Comparison of Proposed Gas Distribution Incident Form to Currently Approved Version

NOTICE: This report is required by 49 CFR Part 191. Failure to report can result in a civil penalty not to exceed
$100,000 for each violation for each day that such violation persists except that the maximum civil penalty shall not
exceed $1,000,000 as provided in 49 USC 60122.

OMB NO: 2137-0522
EXPIRATION DATE: mm/dd/yyyy

Report Date

INCIDENT REPORT – GAS DISTRIBUTION
SYSTEM

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

No.
(DOT Use Only)

A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to
comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a
current valid OMB Control Number. The OMB Control Number for this information collection is 2137-0522. Public reporting for this collection of
information is estimated to be approximately 10 hours per response, including the time for reviewing instructions, gathering the data needed, and
completing and reviewing the collection of information. All responses to this collection of information are mandatory. Send comments regarding
this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection
Clearance Officer, PHMSA, Office of Pipeline Safety (PHP-30) 1200 New Jersey Avenue, SE, Washington, D.C. 20590.
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 PHMSA Pipeline Safety Community Web Page at http://www.phmsa.dot.gov/pipeline.
PART A – KEY REPORT INFORMATION

 Original

Report Type: (select all that apply)

1. Operator’s OPS-issued Operator Identification Number (OPID):

/

/

/

/

/

 Supplemental

 Final

/

2. Name of Operator: ______________________________________________________________________________________
3. Address of Operator:
3.a _______________________________________________________________________
(Street Address)

3.b ___________________________________________________
(City)

3.c State: /

/

/

3.d Zip Code: /

/

/

/

/

/ - /

/

/

/

/

4. Local time (24-hr clock) and date of the Incident:
/

/

/

/

/

/

Hour

/

/

/

/

Month

/

6. National Response Center Report Number :
/

/

Day

/

/

/

/

/

/

/

/

Year

5. Location of Incident:
5.a ___________________________________________________

7. Local time (24-hr clock) and date of initial telephonic report to the
National Response Center:
/

(Street Address or location description)

/

/

/

/

/

Hour

/
Month

/

/

/
Day

/

/

/

/

Year

5.b ___________________________________________________
(City)

5.c ___________________________________________________
(County or Parish)

5.d State: /

/

/

5.e Zip Code: /

/

/

/

5.f Latitude:

/

/

/ . /

/

/

/

Longitude: -

/

/ - /

/

/

/

/

/

/

/

/

/ . /

/

/

/

/

/

/

8. Incident resulted from:
 Unintentional release of gas
 Intentional release of gas
 Reasons other than release of gas
9. Gas released :





Natural Gas
Propane Gas
Other Gas



Name: ___________________________

10. Estimated volume of gas released:

/

/

/,/

/

/

/ Thousand Cubic Feet (MCF)

Form PHMSA F 7100.1 (Rev. xx-2009)

Page 1 of 18

Reproduction of this form is permitted

11. Were there fatalities?  Yes  No
If Yes, specify the number in each category:

12. Were there injuries requiring inpatient hospitalization?
If Yes, specify the number in each category:

 Yes  No

11.a Operator employees

/

/

/

/

/

12.a Operator employees

/

/

/

/

/

11.b Contractor employees
working for the Operator

/

/

/

/

/

12.b Contractor employees
working for the Operator

/

/

/

/

/

11.c Non-Operator
emergency responders

/

/

/

/

/

12.c Non-Operator
emergency responders

/

/

/

/

/

/

/

/

/

/

11.d Workers working on the
right-of-way, but NOT
associated with this Operator

/

/

/

/

/

12.d Workers working on the
right-of-way, but NOT
associated with this Operator

11.e General public

/

/

/

/

/

12.e General public

/

/

/

/

/

11.f Total fatalities (sum of above)

/

/

/

/

/

12.f Total injuries (sum of above)

/

/

/

/

/

13. Was the pipeline/facility shut down due to the incident?
 Yes  No  Explain: ______________________________________________________________________________
If Yes, complete Questions 13.a and 13.b: (use local time, 24-hr clock)
13.a Local time and date of shutdown

/

/

/

/

/

/

Hour

13.b Local time pipeline/facility restarted

/

/

/

/

/

/

Hour

14. Did the gas ignite?
15. Did the gas explode?

 Yes
 Yes

/

/

/

/

Month

/

/

/

/

Day

/

/

Month

/

/

Year

/

/

Day

/

/

 Still shut down*
(*Supplemental Report required)

