7100.1 Incident Reports - Gas Distribution Systems

L\bW 'Iz
NOTICE This report is required by 49 CFR Part 191 Failure to report can result tr
for each day the violation continues up to a maximum of $1 000,000 for any relatec

~ S ~ A - \ % -4457-IY-4
%
:ivtl penalty not to exceed $100 000 for each violation
Form Approved
rtes of violations as provided in 49 USC 60122
OMBNo 2137-

0522

@

INCIDENT REPORT - GAS C

S Depaflment of Transportation
Pipelineand Hazardous Materials Safely
Adm~nislrallon
INSTRUCTIONS
U

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Important: Please read the separate instructions for completii
and provide specific examples If you do not have
Pipeline Safety Web Page at la13 op\ dot "o\
PART A

- GENERAL REPORT INFORMATION I Check: 0 Origin:

this form before you begin. They clarify the information requeste
copy of the instructions, you can obtain one from the Office Of

0 Supplemental Report

ieport

Final Report

I . Operator Name and Address
a. Operator's 5-digit Identification Number I

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b. If Operator does not own the pipeline, enter Owner's 5-digit Identifit

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ion Number1

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c. Name of Operator
d. Operator street address

-

e. Operator address
City, County or Parish, State and Zip Code

..........._........~.~.....~.......~....~~~~..~~~.~...~.~...~~~......~~....~~~~.~...~~~..~.~..~.....~.....

5.

2. Time and date of the incident
l

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l l
hr.

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l

l

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month

l

l
day

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l

l
year

onsequences (check and complete all that apply)
0 Fatality
Total number of people: I

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Employees: I

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Non-employee Contractors. I

3 Incident Location

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GeneralPublic- I

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Injury requiring inpatient hospitalization

a.
Street or nearest street or road

Total number of people: I

b
City and County or Parish

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Employees. I

C.

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/

Non-employee Contractors: I

State and Zip Code

0 Class 3 0

f. Incidenton Federal Land

0 Yes 0 No

Gas loss $

Class 4

0 Leak: OPinhole OConnection Failure (complete sec. F5)
0 Puncture, diameter or cross section (inches)__
0 Rupture (if applicable):
Circumferential - Separation

0

Longitudinal

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Total $

Operator damage $

Publidprivate property damage $

1. Type of leak or rupture

0

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0 Property darnagelloss (estimated)

d. Latitude: I I I I I
I Longitude: I I I I I I
(if not available, see instructionsfor how to provide specific location)
e. Class location description
0 Class I 0 Class 2

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General Public- I

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0

Gas ignited

0

0

Gas did not ignite

0 Explosion 0 No Explosion

7

Evacuation (generalpubliconly)

Explosion

0 No Explosion

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I people

Evacuation Reason:
0 Unknown
0 Emergency worker or public official ordered, precautionary
0Threat to the public
0 Company po~tcy

- TearlCrack. length (inches)

6.

apsed time until area was made safe:

7.

tlephone Report

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- Propagation Length, total, both sides (feet)

0 NIA
0 Other:

1

a.

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/ hr.

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/ / 1 / 1 1
NRC Report Number

I min.

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month

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day

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year

Estimated pressure at point and time of incident:

PSlG
Max. allowable operating pressure (MAOP)
MAOP established by.

0Test Pressure
049 CFR 5 192. 619 (a)(3)
'ART B - PREPARER AND AUTHORIZED SIGNATURE

1
Area Code and Telephone Number

ype or print) Preparer's Name and Title

Area Code and Facsimile Number

reparer'sE-mail Address

uthorized Signature

Psig

(type or print) Name and 7

_ _ _ _ _ _
Date

Area Code and Telephone Number

P SIG

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PART C - ORIGIN OF THE INCIDENT

Material involved (pipe ffff/ng or other component)
0 Steel
0 CastANrought Iron
0 Polyethelene Plastic (complete all items that apply in a-c)
0 Other Plastic (complete all items that apply in a-c)
Plastic failure was 0 a ductile [7 b brittle 0 c joint failure
0 Other material

1 Incident occurred on

0 Main
0 MeterSet
0 Service Line 0 Other
0 Pressure Limiting and Regulating Facility
Failure occurred on
0 Body of pipe
0 Joint
0 Other

2

0 Pipe Seam
0 Component

Year the pipe or component which failed was installed I

1 PART E - ENVIRONMENT

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0 In open ditch
0 Above ground
0 Underwater
0 Other

1 Area of incident
0 Under pavement
0 Under ground
0 lnsidelunder building

in year1

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Important: There are 25 num !red causes in this section. Check the box to the left of the primary
cause of the incident. Check ie circle in each of the supplemental items to the right of or below
the cause you indicate. See t instructions for this form for guidance.

