Form DOT-7000-1 Accident Report - Hazardous Liquids Pipeline Systems

NOTICE: This report is required by 49 CFR Part 195. Failure to report can result in a civil penalty not to exceed $25,000 for each violation
for each day that such violation persists except that the maximum civil penalty shall not exceed $500,000 as provided in 49 USC 60122

Report Date

ACCIDENT REPORT – HAZARDOUS LIQUID
PIPELINE SYSTEMS

U.S. Department of Transportation
Pipeline and Hazardous Materials
Safety Administration

Form Approved
OMB No. 2137-0047

No.
(DOT Use Only)

INSTRUCTIONS

Important: Please read the separate instructions for completing this form before you begin. They clarify the
information requested and provide specific examples. If you do not have a copy of the instructions,
you can obtain one from the Office Of Pipeline Safety Web Page at http://ops.dot.gov.
Check: …

PART A – GENERAL REPORT INFORMATION
1. a.
b.
c.
d.
e.

Original Report … Supplemental Report … Final Report

Operator's OPS 5-digit Identification Number (if known) /
/
/
/
/
/
If Operator does not own the pipeline, enter Owner’s OPS 5-digit Identification Number (if known) /
/
/
/
/
/
Name of Operator ______________________________________________________________________________________
Operator street address _______________________________________________________________________________
Operator address ______________________________________________________________________________________
City, County, State and Zip Code

IMPORTANT: IF THE SPILL IS SMALL, THAT IS, THE AMOUNT IS AT LEAST 5 GALLONS BUT IS LESS THAN 5 BARRELS, COMPLETE
THIS PAGE ONLY, UNLESS THE SPILL IS TO WATER AS DESCRIBED IN 49 CFR §195.52(A)(4) OR IS OTHERWISE REPORTABLE
UNDER §195.50 AS REVISED IN CY 2001.
2. Time and date of the accident
/

/

/

/

/

/

hr.

/

/

/

/

month

/

/

/

day

5. Losses (Estimated)

/
year

Public/Community Losses reimbursed by operator:

3. Location of accident
(If offshore, do not complete a through d. See Part C.1)
a. Latitude:

_____

Public/private property damage

Longitude: __________

(if not available, see instructions for how to provide specific location)

Cost of emergency response phase

$_______________

Cost of environmental remediation

$_______________

Other Costs

$_______________

b. _________________________________________________

(describe) _____________________________________

City, and County or Parish

c. _________________________________________________
State and Zip Code

d. Mile post/valve station { or survey station no.
(whichever gives more accurate location)

{

Operator Losses:
Value of product lost

$_______________

Value of operator property damage

$_______________

Other Costs

$_______________

_________________________________

(describe) _____________________________________

4. Telephone report
/

/

/

/

/

Total Costs
/

/

/

NRC Report Number

/
month

/

/

/

/

/

day

/

$_______________

/

year

6. Commodity Spilled {Yes { No
(If Yes, complete Parts a through c where applicable)
a. Name of commodity spilled ___________________________
b. Classification of commodity spilled:
{ HVLs /other flammable or toxic fluid which is a gas at ambient conditions
{ CO2 or other non-flammable, non-toxic fluid which is a gas at ambient conditions
{ Gasoline, diesel, fuel oil or other petroleum product which is a liquid at ambient conditions
{ Crude oil
CAUSES FOR SMALL SPILLS ONLY (5 gallons to under 5 barrels) :

{ Corrosion

{ Natural Forces

{ Material and/or Weld Failures

$_______________

c. Estimated amount of commodity
involved :
{ Barrels
{ Gallons (check only if spill is
less than one barrel)
Amounts:
Spilled : ____________
Recovered: ____________

(For large spills [5 barrels or greater] see Part H)

{ Excavation Damage

{ Other Outside Force Damage

{ Equipment

{ Incorrect Operation

{ Other

PART B – PREPARER AND AUTHORIZED SIGNATURE
(type or print) Preparer's Name and Title