Year

 No
 No

16. Number of general public evacuated: /___/___/

/,/

/

/

/

17. Time sequence (use local time, 24-hour clock):
17.a Local time operator identified Incident

/

/

/

/

/

/

Hour

17.b Local time operator resources arrived on site

/

/

/
Hour

/

/

/

Month

/

/

/

/
Month

/

/

/

Day

/

/

/
Day

Form PHMSA F 7100.1 (Rev. xx-2009)

/

/

Year

/

/

/

/

Year

Page 2 of 18

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PART B – ADDITIONAL LOCATION INFORMATION

 Yes

1. Was the Incident on Federal land?

 No

2. Location of Incident: (select only one)



Operator-controlled property



Public property



Private property



Utility Right-of-Way / Easement

3. Area of Incident: (select only one)



Underground Specify:

 Under soil
 Under a building
 Under pavement
 Exposed due to excavation
 In underground enclosed space (e.g., vault)
 Other ____________________________
Depth-of-Cover (in): / _ /,/_

/_

/_

/



Aboveground



Transition Area Specify:  Soil/air interface
 Wall sleeve
 Pipe support or other close contact area
 Other ______________________________________________________

Specify:

4. Did Incident occur in a crossing?
If Yes, specify type below:








Road crossing 
Water crossing 

 Typical aboveground facility piping or appurtenance (e.g. valve or regulator station, outdoor meter set)
 Overhead crossing
 In or spanning an open ditch
 Inside a building
 In other enclosed space
 Other _______________________________________

 Yes

 No

 Cased

Bridge crossing

Specify:

Railroad crossing

(Select all that apply)
(Select all that apply)
(Select all that apply)

 Uncased
 Cased
 Uncased
 Cased
 Uncased
 Cased
 Uncased

 Bored/drilled
 Bored/drilled
 Bored/drilled

Name of body of water (If commonly known): _________________________
Approx. water depth (ft): / _ /,/ _ / _ / _ /

Form PHMSA F 7100.1 (Rev. xx-2009)

Page 3 of 18

Reproduction of this form is permitted

PART C – ADDITIONAL FACILITY INFORMATION
1. Indicate the type of pipeline system:






Natural Gas Distribution, privately owned
Natural Gas Distribution, municipally owned
Petroleum Gas Distribution
Other  Specify: ____________________________________ __






2. Part of system involved in Incident: (select only one)

Main
 Service  Service Riser  Outside Meter/Regulator set
Inside Meter/Regulator set
 Farm Tap Meter/Regulator set
District Regulator/Metering Station
 Valve
Other _________________________________

2.a. Year ”Part of system involved in Incident” was installed: / _ /_

/_

/_

/

or



Unknown

3. When “Main” or “Service” is selected as the “Part of system involved in Incident” (from PART C, Question 2), provide the following:
3.a Nominal diameter of pipe (in): /
/
/./___/___/___/
3.b Pipe specification (e.g., API 5L, ASTM D2513): ___________________
3.c Pipe manufacturer: ______________________ or
3.d Year of manufacture: / _ / _ / _

4. Material involved in Incident:

/_

/

or





Unknown

Unknown

 Steel
 Cast/Wrought Iron
 Ductile Iron
 Copper
 Other  Specify: __________________________________

4.a. If Steel  Specify seam type: _______________________________ or
4.b. If Steel  Specify wall thickness (inches): /
4.c. If Plastic  Specify type:

/./

/

/

/



None or



 Plastic



Unknown

Unknown

or  Unknown

 Polyvinyl Chloride (PVC)
 Polyethylene (PE)
 Cross-linked Polyethylene (PEX)
 Polybutylene (PB)
 Polypropylene (PP)
 Acrylonitrile Butadiene Styrene (ABS)
 Polyamide (PA)
 Cellulose Acetate Butyrate (CAB)
 Other _______________________________________________
 Unknown

4.d. If Plastic  Specify Standard Dimension Ratio (SDR): /

/

/

/

/

or wall thickness: /

4.e. If Polyethylene (PE) is selected as the type of plastic in PART C, Question 4.c 
Specify PE Pipe Material Designation Code (i.e., 2406, 3408, etc.) PE /

/

/./

/

/

/

/

/

/

or

or





Unknown

Unknown

5. Type of release involved: (select only one)





Mechanical Puncture



Approx. size: /__/__/__/__/./__/in. (axial) by /__/__/__/__/./__/in. (circumferential)