PART F -APPARENT CAUSE

1

(2) lnternal Corrosion is checked, complete all subparts a - e.

a Pipe Coating
I

0
0
0

.OExternal Corrosion

Internal Corrosion

'3

c. Cause of Corrosion
0 Galvanic
0 Stray Current
0 Improper Cathodic Protection
0 Microbiological
0 Other:

d Was corroded part of pipeline consi( red to be under cathodic protection prior to discovering incident?
0 No
0 Yes 0 Unknow
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Year Protection Started: I

!.a
'2

Bare
Coated
Unknown

b Visual Exan Nation
0 Localize Pitting
0 General orrosion
0 Other -

e Was pipe previously damaged in the rea of corrosion?
0 No
0 Yes 0 Unknoh
How long prior to incident:

I

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lyears I

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lmonths

- NATURAL FORCES
3

Earth Movement

4

Lightning

5

Heavy RainsIFloods 3

6

Temperature

7

High Winds

I
)

3

0 Earthquake

0 Subsidence

0 Landslide

0 Washouts
0 Thermal stress

0 Flotation

0 Mudslide
0 Scouring
0 Frozen components

0 Frost heave

0 Other:
0 Other:
0 Other:

- EXCAVATION
Operator Excavation Damage (mcluding their contractors) I Not

8

9

iird Party

Third Party Excavation Damage (complete a-d)
a Excavator group
0 General Public 0 Government 0 Excavator othe Ian Operatorlsubcontractor
0 Road Work 0 Pipeline 0 Water 0 Electri 0 Sewer 0 Phone/Cable/Fiber 0 Landowner 0 Railroad
b TvDe
,.
0 Building Construction
0 Other:
c. Did operator get prior notification of excavation activity?
0 No 0 Yes: Date received: I I / mo. / / I day I / / yr.
Notification received from. 0 One Call Systen 0 Excavator 0 General Contractor 0 Landowner
d. Was pipeline marked?
0 No 0 Yes (If Yes, check appkable items I - Iv)
i. Temporary markings:
0 Flags
0 Stakes 0 Paint
ii. Permanent markings:
0 Yes
No
iii. Marks were (check one)
0 Accurate
Not Accurate
iv. Were marks made within required time? 0 Yes 0 No
OTHER OUTSIDE FORCE DAMAGE

c

c)

'4 -

IO.

0

11.

12.

FireIExplosion as primary cause of failure

FireIExplosion cause:

0 Man made

0 Natural

Descrfbe in Part G

Car, truck or other vehicle not relating to excavation activity dariaging pipe

u

Rupture of Previously Damaged Pipe

13.
Vandalism
orm PHMSA F 7100.1 (03-04 )

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F5 - MATERIAL OR WELDS
Material
14

0

BodyofPipe

2

Component

3

0

Joint

3

Butt

=>

Fillet

3

Pipeseam

3

15

16

0 Dent

0 Gouge

0 Wrinkle Bend

0 Valve
0 Gasket

0 Fitting
0 0-Ring

0 Threads

0 Pipe
0 Branch

0 Fabrication
0 Hot Tap

0 Fitting

0 Vessel

0 Arc Burn
0 Extruded Outlet
0 Fusion

0 Other
0 Other
0 Other

Weld
17

18

19

0
0
0

o LF ERW

o DSAW

0 Seamless

0 HFERW

0 SAW

0 Spiral

Complete a-f If you mdcate any cause /n part F5

0 Repair Sleeve
0 Flash Weld

0 Other
0 Other
0 Other

T

a Type of failure

0 Construction Defect a0 Poor Workmanship
0 Material Defect

0 Procedure not followed

0 Poor Construction Procedures

b Was failure due to pipe damage sustained in transportation to t'le construction or fabrication site7
c Was part which leaked pressure tested before incident occurred7 0 Yes, complete d-[ if known
d Dateoftest

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e Time held at test pressure

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0 Yes
0 No

0

No

I y.