Area Code and Telephone Number

Preparer's E-mail Address

Area Code and Facsimile Number

Authorized Signature

(type or print) Name and Title

Date

Form PHMSA F 7000-1 ( 01-2001 )

Area Code and Telephone Number

Page 1 of 4

Reproduction of this form is permitted

PART C – ORIGIN OF THE ACCIDENT (Check all that apply)
1. Additional location information
a. Line segment name or ID _______________________
b. Accident on Federal land other than Outer Continental
Shelf { Yes { No
c. Is pipeline interstate? { Yes { No

Offshore:

/

/

Block # ______________

or Outer Continental Shelf …

Propagation Length, total, both sides (feet) _________

{N/A
{Other _______________________________
b.Type of block valve used for isolation of immediate section:
… Manual … Automatic … Remote Control
Upstream:
… Check Valve
… Automatic … Remote Control
Downstream: … Manual
… Check Valve
c. Length of segment isolated
_______ ft
d. Distance between valves
_______ ft
e. Is segment configured for internal inspection tools? {Yes { No
f. Had there been an in-line inspection device run at the point of
failure? { Yes { No { Don’t Know
{ Not Possible due to physical constraints in the system
g. If Yes, type of device run (check all that apply)
… High Resolution Magnetic Flux tool Year run: ______
… Low Resolution Magnetic Flux tool Year run: ______
… UT tool
Year run: ______
… Geometry tool
Year run: ______
… Caliper tool
Year run: ______
… Crack tool
Year run: ______
… Hard Spot tool
Year run: ______
… Other tool
Year run: ______

If failure occurred on Pipeline, complete items a - g:

{ Scraper Trap
{ Joint
{ Metering Facility
{ Bolted Fitting

Year the component that failed was installed: /
/
/
/
/
5. Maximum operating pressure (MOP)
a. Estimated pressure at point and time of accident:
PSIG
____
b. MOP at time of accident:
___________PSIG
c. Did an overpressurization occur relating to the accident?
{Yes { No
PART D – MATERIAL SPECIFICATION

PART E – ENVIRONMENT

1. Nominal pipe size (NPS)

/

/

/

/

/ in.

2. Wall thickness

/

/

/

/

/ in.

SMYS /

/

/

/

/

3. Specification

No (complete d if offshore)

{Leak: { Pinhole { Connection Failure (complete sec. H5)
{ Puncture, diameter (inches)
_________
{Rupture: { Circumferential – Separation
{ Longitudinal – Tear/Crack, length (inches) ___________

Onshore pipeline, including valve sites
Offshore pipeline, including platforms

{ Pipe Seam
{ Sump
{ Valve
{ Welded Fitting

{

a. Type of leak or rupture

3. Part of system involved in accident
{ Above Ground Storage Tank
{ Cavern or other below ground storage facility
{ Pump/meter station; terminal/tank farm piping and
equipment, including sumps
{ Other Specify: _________________________________

4. Failure occurred on
{ Body of Pipe
{ Pump
{ Component
{ Repair Sleeve
{ Girth Weld
Other (specify)

Yes

State /

2. Location of system involved (check all that apply)
… Operator’s Property
… Pipeline Right of Way
… High Consequence Area (HCA)?
Describe HCA____________________________________

{
{

{

d. Area ___________________

/

/

4. Seam type

1. Area of accident
{ Under pavement
{ Underground
{ Inside/under building

{
{
{
{

In open ditch
Above ground
Under water
Other

____________

5. Valve type
6. Manufactured by

in year /

/

/

/

/

2. Depth of cover:

inches

PART F – CONSEQUENCES
1. Consequences (check and complete all that apply)
a.
Fatalities Injuries

c. Product ignited

Number of operator employees:

e. … Evacuation (general public only)

{Yes { No

d. Explosion

_______

Contractor employees working for operator:

_______

_______

Reason for Evacuation:

General public:

_______

_______

{ Precautionary by company

Totals:

_______

_______

{ Evacuation required or initiated by public official

b. Was pipeline/segment shutdown due to leak? {Yes { No
If Yes, how long? ______ days ______ hours _____ minutes
2. Environmental Impact
a. Wildlife Impact:
Fish/aquatic { Yes { No
{ Yes { No
Birds
{ Yes { No
Terrestrial
b. Soil Contamination { Yes { No
If Yes, estimated number of cubic yards: _________
c. Long term impact assessment performed: { Yes { No
d. Anticipated remediation { Yes { No
If Yes, check all that apply: … Surface water … Groundwater
Form PHMSA F 7000-1 ( 01-2001 )

/

/

{Yes { No

_______

/

/

/ people

f. Elapsed time until area was made safe:
/
/
/ hr.
/
/
/ min.
e. Water Contamination: { Yes { No (If Yes, provide the following)
Amount in water _________ barrels
Ocean/Seawater { No
{ Yes
Surface { No
{ Yes
Groundwater { No
{ Yes
Drinking water
{ No { Yes (If Yes, check below.)
{ Private well { Public water intake
… Soil … Vegetation … Wildlife
Page 2 of 4

Reproduction of this form is permitted

PART G – LEAK DETECTION INFORMATION
1. Computer based leak detection capability in place?

{ Yes { No

2. Was the release initially detected by? (check one):

{ CPM/SCADA-based system with leak detection
{ Static shut-in test or other pressure or leak test
{ Local operating personnel, procedures or equipment
{ Remote operating personnel, including controllers
{ Air patrol or ground surveillance
{ A third party
{ Other (specify) _________________

3. Estimated leak duration

days ____ hours ____

PART H – APPARENT CAUSE
H1 – CORROSION
1.

†

External Corrosion

2.

†

Internal Corrosion

(Complete items a – e where
applicable.)

Important: There are 25 numbered causes in this Part H. Check the box corresponding to the
primary cause of the accident. Check one circle in each of the supplemental categories corresponding
to the cause you indicate. See the instructions for guidance.
c. Cause of Corrosion
a. Pipe Coating
b. Visual Examination
{ Bare
{ Localized Pitting
{ Galvanic
{ Atmospheric
{ Coated
{ General Corrosion
{ Stray Current { Microbiological
{ Other ____________________
{ Cathodic Protection Disrupted
{ Stress Corrosion Cracking
{ Selective Seam Corrosion
{ Other ____________________
d. Was corroded part of pipeline considered to be under cathodic protection prior to discovering accident?
{ No { Yes, Year Protection Started: / / / / /
e. Was pipe previously damaged in the area of corrosion?
{ No { Yes ⇒ Estimated time prior to accident: / /

/ years /

/

/ months Unknown …

H2 – NATURAL FORCES
3.
4.
5.
6.
7.

H3

†
†
†
†
†

⇒

Earth Movement

{ Earthquake

{ Subsidence

{ Landslide

{ Other

{ Washouts

{ Flotation

{ Mudslide

{ Scouring

{ Thermal stress

{ Frost heave

{ Frozen components

Lightning
Heavy Rains/Floods ⇒
⇒

Temperature

{ Other
{ Other

High Winds

– EXCAVATION DAMAGE

8.
9.