 Pinhole
 Crack

Rupture  Select Orientation:  Circumferential
Leak

Select Type:



 Connection Failure
 Seal or Packing
 Other
 Longitudinal
 Other ________________________________

 Approx. size: /__/__/__/__/./__/ in. (widest opening) by /__/__/__/__/__/./__/in. (length circumferentially or axially)
 Other  Describe: ___________________________________________________________________

Form PHMSA F 7100.1 (Rev. xx-2009)

Page 4 of 18

Reproduction of this form is permitted

PART D – ADDITIONAL CONSEQUENCE INFORMATION
1. Class Location of Incident: (select only one)






Class 1 Location
Class 2 Location
Class 3 Location
Class 4 Location

2. Estimated cost to Operator :
2.a Estimated cost of public and non-Operator private property damage
paid/reimbursed by the Operator
$/

/

/

/,/

/

/

/,/

/

/

2.b Estimated cost of gas released

$/

/

/

/,/

/

/

/,/

/

/

/

2.c Estimated cost of Operator’s property damage & repairs

$/

/

/

/,/

/

/

/,/

/

/

/

2.d Estimated cost of Operator’s emergency response

$/

/

/

/,/

/

/

/,/

/

/

/

2.e Estimated other costs

$/

/

/

/,/

/

/

/,/

/

/

/

/

/,/

/

/

/,/

/

/

/

/

Describe: ___________________________________________________
2.f Estimated total costs (sum of above)

$/

/

3. Estimated number of customers out of service:
3.a Commercial entities /

/,/

/

/

/

3.b Industrial entities

/

/,/

/

/

/

3.c Residences

/

/,/

/

/

/

Form PHMSA F 7100.1 (Rev. xx-2009)

Page 5 of 18

Reproduction of this form is permitted

PART E – ADDITIONAL OPERATING INFORMATION
1. Estimated pressure at the point and time of the Incident (psig):

/

/

/

/

/

2. Normal operating pressure at the point and time of the Incident (psig):

/

/

/

/

/

3. Maximum Allowable Operating Pressure (MAOP) at the point and time of the Incident (psig):

/

/

/

/

/

4. Describe the pressure on the system relating to the Incident: (select only one)
 Pressure did not exceed MAOP
 Pressure exceeded MAOP, but did not exceed 110% of MAOP
 Pressure exceeded 110% of MAOP
5. Was a Supervisory Control and Data Acquisition (SCADA)-based system in place on the pipeline or facility involved in the Incident?
 No
 Yes  5.a Was it operating at the time of the Incident?
 Yes
 No
5.b Was it fully functional at the time of the Incident?
 Yes
 No
5.c Did SCADA-based information (such as alarm(s), alert(s), event(s), and/or volume or pack calculations) assist with the
detection of the Incident?
 Yes
 No
5.d Did SCADA-based information (such as alarm(s), alert(s), event(s), and/or volume calculations) assist with the
confirmation of the Incident?
 Yes
 No
6. How was the Incident initially identified for the Operator? (select only one)

 SCADA-based information (such as alarm(s), alert(s), event(s), and/or volume or pack calculations)
 Static Shut-in Test or Other Pressure or Leak Test
 Controller
 Local Operating Personnel, including contractors
 Air Patrol
 Ground Patrol by Operator or its contractor
 Notification from Public
 Notification from Emergency Responder
 Notification from Third Party that caused the Incident
 Other _________________________________________________
6.a If “Controller”, “Local Operating Personnel, including contractors”, “Air Patrol”, or “Ground Patrol by Operator or its contractor” is selected
in Question 6, specify the following: (select only one)

 Operator employee

 Contractor working for the Operator

7. Was an investigation initiated into whether or not the controller(s) or control room issues were the cause of or a contributing factor to the
Incident? (select only one)



