b.
Employees: I
City and County or Parrish
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State and Zip Code
c
0 Property damagelloss [estimated)
d. Mile PostlValve Station
Longitude:
(if not available, see insfructions for how to provide specific location)
g Class location description
Onshore 0 Class 1 0 Class 2
0 Class 1
d.
E.
0 Class 3 0
Class 4
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or Outer Continental Shelf
0
0 Gas ignited - No explosion
Evacuation (generalpublic only)
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1
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I hr.
1
1
1
1
1
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I people
I min.
1
1
NRC Report Number
f5)
1
1
1
1
month
1
I
day
PSIG
c. MAOP established by 49 CFR section:
0 192.619 (a)(l) 0 192. 619 (a)(2) 0 192. 619 (a)(3)
0 192.619(a)(4) 0 192 619 (c)
d. Did an overpressurization occur relating to the incident? OYes 0 No
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Area Code and Telephone Number
(type or print) Preparer's Name and Title
Area Code and Facsimile Number
Preparer's E-mail Address
Date
Form PHMSA F 7100.2 (01-2002)
l
year
PSIG
b. Max. allowable operating pressure (MAOP)'
0 NIA
0 Other
Authorized Signature
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8 a. Estimated pressure at point and time of incident:
- TearlCrack length jmches) - Propagation Length total both sides (feet)
- PREPARER AND AUTHORIZED SIGNATURE
Explosion
7. Telephone Report
4 Type of leak or rupture
0 Leak OPinhole OConnection Failure (complete sec
0 Puncture diameter (mches)
0 Rupture 0 Circumferential - Separation
0 Longitudinal
f.
6. Elapsed time until area was made safe:
h Incident on Federal Land other than Outer Continental Shelf
0 Yes 0 No
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IS pipeline Interstate 0 yes 0 No
PART B
Total $
Reason for Evacuation:
0 Emergency worker or public official ordered, precautionary
0 Company policy
0Threat to the public
Block #
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Release Occurred in a 'High Consequence Area'
c,
(complete rest ofthis item)
Area
State I
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Publidprivate property damage $
f. Latitude:
Offshore
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Operator damage $
Gas loss $
e. Survey Station No.
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GeneralPublic
/
Non-employee Contractors. I
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Injury requiring inpatient
hospitalization
Total number of people. I
b.
a.
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GeneralPubhc:
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Non-employee Contractors: l
I.
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Area Code and Telephone Number
(type or print) Name and Title
Reproduction of this form is permitted
Page I of 3
daterial involved (pipe, fitting, or other component)
Steel
Plastic (If plastic, complete all items that apply in a-c)
Plastic failure was:
a.ductile
b.brittle
c.joint failure
3 Material other than plastic or steel:
3
3
'art of system involved in incident
3 Pipeline
0 RegulatorIMetering System
3 Compressor Station
0 Other:
ear the pipe or component which failed was installed: /
PART E
- ENVIRONMENT
1. Area of incident
0 Under pavement
0 Under ground
0 Insidehnder building
0 In open ditch
0 Above ground
0 Underwater
0 Other:
inches
in year1
PART F -APPARENT CAUSE
a Pipe Coating
0 Bare
0 Coated
.a External Corrosion
1
b Visual Exam
0 Localize(
0 General
0 Other -
d Was corroded part of pipeline consid
0 No
0 Yes, Year Protectr
2 . 0 Internal Corrosion
F2
7
0
6
3
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0
0
Heavy RainsIFloodsa
Temperature
3
2) lnternal Corrosion is checked, complete all subparfs a - e.
c. Cause of Corrosion
0 Galvanic
0 Stray Current
0 Improper Cathodic Protection
0 Microbiological
0 Stress Corrosion Cracking
0 Other:
:d to be under cathodic protection prior to discovering incident?
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1 I
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Xaiied: /
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/
/years /
0 Earthquake
0 Subsidence
0 Landslide
0 Washouts
0 Thermal stress
0 Flotation
0 Frost heave
0 Mudslide
0 Scouring
0 Frozen components
7
/
Imonths
0 Other
HighNnds
8
Operator ExcavatJon Damage jlncluding their contractors) I Not Third Party
0 Other
0 Other
- EXCAVATION
9
0
Third Party Excavation Damage (complete a-d)
a Excavator group
0 General Public 0 Government 0 Excavator other than Operatorlsubcontractor
b Type 0 Road Work 0 Pipeline 0 Water 0 Electrc 0 Sewer 0 PhoneICable 0 Landowner 0 Railroad
0 Other
c Did operator get prior notification of excavation activity7
0 No 0 Yes Datereceived I I I mo I I I day I I I yr
Notification received from
0 One Call System 0 Excavator 0 Contractor 0 Landowner
d Was pipeline marked?
0 No 0 Yes (If Yes check applicable items I- rv)
I Temporary markings
0 Flags
0 Stakes 0 Paint
II Permanent markings
0 Yes 0 No
iii Marks were (check one)
0 Accurate (3 Not Accurate
VI Were marks made within required time?
Yes 0 No
F4 - OTHER OUTSIDE FORCE DAMAGE
10
11
[7
[7
FireIExplosion as primary cause of failure
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tion
itting
rrosion
Lightning
4
5
Earth Movement
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,dcauses in this section Check the box to the left of the primary cause
each of the supplemental items to the right of or below the cause you
is form for guidance.
e Was pipe previously damaged in the area of corrosion?