I hr

PSlG

f Estimated test pressure at point of incident
F6 - EQUIPMENT OR OPERATIONS

22

0
0
0

23

0 Incorrect Operation

20
21

Malfunction of ControllRelief Equipment

3

Threads Stripped Broken Pipe Coupling

3

0 Valve 0 1ns:rumentatron 0 Pressure Regulator
0 Nipples 0 Va ve Threads 0 Mechanical Couplings

Other

0 Inadequate Procedures 0 Inadequate Safety Practices 0 Failure to Follow Procedures 0 Other

b Number of employees involved in incident who failed post-incidznt drug test I
c Was person involved in incident qualified per OQ rule?

0

Yes

0

No

I Alcohol test 1

1

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d Hours on duty for person involved I

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- OTHER

24
25

0

Leaking Seals

a Type

F7

0 Other

Miscellaneous, descnbe

0

PART G

-

Unknown
0 Investigation Complete

0 Still Under Investigation (submft a supplemental report when /nvest/gat/on IS complete)

- NARRATIVE DESCRIPTION OF FACTORS CONTRIBUTING -'OTHE EVENT I

Form PHMSA F 7100 1 (03-04 )

(Attach addrtional sheets as necessaryl

Page 3 of 3

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Page 1 of 10

INSTRUCTIONS FOR COMPLETI

All references are to Title 49 of the Code of
distribution system, i
for any incident de
occurrence of the
and transmission line.

M PHMSA F 7100.1 (03-04)

Regulations. Each operator of a gas
192.1I),
shall file Form PHMSA F 7100.1
e but not more than 30 days following the
f operator, distribution line, gathering line,

Master meter and LNG facilities need not file a
Release of gas, for the purpose of maintenanc
the only reportable criterion is loss of gas o
"Incident" (l)(ii).

If you have any questions conce
7100.1, please call Jefferson Ta

1. An entry should be made in each space.
2. Please try to obtain the information
question.
3. If the data is unavailable, enter "unknown."
4. If possible, provide an estimate in
5. For unknown or estimated data
additional information
6. If the block is not applicable,

vities, need not be reported if
described in 3191.3 under

or copies of Form PHMSA F
structions are available over

and completely answer each
with "unknown."
supplemental report when

Page 2 of 10
In blocks requiring numbers, all blocks should be illed in using zeroes when appropriate. When
decimal points are required, the decimal point sh jld be placed in a separate block.
Examples:
Nominal Pir

Wall Thickn

Size

IS

/0/0/2/4/ inches
/1/./2/5/ inches
/./5/0/0/ inches
/1/./4/5/ inches

If OTHER is checked, include an explanation or c scription on the line next to the item checked.

SPECIFIC IN TRUCTIONS
PART A - GENERAL

F PORT INFORMATION

Initial, Supplemental, Final Report Section - Chec the appropriate box:
Original Report

Suppleme :a1 Report

Final Report.

If this is the initial report filed for this incident, ct ck the box for "Original Report." If all of the
information requested is known and provided at 2 time the initial report is filed, including final
property damages and failure cause information, c x k the box for Final Report as well as the box
for Original Report, indicating that no further infor1 ation will be forthcoming.
If this is an update or revision to an Original Repor )ut all information requested is still not known,
check " S upplement a I Rep0rt."
If all requested relevant information has been prc ided, and there will be no further updates to
reported property damages or incident cause info iation, check the box for "Final Report.''
If you are filing a supplemental or final report, pl ase check the Supplemental Report or Final
and Part B. Please do not enter previously
Report box and complete Part A, Items 1, 2 and
submitted information.
A 1. The Pipeline and Hazardous Material Safety P
five digit identification number. If you do not kno)
Jefferson Tancil at (202) 366-8075. If you wish to
field blank. The operator address entry in 1.d. is th
does not own the pipeline, enter the owner's five c

ministration (PHMSA) assigns the operator's
the identification number, please contact the
le the report immediately, you may leave the
office filing the incident report. If the operator
lit identification number in 1.b., if known.