Yes, but the investigation of the control room and/or controller actions has not yet been completed by the operator (Supplemental
Report required)
 No, the facility was not monitored by a controller(s) at the time of the Incident
 No, the operator did not find that an investigation of the controller(s) actions or control room issues was necessary due to:
(provide an explanation for why the operator did not investigate)
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
____________________________________________________________________________________________________
 Yes, Specify investigation result(s): (select all that apply)
 Investigation reviewed work schedule rotations, continuous hours of service (while working for the Operator) and other
factors associated with fatigue
 Investigation did NOT review work schedule rotations, continuous hours of service (while working for the Operator) and other
factors associated with fatigue (provide an explanation for why not)
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_________________________________________________________________________________________________
 Investigation identified no control room issues
 Investigation identified no controller issues
 Investigation identified incorrect controller action or controller error
 Investigation identified that fatigue may have affected the controller(s) involved or impacted the involved controller(s)
response
 Investigation identified incorrect procedures
 Investigation identified incorrect control room equipment operation
 Investigation identified maintenance activities that affected control room operations, procedures, and/or controller response
 Investigation identified areas other than those above  Describe: ___________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_________________________________________________________________________________________________

Form PHMSA F 7100.1 (Rev. xx-2009)

Page 6 of 18

Reproduction of this form is permitted

PART F – DRUG & ALCOHOL TESTING INFORMATION
1. As a result of this Incident, were any Operator employees tested under the post-accident drug and alcohol testing requirements of DOT’s Drug
& Alcohol Testing regulations?

 No
 Yes 



1.a Specify how many were tested:

/

/

/

1.b Specify how many failed:

/

/

/

2. As a result of this Incident, were any Operator contractor employees tested under the post-accident drug and alcohol testing requirements of
DOT’s Drug & Alcohol Testing regulations?

 No
 Yes 

2.a Specify how many were tested:

 2.b

Specify how many failed:

/

/

/

/

/

/

Form PHMSA F 7100.1 (Rev. xx-2009)

Page 7 of 18

Reproduction of this form is permitted

PART G – APPARENT CAUSE

Select only one box from PART G in the shaded column on the left representing the
APPARENT Cause of the Incident, and answer the questions on the right. Describe secondary,
contributing, or root causes of the Incident in the narrative (PART H).

G1 – Corrosion Failure – only one sub-cause can be picked from shaded left-hand column
 External Corrosion

1. Results of visual examination:
 Localized Pitting  General Corrosion
 Other _____________ _______________________________________________
2. Type of corrosion: (select all that apply)
 Galvanic  Atmospheric  Stray Current  Microbiological  Selective Seam
 Other _____________________________________________________________
3. The type(s) of corrosion selected in Question 2 is based on the following: (select all that
apply)
 Field examination
 Determined by metallurgical analysis
 Other _____________________________________________________________
4. Was the failed item buried under the ground?
 Yes 4.a Was failed item considered to be under cathodic protection at the time of
the incident?
 Yes  Year protection started: / / / / /

 No

4.b Was shielding, tenting, or disbonding of coating evident at the point of
the incident?
 Yes  No
4.c Has one or more Cathodic Protection Survey been conducted at
the point of the incident?
 Yes, CP Annual Survey  Most recent year conducted:
/ / /

 Yes, Close Interval Survey  Most recent year conducted:
 Yes, Other CP Survey  Most recent year conducted:
 No
 No 

4.d Was the failed item externally coated or painted?

/

/

/

/

/

/

/

/

/

/

/

/

 Yes  No

5. Was there observable damage to the coating or paint in the vicinity of the corrosion?
 Yes  No
6. Pipeline coating type, if steel pipe is involved: (select only one)
 Fusion Bonded Epoxy
 Coal Tar
 Asphalt
 Polyolefin  Extruded Polyethylene
 Field Applied Epoxy
 Cold Applied Tape
 Paint
 Composite
 None
 Other __________________ ________________
 Unknown

Form PHMSA F 7100.1 (Rev. xx-2009)

Page 8 of 18

Reproduction of this form is permitted

 Internal Corrosion

7. Results of visual examination:
 Localized Pitting
 General Corrosion
 Not cut open
 Other ____________________________________________________________
8. Cause of corrosion: (select all that apply)
 Corrosive Commodity  Water drop-out/Acid  Microbiological  Erosion
 Other ____________ ________________________________________________
9. The cause(s) of corrosion selected in Question 8 is based on the following; (select all that
apply)
 Field examination
 Determined by metallurgical analysis
 Other _____________________________________________________________
10. Location of corrosion: (select all that apply)
 Low point in pipe  Elbow  Drop-out
 Other ____________________________________________________________
11. Was the gas/fluid treated with corrosion inhibitors or biocides?