0 No
0 Yes, How long prio to incident I I
- NATURAL FORCES
3
F3
1
1 /
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2. Depth of cover:
Important: There are 25 numb(
of the incident Check one Circle
indicate See the instructions foi
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a FireIExplosioi cause
0 Man made
Car truck or other vehicle not relating to excavation activity dgmaging pipe
0 Natural
F5 - MATERIAL AND WELDS
Material
14
15
16
c]BodyofPipe
0 Component
0 Joint
3
r,
0 Dent
0 Valve
0 Gasket
0 Gouge
0 Fitting
0 0-Ring
0 W-inkle Bend
0 Vessel
0 Other
0 Other
0 Other
0 Arc Burn
0 Extruded Outlet
0 Threads
Weld
17
[7
Butt
=3
0 Pipe
18
0
Fillet
3
0 Branch
0 Fabrication
0 HotTap
Pipe Seam
3
o LF ERW
o DSAW
0 F tting
0 S2amless
OHFERW
OSAW
0 Sp,ral
19
Complete a-g I f you IndIcafe any cause in part F5
[7
Construction Defect
3
0 Other
1 -4.
-
a Type of failure
0 Procedure not followed
0 Poor Workmanship
0 Other
0 Other
0 Repair Sleeve
0 Flash Weld
0 Poor Construction Procedures
c] Material Defect
0 Yes
b Was failure due to pipe damage sustained in transportation to th? construction or fabrication site?
c Was part which leaked pressure tested before incident occurred'' 0 Yes complete d-g 0 NO
d Dateoftest
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e Test medium
0
Water
I mo
f Time held at test pressure
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0
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Natural Gas
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l
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I day
0
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F6
0
Inert Gas
Other
I hr
PSlG
- EQUIPMENT AND OPERATIONS
0
Malfunction of ControllRelief Equipment
3
21
Threads Stripped Broken Pipe Coupling
3
22
Ruptured or Leaking SeallPump Packing
23
NO
I yr
g Estimated test pressure at point of incident
20
0
0
Incorrect Operation
0 Inadequate Procedures
a Type
0 Valve 0 lnst-umentation 0 Pressure Regulator
0 Nipples 0 Val\ e Threads 0 Mechanical Couplings
0 Other
0 Other
0 Inadequate Safety Prictices 0 Failure to Follow Procedures 0 Other
b Number of employees involved who failed post-incident drug te5t I
c Were most senior employee(s) involved qualified?
0
Yes
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0
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l Alcohol test I
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d Hours on duty I
No
F7 -OTHER
24
25
0
0
Miscellaneous, descnbe
Unknown
0 Investigation Complete
0 Still Under Investigation (submit a supplemental report when invesbgahon IScomplete)
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PART G - NARRATIVE DESCRIPTION OF FACTORS CONTRIBUTING 70 THE EVENT
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(Attach addlbonal sheets as necessav)
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Form PHMSA F 7100.2 ( 01-2002 )
Page 3 o f 3
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INSTRUCTIONS FOR FORM PHMSA F 7100.2 (01-2002)
INCIDENT REPORT - GAS TRANSMI; 3ION AND GATHERING SYSTEMS
GENERAL INS' XUCTIONS
Each gas transmission or gather! ig system operator shall
file Form PHMSA F 7100.2 for an incident that meets the
criteria in S191.3 as soon as pral ticable but not more than
30 days after the incident.
Ope :ator, distribution line,
gathering line, and transmission 1 ne are defined in §191.3
Code of Federal Regulations (CFR). Liquid natural gas (LNG)
facility operators are exempt from filing reports in
§191.15(c).
Releasing gas dur: ig maintenance or other
reported if the only
routine activities need not bt
reportable criteria met is losing gas of $50,000 or more as
defined in §191.3 (1)(it).
Damage from secondary ignition ne d not be reported unless
the damage to facilities subje t to Part 192 exceeds
$50,000. Secondary ignition is a gas fire where the cause
is unrelated to the gas facili ies, such as electrical
fires, arson, etc.
Please sub it reports according to
§191.7. If you have questions a1 )ut this report or these
instructions or need copies of Fc .m PHMSA F 7100.2, please
write to Roger Little, Informati In Resources Manager, or
call (202)366-4569. All forms ar I instructions are on the
OPS home page, http://ops.dot.qov.
SPECIAL INSTRU 'TIONS
If the data is
An entry should be made in eack block.
Please avoid Unknown
unavailable, please enter Unknow .
data is preferable to
entries if possible.
Est imatec
unknown data.
If Unknown or ec ;imated data entries are
made, a supplemental report shou. 3 follow if the operator
If the block is not
learns the answers to the questic is.
applicable, please enter N/A.
In blocks requiring numbers, all : locks should be filled in
When decimal points are
using zeroes when appropriate.
required, the decimal point shoul be placed in a separate
block.
Examples: (Part 5) Nominal Pipe ;ize
/0/0/2/4/ inches
/1/./5/0/inches
Wall Thic: iess
/./5/0/0/
inches
inches
If OTHER is checked, include an t | File Type | application/pdf |
| File Modified | 2007-04-05 |
| File Created | 2007-04-05 |