†
†

Operator Excavation Damage (including their contractors/Not Third Party)
Third Party (complete a-f)
a. Excavator group
{ General Public
b. Type:

{

Government

{

Excavator other than Operator/subcontractor

{ Road Work { Pipeline { Water { Electric { Sewer { Phone/Cable
{ Landowner-not farming related
{ Farming { Railroad
{ Other liquid or gas transmission pipeline operator or their contractor
{ Nautical Operations
{ Other
________

c. Excavation was:

{Open Trench

{ Sub-strata (boring, directional drilling, etc…)

d. Excavation was an ongoing activity (Month or longer) {Yes

{ No

e. Did operator get prior notification of excavation activity?
{ Yes; Date received: / / / mo. / / / day / /
Notification received from: { One Call System { Excavator
f. Was pipeline marked as result of location request for excavation?
i. Temporary markings:
{ Flags { Stakes { Paint
ii. Permanent markings:
{
iii. Marks were (check one) : { Accurate { Not Accurate
iv. Were marks made within required time? { Yes { No
H4 – OTHER OUTSIDE FORCE DAMAGE

†
11. †
12. †
13. †
10.

Fire/Explosion as primary cause of failure

⇒ Fire/Explosion cause:

If Yes, Date of last contact /___/___/___/

/___/___/ yr.
{ No
{ Contractor { Landowner
{ No { Yes (If Yes, check applicable items i - iv)

{ Man made

{ Natural

Car, truck or other vehicle not relating to excavation activity damaging pipe
Rupture of Previously Damaged Pipe
Vandalism

Form PHMSA F 7000-1 ( 01-2001 )

Page 3 of 4

Reproduction of this form is permitted

H5 – MATERIAL AND/OR WELD FAILURES
Material

†
15. †
16. †
14.

Body of Pipe

⇒

{ Dent

{ Gouge

{ Bend

{ Arc Burn

{ Other

Component

⇒

{ Valve

{ Fitting

{ Vessel

{ Extruded Outlet

{ Other

Joint

⇒

{ Gasket

{ O-Ring

{ Threads

Butt

⇒

{ Pipe

{ Fabrication

Fillet

⇒

{ Branch

{ Hot Tap

{ Fitting

{ Repair Sleeve

Pipe Seam

⇒

{ LF ERW

{ DSAW

{ Seamless

{ Flash Weld

{ HF ERW

{ SAW

{ Spiral

{ Other

Weld

†
18. †
19. †
†
17.

{ Other
{ Other
{ Other

Complete a-g if you indicate any cause in part H5.
a. Type of failure:
{ Construction Defect ⇒
{ Material Defect

{ Poor Workmanship

{ Procedure not followed

{ Poor Construction Procedures

b. Was failure due to pipe damage sustained in transportation to the construction or fabrication site? { Yes
c. Was part which leaked pressure tested before accident occurred? { Yes, complete d-g { No
d. Date of test:

/

/

/

e. Test medium:

{

Water

f. Time held at test pressure:

/

/ yr.

{

Inert Gas

/

/

/

/

/ mo.

{

Other

/

/

{

No

/ day

/ hr.

g. Estimated test pressure at point of accident:

PSIG

H6 – EQUIPMENT
20.

†

†
22. †
21.

Malfunction of Control/Relief Equipment

⇒

Threads Stripped, Broken Pipe Coupling ⇒
Seal Failure

⇒

{ Control valve
{ Instrumentation { SCADA
{ Communications
{ Block valve
{ Relief valve
{ Power failure { Other
{ Nipples { Valve Threads { Dresser Couplings { Other
{ Gasket

{ O-Ring

{ Seal/Pump Packing { Other

H7 – INCORRECT OPERATION

†

23.
Incorrect Operation
a. Type:
{ Inadequate Procedures { Inadequate Safety Practices { Failure to Follow Procedures
{ Other
_______________________________________
b. Number of employees involved who failed a post-accident test: drug test: /

/

/

/

alcohol test /___/___/___/

H8 – OTHER

†
25. †
24.

Miscellaneous, describe:

Unknown
{ Investigation Complete { Still Under Investigation (submit a supplemental report when investigation is complete)
(Attach additional sheets as necessary)
PART I – NARRATIVE DESCRIPTION OF FACTORS CONTRIBUTING TO THE EVENT

Form PHMSA F 7000-1 (01-2001 )

Page 4 of 4

Reproduction of this form is permitted