 Yes  No

12. Were any liquids found in the distribution system where the Incident occurred?
 Yes  No
Complete the following if any Corrosion Failure sub-cause is selected AND the “Part of system involved in Incident” (from PART C,
Question 2) is Main, Service, or Service Riser.
13. Date of the most recent Leak Survey conducted:

/

/

/

Month

/

/

/

/

Day

/

/

Year

14. Has one or more pressure test been conducted since original construction at the point of the Incident?
 Yes  Most recent year tested: / / / / /
Test pressure (psig): /
/
/
/

/

/

 No

G2 – Natural Force Damage – only one sub-cause can be picked from shaded left-handed column


Earth Movement, NOT due to Heavy
Rains/Floods

1. Specify:  Earthquake

 Subsidence  Landslide

 Other ___________________



Heavy Rains/Floods

2. Specify:



Lightning

3. Specify:

 Direct hit  Secondary impact such as resulting nearby fires



Temperature

4. Specify:

 Thermal Stress
 Frozen Components



High Winds



Other Natural Force Damage

 Washouts/Scouring  Flotation  Mudslide  Other ________________

 Frost Heave
 Other ________________________________

5. Describe: _________________________________________________

Complete the following if any Natural Force Damage sub-cause is selected.
6. Were the natural forces causing the Incident generated in conjunction with an extreme weather event?
6.a. If Yes, specify: (select all that apply)

 Yes

 No

 Hurricane  Tropical Storm
 Tornado
 Other ______________________________

Form PHMSA F 7100.1 (Rev. xx-2009)

Page 9 of 18

Reproduction of this form is permitted

G3 – Excavation Damage – only one sub-cause can be picked from shaded left-hand column


Excavation Damage by Operator
(First Party)



Excavation Damage by Operator’s
Contractor (Second Party)



Excavation Damage by Third Party



Previous Damage due to Excavation
Activity

Complete the following ONLY IF the “Part of system involved in Incident” (from PART C,
Question 2) is Main, Service, or Service Riser.
1. Date of the most recent Leak Survey conducted:

/

/

/

/

Month

/

/

/

Day

/

/

Year

2. Has one or more pressure test been conducted since original construction at the point of the
Incident?
 Yes  Most recent year tested: / / / / /
Test pressure (psig):
/
/
/
/
/
/
 No
Complete the following if Excavation Damage by Third Party is selected.
3. Did the operator get prior notification of the excavation activity?
3.a If Yes, Notification received from: (select all that apply)

 Yes  No
 One-Call System

 Excavator

 Contractor

 Landowner

Complete the following mandatory CGA-DIRT Program questions if any Excavation Damage sub-cause is selected.
4. Do you want PHMSA to upload the following information to CGA-DIRT (www.cga-dirt.com)?

Yes

 No

5. Right-of-Way where event occurred: (select all that apply)

 Public  Specify:  City Street  State Highway  County Road  Interstate Highway
 Private  Specify:  Private Landowner  Private Business  Private Easement
 Pipeline Property/Easement
 Power/Transmission Line
 Railroad
 Dedicated Public Utility Easement
 Federal Land
 Data not collected
 Unknown/Other

 Other

6. Type of excavator: (select only one)

 Contractor
 Railroad

 County
 State

 Developer
 Utility

 Farmer
 Municipality
 Data not collected

 Occupant
 Unknown/Other

7. Type of excavation equipment: (select only one)

 Auger
 Explosives
 Probing Device

 Backhoe/Trackhoe
 Farm Equipment
 Trencher

 Boring
 Grader/Scraper
 Vacuum Equipment

 Drilling
 Directional Drilling
 Hand Tools
 Milling Equipment
 Data not collected  Unknown/Other

8. Type of work performed: (select only one)

 Agriculture
 Drainage
 Grading
 Natural Gas
 Sewer (Sanitary/Storm)
 Telecommunications
 Data not collected

 Cable TV
 Curb/Sidewalk
 Driveway
 Electric
 Irrigation
 Landscaping
 Pole
 Public Transit Authority
 Site Development
 Steam
Traffic Signal
 Traffic Sign
 Unknown/Other

 Building Construction
 Engineering/Surveying
 Liquid Pipeline
 Railroad Maintenance
 Storm Drain/Culvert
 Water

 Building Demolition
 Fencing
 Milling
 Road Work
Street Light
 Waterway Improvement

(This CGA-DIRT section continued on next page with Question 9.)