A 2. The time of the incident should be shown by

$-hour clock notation

Examples:
1. (0000) = midnight = /O/O/O/O/
2. (0800) = 8:OO a.m. = /0/8/0/0/
3. (1200) = Noon
= /1/2/0/0/
4. (1715) = 5:15 p.m. = /1/7/1/5/
5. (2200) = 1O:OO p.m.=/2/2/0/0/

Page 3 of 10
A 3. Incident location information should be as c nplete as possible, including the nearest City,
:tion, and Range. In addition to the general
Town, Township, County or Parish, Borough,
location information, provide latitude and longituc in block 3d. Latitude and longitude should be
stated in decimal degrees (no projection). A mini i m of five decimal places is required. Western
Hemisphere longitude should be a negative value Acceptable values are -180.00000 to 0.00000,
Northern Hemisphere latitude should be a pos ‘e value. Acceptable values are 0.00000 to
90.00000.
If latitude and longitude of the incident are unkr
located at: http://tiqer.census.qov/cqi-binlmapbrol
are available that will provide adequate latitude/lc
tool to identify the geographic location of the incic
below the map. These coordinates are in a de
-77.04327 are for the Washington Monume
degree/minute/second. If a filer has questions ab
access, please contact Sam Hall at 202-493-059’
map that can be used in identifying the incident I(

Nn, the U.S. Census Bureau provides a tool,
for determining them. Many similar tools
iitude information. The filer can use the online
it. The tool displays the latitude and longitude
nal degree format (e.g. Lat: 38.89664 Long:
) but do not have to be converted to
t the use of this tool, or does not have Internet
PHMSNOPS will provide the filer with a base
ation.

The class location should be the class location a1 te incident site as defined in 9192.5.
Federal Lands: As defined in 30 U.S.C. 5185, fed
States except lands in the National Park System,
and lands on the Outer Continental Shelf.”

lands means “all lands owned by the United
nds held in trust for an Indian or Indian tribe,

31

A 4. Leak - an unintentional release of gas from pipeline requiring repair of the pipeline. The
source of the leak may be holes, cracks (includinc ropagating and non-propagating, longitudinal
and circumferential cracks), separation or pull-ou, ind loose connections.

Note: Do not report leaks that are either inconseqi itial or incidental to the operation of a pipeline
and which can be repaired under routine daily ma enance. Examples of such leaks include gas
escaping through valve stem packing, compress rod packing, loosened connections or relief
valves. Such leaks do not meet the reporting critc 3 for natural gas distribution incidents.
Only report information about the one leak the oper
incident.

)r determined to be the proximate cause of the

Pinhole - a leak that is hard to see with the naked e ) :haracterized as being a small hole made as by
a pin. We do not request a diameter or length me urement for a pinhole leak.
Puncture - a leak which can readily be measured i
in inches, such as average length or width.

to diameter or representational cross section

Rupture - a complete failure of a portion of the pip

ne.

Propagation - the extension of the original open
thickness resulting from the internal forces on the

b

in the pipeline in an area of nominal wall
eline.

Tear - an extension of the original opening in the pipe ine resulting from an externally applied force,
such as a bulldozer, backhoe, or grader.

A 5b. In-patient hospitalization means hospital admission and at least one overnight stay.

Page 4 of 10

A 5c. Estimate costsAosses for the items provide
due to property damage to the operator's facilitie
replacement; leak locating; right-of-way cleanup;
relighting. Do not report costs incurred for facilit)
to the incident and performed solely for convenie
convenience is working on facilities unearthed be
other legal expenses related to the incident.

n this section. Include property damage or loss
to others' property; gas lost; facility repair and
ivironmental cleanup and damage, and cost of
!pair, replacement, or change that is not related
e. An example of doing work for the operator's
use of the incident. Do not report litigation and

A 5d. Check this box if gas ignited and indicate w
the appropriate circular radio button.

ther or not there was an explosion by checking

A 5e. Check this box if gas did not ignite, and in1 :ate whether or not there was an explosion by
checking the appropriate circular radio button.
An explosion is a sudden violent burst as an effe

of sudden release of pressure.