Form PHMSA F 7100.1 (Rev. xx-2009)

Page 10 of 18

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 Yes

9. Was the One-Call Center notified?

 No

9.a If Yes, specify ticket number: /__/__/__/__/__/__/__/__/__/__/__/__/__/__/__/__/__/__/
9.b If this is a State where more than a single One-Call Center exists, list the name of the One-Call Center notified:
_____________________________________________________________
10. Type of Locator:

 Utility Owner

 Contractor

Locator

 Data not collected

 Unknown/Other

11. Were facility locate marks visible in the area of excavation?

 No

 Yes

 Data not collected

 Unknown/Other

12. Were facilities marked correctly?

 No

 Yes

 Data not collected

 Unknown/Other

No

 Yes

 Data not collected

 Unknown/Other

13. Did the damage cause an interruption in service?
13.a If Yes, specify duration of the interruption:

/___/___/___/___/ hours

14. Description of the CGA-DIRT Root Cause (select only the one predominant first level CGA-DIRT Root Cause and then, where available as
a choice, the one predominant second level CGA-DIRT Root Cause as well):



One-Call Notification Practices Not Sufficient: (select only one)

 No notification made to the One-Call Center
 Notification to One-Call Center made, but not sufficient
 Wrong information provided


Locating Practices Not Sufficient: (select only one)

 Facility could not be found/located
 Facility marking or location not sufficient
 Facility was not located or marked
 Incorrect facility records/maps


Excavation Practices Not Sufficient: (select only one)

 Excavation practices not sufficient (other)
 Failure to maintain clearance
 Failure to maintain the marks
 Failure to support exposed facilities
 Failure to use hand tools where required
 Failure to verify location by test-hole (pot-holing)
 Improper backfilling


One-Call Notification Center Error



Abandoned Facility



Deteriorated Facility



Previous Damage



Data Not Collected



Other / None of the Above (explain)_____________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________

Form PHMSA F 7100.1 (Rev. xx-2009)

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G4 – Other Outside Force Damage

– only one sub-cause can be selected from the shaded left-hand column



Nearby Industrial, Man-made, or Other
Fire/Explosion as Primary Cause of
Incident



Damage by Car, Truck, or Other
Motorized Vehicle/Equipment NOT
Engaged in Excavation

1. Vehicle/Equipment operated by: (select only one)
 Operator
 Operator’s Contractor



Damage by Boats, Barges, Drilling
Rigs, or Other Maritime Equipment or
Vessels Set Adrift or Which Have
Otherwise Lost Their Mooring

2. Select one or more of the following IF an extreme weather event was a factor:
 Hurricane
 Tropical Storm
 Tornado
 Heavy Rains/Flood
 Other ______________________________



Routine or Normal Fishing or Other
Maritime Activity NOT Engaged in
Excavation



Electrical Arcing from Other
Equipment or Facility



Previous Mechanical Damage NOT
Related to Excavation

 Third Party

Complete the following ONLY IF the “Part of system involved in Incident” (from PART C,
Question 2) is Main, Service, or Service Riser.
3. Date of the most recent Leak Survey conducted:

/

/
Month

/

/

/
Day

/

/

/

/

Year

4. Has one or more pressure test been conducted since original construction at the point of
the Incident?
 Yes  Most recent year tested:
/
/
/
/
/
Test pressure (psig):
/
/
/
/
/
/
 No



Intentional Damage

5. Specify:



Other Outside Force Damage

6. Describe: _____________________________________________________

 Vandalism
 Terrorism
 Theft of transported commodity  Theft of equipment
 Other ________________________________________

Form PHMSA F 7100.1 (Rev. xx-2009)

Page 12 of 18

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G5 – Pipe, Weld, or Joint Failure – only one sub-cause can be selected from the shaded left-hand column
 Body of Pipe

1. Specify:

 Dent  Gouge  Bend  Arc Burn  Crack
 Other ___________________________

 Butt Weld

2. Specify:

 Pipe  Fabrication  Other ________________________________

 Fillet Weld

3. Specify:

 Branch  Hot Tap  Fitting  Repair Sleeve
 Other _______________________________

 Pipe Seam

4. Specify:

 LF ERW  DSWA  Flash Weld 
 Other ________________________

HF ERW



SAW

 Spiral

 Threaded Metallic Pipe
 Mechanical Fitting

5. Specify the mechanical fitting involved:
 Stab type fitting
 Nut follower type fitting
 Bolted type fitting
 Other _____________________________________________________
6. Specify the type of mechanical fitting:
 Service Tee
 Coupling
 Service Head Adapter
 Basement Adapter
 Riser
 Elbow
 Other _____________________________________________________
7. Manufacturer: _____________________________
8. Year manufactured:

/

/

/

/

/

9. Year installed:

/

/

/

/

/

10. Other attributes:________________________________________________________
11. Specify the two materials being joined:
11.a First material being jointed:
 Steel
 Cast/Wrought Iron
 Ductile Iron
 Copper
 Plastic
 Unknown
 Other  Specify: __________________________________
11.b If Plastic  Specify:

 Polyvinyl Chloride (PVC)
 Polyethylene (PE)
 Cross-linked Polyethylene (PEX)
 Polybutylene (PB)
 Polypropylene (PP)
 Acrylonitrile Butadiene Styrene (ABS)
 Polyamide (PA)
 Cellulose Acetate Butyrate (CAB)
 Other  Specify: __________________________________
11.c Second material being joined:
 Steel
 Cast/Wrought Iron
 Ductile Iron
 Copper
 Plastic
 Unknown
 Other  Specify: __________________________________
11.d If Plastic  Specify:

 Polyvinyl Chloride (PVC)
 Polyethylene (PE)
 Cross-linked Polyethylene (PEX)
 Polybutylene (PB)
 Polypropylene (PP)
 Acrylonitrile Butadiene Styrene (ABS)
 Polyamide (PA)
 Cellulose Acetate Butyrate (CAB)
 Other  Specify: __________________________________
12. If used on plastic pipe, did the fitting – as designed by the manufacturer – include
restraint?
 Yes
 No
 Unknown
12.a If Yes, specify:

 Cat. I

 Cat. II

Form PHMSA F 7100.1 (Rev. xx-2009)

 Cat. III

 DOT 192.283

Page 13 of 18

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 Compression Fitting

13.
14.
15.
16.
17.

Fitting type: ______________________________
Manufacturer: _____________________________
Year manufactured:
/ / / / /
Year installed:
/ / / / /
Other attributes ________________________________________________________

18. Specify the two materials being joined:
18.a First material being jointed:
 Steel
 Cast/Wrought Iron
 Ductile Iron
 Copper
 Plastic
 Unknown
 Other  Specify: __________________________________
18.b If Plastic  Specify :

 Polyvinyl Chloride (PVC)
 Polyethylene (PE)
 Cross-linked Polyethylene (PEX)
 Polybutylene (PB)
 Polypropylene (PP)
 Acrylonitrile Butadiene Styrene (ABS)
 Polyamide (PA)
 Cellulose Acetate Butyrate (CAB)
 Other  Specify: __________________________________
18.c Second material being joined:
 Steel
 Cast/Wrought Iron
 Ductile Iron
 Copper
 Plastic
 Unknown
 Other  Specify: __________________________________
18.d If Plastic  Specify:

 Polyvinyl Chloride (PVC)
 Polyethylene (PE)
 Cross-linked Polyethylene (PEX)
 Polybutylene (PB)
 Polypropylene (PP)
 Acrylonitrile Butadiene Styrene (ABS)
 Polyamide (PA)
 Cellulose Acetate Butyrate (CAB)
 Other  Specify: __________________________________
 Fusion Joint

19. Specify:

 Butt, Heat Fusion  Butt, Electrofusion  Saddle, Heat Fusion
 Saddle, Electrofusion  Socket, Heat Fusion  Socket, Electrofusion
 Other _______________________________

20. Year installed:

/

/

/

/

/

21. Other attributes:_________________________________________________________
22. Specify the two materials being joined:
22.a First material being jointed:
 Polyvinyl Chloride (PVC)
 Polyethylene (PE)
 Cross-linked Polyethylene (PEX)
 Polybutylene (PB)
 Polypropylene (PP)
 Acrylonitrile Butadiene Styrene (ABS)
 Polyamide (PA)
 Cellulose Acetate Butyrate (CAB)
 Other  Specify: __________________________________
22.b Second material being joined:
 Polyvinyl Chloride (PVC)
 Polyethylene (PE)
 Cross-linked Polyethylene (PEX)
 Polybutylene (PB)
 Polypropylene (PP)
 Acrylonitrile Butadiene Styrene (ABS)
 Polyamide (PA)
 Cellulose Acetate Butyrate (CAB)
 Other  Specify: __________________________________



Other Pipe, Weld, or Joint Failure

23. Describe: ______________________________________________________________

Form PHMSA F 7100.1 (Rev. xx-2009)

Page 14 of 18

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Complete the following if any Pipe, Weld, or Joint Failure sub-cause is selected.
10. Additional Factors: (select all that apply)  Dent  Gouge  Pipe Bend
 Lamination
 Buckle
 Wrinkle
 Misalignment
 Other __________________________________
11. Was the Incident a result of:
 Construction defect, specify: 
 Material defect, specify: 

 Arc Burn  Crack
 Burnt Steel

 Lack of Fusion

 Poor workmanship  Procedure not followed  Poor construction/installation procedures

 Long seam  Other ___________________________________________________

 Design defect
 Previous damage
12. Has one or more pressure test been conducted since original construction at the point of the Incident?