Estimate the number of persons (not including em( lyees or contractors) evacuated in item 5e, and
check off the reason for evacuation. Provide an e: nate to closest order of magnitude (i.e., closest
1, I O , closest hundred if less than 1,000, closest Dusand if less than 10,000, etc.)
A 6. "Elapsed time until the area was made saf means the amount of time starting from the
incident occurrence until the time that the inc ?nt is brought under control and does not
significantly threaten public safety. This does no iecessarily mean that the flow of product has
been stopped. If the time of occurrence is unknow the time when the operator was first notified or
made aware of the incident should be used to cal late elapsed time.
PART B - PREPARER AND AUTHORIZED SlGl

TURE

Preparer is the name of the person who preparf
contacted for more information (preferably the per:
the report).

i most knowledgeable about the

Authorized Signature may be the preparer, an o
designated to review and sign reports. Please en
has one.
PART C - ORIGIN OF INCIDENT

the responses to the form and who is to be
information in

the preparer's e-mail address if the preparer

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C 1. METER SET ASSEMBLY is that portion of the s rvice line extending from the service line riser
valve (stop cock) to the connection to the customers piping; including the meter, regulator, and
relief vent line. In the absence of a service line riser v Ive, the meter set assembly starts at the first
above ground fitting.

C 2. If the failure occurred on an item not provided n this section, check the "OTHER" box and
specify the item in the space provided. A sample I st of possible "OTHERS" is included in the
appendix under Part C, Item 2, Other.
C 3. If OTHER is checked, state the type of material. For example, copper, aluminum, etc.
C 4. "Year the pipe or component which failed was installed" means the year installed at the

Page 5 of 10
incident location

PART D - MATERIAL SPECIFICATION
Complete section D ( D I through D6) if a pipe or L dve failed.

D 1 . Nominal Pipe Size is the diameter in inches ]sed to describe the pipe size; for example, 2inch, 4-inch, 8-inch, 12-inch.
D 2. Enter pipe wall thickness in inches. Use dec

als as necessary.

D 3. Specification is the specification to which the
or component was manufactured, such as
API 5L or ASTM A106. When more than one item 'has failed] and the origin of the failure is not
clear, complete Part C Item 2 to explain the additicnal item(s).
D 4. See the appendix section of these instructicns under Part D, Item 4, Seams for a list of
common seam types.
D 5. Enter valve type (flange-welded, bell-plug, etc.) See the appendix section of these instructions
under Part D, Item 5, Valves for a list of common valve types.

D 6. Provide the pipe or valve manufacturer if failure was on pipe or valve. Enter year pipe or valve
was manufactured. See the appendix section of 'hese instructions under Part D, Item 6, Pipe
Manufacturers for a list of common pipe manufactu-ers.
PART E - ENVIRONMENT
"Under pavement" includes under streets, sidewalk1 , paved roads, driveways and parking lots
Provide depth of cover in inches where incident invl lved buried pipe or component
PART F -APPARENT CAUSE
There are 25 numbered causes in Part F. The 25 causes are divided into seven categories in
sections F1 through F7. Check the box indicating thc general cause of the incident and check the
circle indicating the specific cause.
PART F1 - CORROSION
Corrosion includes a leak or failure caused by galvar ic, bacterial, chemical, stray current, or other
corrosive action. Examples: A corrosion leak is not limited to a hole in the pipe. If the bonnet or
packing gland on a valve or flange on piping become ; loose and leaks due to corrosion and failure
of bolts, it is classified as "Corrosion." If the bonnc t, packing, or other gasket has deteriorated
before the end of its expected life and caused a leal or failure and a new gasket is required, it is
classified as a Material Defect. Leaks resulting from naterial deteriorating after the expected life of
the materials are classified as "Other." Leaks due t I deterioration from corrosion, however, are
classified as "Corrosion ."
Complete F1 parts a - e if applicable

Page 6 of 10
Subpart a - Pipe Coating
Galvanized pipe with no dielectric coating is con

lered bare.