 Yes
 No

 Most recent year tested: /

/

/

/

/

Test pressure (psig): /

/

/

/

Form PHMSA F 7100.1 (Rev. xx-2009)

/

/

Page 15 of 18

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G6 – Equipment Failure– only one sub-cause can be selected from the shaded left-hand column
 Malfunction of Control/Relief
Equipment

1. Specify: (select all that apply)
 Control Valve
 Instrumentation
 SCADA
 Communications  Block Valve
 Check Valve
 Relief Valve
 Power Failure
 Stopple/Control Fitting
 Pressure Regulator
 Other____________________________________________

 Threaded Connection Failure

2. Specify:

 Pipe Nipple
 Valve Threads
 Threaded Pipe Collar
 Threaded Fitting
 Other ____________________________________________

 Non-threaded Connection Failure

3. Specify:

 O-Ring
 Gasket
 Other Seal or Packing
 Other_____________________________________________

 Valve

4. Specify:

 Manufacturing defect

 Other

________________________________

5.a Valve type: ____________________________________
5.b Manufactured by: ________________________________
5.c Year manufactured: /



Other Equipment Failure

/

/

/

/

5. Describe: ___________________________________________________________________
______________________________________________________________________________

Form PHMSA F 7100.1 (Rev. xx-2009)

Page 16 of 18

Reproduction of this form is permitted

G7 – Incorrect Operation – only one sub-cause can be selected from the shaded left-hand column


Damage by Operator or Operator’s
Contractor NOT Related to Excavation
and NOT due to Motorized
Vehicle/Equipment Damage



Valve Left or Placed in Wrong
Position, but NOT Resulting in an
Overpressure

 Pipeline or Equipment Overpressured



Equipment Not Installed Properly



Wrong Equipment Specified or
Installed



Other Incorrect Operation

1. Describe: __________________________________________________

Complete the following if any Incorrect Operation sub-cause is selected.
2. Was this Incident related to: (select all that apply)
 Inadequate procedure
 No procedure established
 Failure to follow procedure
 Other: ________________________________________________________
3. What category type was the activity that caused the Incident:
 Construction
 Commissioning
 Decommissioning
 Right-of-Way activities
 Routine maintenance
 Other maintenance
 Normal operating conditions
 Non-routine operating conditions (abnormal operations or emergencies)
4. Was the task(s) that led to the Incident identified as a covered task in your Operator Qualification Program?  Yes

 No

4.a If Yes, were the individuals performing the task(s) qualified for the task(s)?

 Yes, they were qualified for the task(s)
 No, but they were performing the task(s) under the direction and observation of a qualified individual
 No, they were not qualified for the task(s) nor were they performing the task(s) under the direction and observation of a
qualified individual

G8 – Other Incident Cause – only one sub-cause can be selected from the shaded left-hand column
 Miscellaneous

1. Describe:
___________________________________________________________________________
___________________________________________________________________________
2. Specify:

 Unknown

 Investigation complete, cause of Incident unknown
 Still under investigation, cause of Incident to be determined*
(*Supplemental Report required)

Form PHMSA F 7100.1 (Rev. xx-2009)

Page 17 of 18

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PART H – NARRATIVE DESCRIPTION OF THE INCIDENT

(Attach additional sheets as necessary)

__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
PART I – PREPARER AND AUTHORIZED SIGNATURE

Preparer's Name (type or print)

Preparer’s Telephone Number

Preparer's Title (type or print)

Preparer's E-mail Address
Authorized Signature

Preparer’s Facsimile Number
Date

Authorized Signature Telephone Number

Authorized Signature’s Name (type or print)

Authorized Signature’s Title (type or print)

Authorized Signature’s E-mail Address

Form PHMSA F 7100.1 (Rev. xx-2009)

Page 18 of 18

Reproduction of this form is permitted