Subpart d - Cathodic Protection
"Under cathodic protection" means cathodic prot tion in accordance with Part 192, Appendix D.
Recognizing that older pipelines may have had c; odic protection added over a number of years,
provide an estimate if exact year cathodic protec 'n started is unknown.
PART F2 - NATURAL FORCES
F2 3 - 7: This includes all outside forces attrib, ible to causes not involving humans. "Earth
Movement" refers to failures caused by land shift: Jch as earthquakes, landslides, or subsidence.
"Heavy rains and floods" refer to all water relal I failure causes such as washouts, flotation,
mudslides, or water scouring. While mudslides i olve earth movement, report them here since
typically they are an effect of heavy rains or flooa
"Temperature" refers to those causes that are rela j to temperature effects, or where temperature
was the initial cause; for example, thermal stress 'ost heave, or frozen component failures.
F3 - EXCAVATION
F3 8 Operator Excavation Damage/Not Third Pal - Check this item if the failure was caused by
the operator or the operator's contractor or agent ( ither party working for the operator as a result
of excavation.
F3 9 Third Party Excavation Damage - check 1 ; item if failure cause was from excavation
damages resulting from action by outside party/thi party caused by personnel or other party other
than the operator or his agent.
F3 9c - "Prior notification" means that the operator
work was to be done near the pipeline before the ir
the operator believes the notice was inadequate, it
Part G, Narrative Description Of Factors Contribu

d been notified that excavation or construction
jent occurred. If the operatorwas notified, but
roper, or incomplete, check NO and explain in
g to the Event.

Examples: A contractor working for the operatc jouges the operator's pipeline and buries it
without repair. If the pipeline leaks at a later date, tl leak should be classified as damage resulting
from item F3.8 - Operator Excavation Damage (ir Jding their contractors)/Not Third Party if the
operator can determine the leak resulted from the ntractor's actions. If the contractor had been
working for someone other than the operator, the ak should be classified as F3.9 - Third Party
Excavation Damage.
A contractor working for the operator excavates near e operator's pipeline, which is later damaged
by earth movement in the zone the excavation
The damage should be classified as F3.8 Operator Excavation Damage (including their
Third Party. If the contractor had
been working for other than the operator in this
Party Excavation Damage. In
both situations, the damage should not be
Pipeline leaks resulting from vehicular traffic loading should be classified as "Car, truck or other
vehicle not relating to excavation activity damaging plipe."

Page 7 of 10

Pipeline leaks resulting from pullout of a mec
should be classified as "Temperature, Frost

tting due to the repeated action of freezing

A pipeline or coating that an outsi
outside force should be reported under F3.9 -

damages that later leaks due to corrosion or
arty Excavation Damage.

A pipeline or coating that the operator or a co
later leaks due to corrosion or outside force
Damage (including their contractors)/Not T

rking for the operator damages that causes
eported under F3.8 - Operator Excavation

PART F4 - OTHER OlJTSlDE FORCE DAMAGE

ITEMS 10- 13 cover other failures caused
excavation or natural forces.

to pipelines by external forces other than

Fire/explosion as primary cause of failure i
as a result of failure. If a firelex
the failure, do not c

/explosion occurred prior to failure and not
sult of the failure not as primary cause of

If the primary failure cause was damag
check item 11. If a vehicle involved in
under the Excavation Damage sectio

han a vehicle involved in excavation,
damage, check the appropriate item

PART F5 - MATERIAL OR WELDS
"Fitting" means a device, usually met
includes couplings, ells, tees, crosse

us piping systems. It

F5 14 - 16, Material.
pipe, component or
deterioration and not resulting fro
Complete subparts a - f if any cau

the material of the
ures from material
ported under "Other."

F5 17 - 19, Welds.
Acronyms used in this section:
LF ERW : low frequency electro-resistance weld
HF ERW : high frequency electro-resistance weld
DSAW : double-submerged arc weld
SAW : submerged arc weld

i

"Weld-related material defects" includes leaks or fail res from a defect within the material of the
pipe, component or longitudinal weld or seam due to aulty welding or weld-related manufacturing
procedures. Leaks or failures from material deteri ration in service that do not result from an
original defect or corrosion are reported under "Othe ".
Sub-Elements a - f.
"Construction defect" force applied during field cons:ruction results in a dent, gouge, excessive
stress, or some other defect to originally sound mate'ial that leads to eventual failure of the pipe,
Includes leaks due to wrinkle bends, faulty field welds, and damage sustained in transportation to
the construction or fabrication site.

Page 8 of 10

PART F6 - EQUIPMENT OR OPERATIONS
This section includes malfunctions of control and
leaking valves), failures of threaded components
as compressor pump packing failures. Incidents
procedures are also included in this category. RE
16, Joints, by checking the appropriate circle for

lief equipment (typically the result of failed and
d broken pipe couplings, and seal failures such
iulting from incorrect operations or inadequate
~ r gasket
t
or O-ring failures under Part F5, item
isket or O-ring.

F6 20 - Malfunction of ControVRelief Equipment
Examples of this type of failure cause include 01 -pressurizations resulting from malfunction of
control or alarm device, relief valve malfunction, ai valves failing to open or close on command; or
which opened or closed when not commanded tc 0 so.
F6 21 - Threads stripped, broken pipe coupling

Examples of this type of failure include failures on (
the failure resulted from a crack in a componer
flanges, valve connections, line pipe collars, etc.

npressors, meters, or regulator stations where
3r threads of a component such as nipples,

F6 22 - Leaking Seals
F6 23 - Incorrect Operation

Incorrect operation failures typically result from fa
failures most often occur during maintenance actit
unintentional product ignition during a welding or I
causing a fire; or failures where human error, en
have played a role.

:y or inadequate procedures. These types of
es. Some examples of this type of failure are
iintenance activity; other reportable incidents
Ioyee fatigue, and/or lack of experience may

Part F7 - OTHER
This section is provided for failure causes that do r
If the failure cause is unknown at time of filing thi
known but doesn't fit in any category in sections F
cause. Continue in Part G, narrative description, I

through F6, check item 24 and describe the
lore space is needed.

PART G - NARRATIVE DESCRIPTION
OF FACTORS CONTRIBUTING TO THE EVENT

I

Concisely describe the incident, including the facts, ircumstances, and conditions that may have
contributed directly or indirectly to causing the incide t. You may explain any estimated data in the
narrative. If you checked the OTHER block in Part F item 24 or 25, the narrative should describe
the incident in detail, including the timeline, seque ce of events, and all known or suspected
causes. Use this section to clarify or explain unusua conditions.

Page 9 of 10
APPENDIX
Part C, Item 2, Other
NIPPLE FITTING
FLANGE FITTING
COMPRESS0R/TURB INE
GASKET
DRIPIR IS ER
GIRTH WELD
LONG ITUDlNAL WELD
FILLET WELD

Part C, Item 3, Other Material
PACK1NG
ALUMINUM
ASBESTOS
FIBER GLASS
GALVANIZED RUBBER
REINFORCED RUBBER
UNKNOWN
Part D, Item 4, Seam Types
---------------_---------ELECTRIC RESISTANCE WELD
SUBMERGED ARC WELD
DOUBLE SUBMERGED ARC WELD
BUTT WELD
FURNACE LAP WELD
SEAMLESS WELD
FLASH WELD
Part D, Item 5, Valve Types
BALL
CHECK
BLEEDING
PRESSURE REDUCI NG
RECIPROCATING
GATE
PLUG
UNKNOWN

Page 10 of 10
Part D, Item 6, Pipe Manufacturers
ACME NEWPORT
AMER. MANNEX CO
ANDERSON GREENWOOD
A 0 SMITH
ARMCO STEEL
BETHLEHEM STEEL
CONSOLIDATED WESTERN
GROVE
INGERSOL-RAND
JONES & LAUGHLIN
KAISER STEEL CO.
LONE STAR STEEL
NATIONAL TUBE
REPUBLIC STEEL
ROCKWELL
U S STEEL
YOUNGSTOWN
YOUNGSTOWN SHEET&TUBE
Unknown

Part F1, Subpart c, Cause of Corrosion - "Other"
ATMOSPHERIC CORROSION
CHEM ICA L COR ROSI 0 N
SOUR GAS
I NTERG RA NULAR C 0F? ROS ION