9100-1 (Proposed) Safety-Related Condition Report

Notice: Each report of a safety-related condition under §191.23(a) for natural gas pipelines and LNG facilities and
under §195.55(a) for hazardous liquid pipelines must be filed within 5 working days after the day the operator first
determines the condition exists, but not later than 10 working days after the day the operator discovers the condition.

SAFETY-RELATED CONDITION REPORT
U.S. Department of Transportation
Pipeline and Hazardous Materials
Safety Administration

Form Approved
No. xxxx-xxxx
mm/dd/yyyy

INITIAL REPORT

SUPPLEMENTAL REPORT

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://www.phmsa.dot.gov/pipeline.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB
control number. The valid OMB control number for this information collection is xxxx-xxxx. The filling out of this information is mandatory and will
take XX minutes to complete.

Instructions:

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Part A – Operator Information

1. Pipeline/Facility Type: (select only one) … Natural and Other Gas
2. Operator ID: /___/___/___/___/___/

… Hazardous Liquid

… LNG Facility

3. Operator Name:_________________________________________

4. Operator Address:
a) __________________________________________ b) __________________________________________
(Street)
(City)
d) /__/__/
e) /__/__/__/__/__/
State)
(Zip Code)
Part B – Reporter Information

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1. Date of Report: :

/

/

/

/

/

/

/

(mm/dd/yy)

2. Name of Person Submitting Report: _____________________________
a): Job Title: ________________________________________
b): Phone Number: /__/__/__/-/__/__/__/-/__/__/__/__/
c): Email Address: ___________________________________

3. Name of Person who Determined the Condition Exists: _____________________________
a): Job Title: ________________________________________
b): Phone Number: : /__/__/__/-/__/__/__/-/__/__/__/__/
Part C – Condition Information:

1. Name of Pipeline or Facility: _____________________________
2. Date Condition was Discovered:

/

/

/

/

3. Date Condition was First Determined to Exist:

/

/

/

/

(mm/dd/yy)

/

/

/

/

/

/

(mm/dd/yy)

4. Onshore Location of Condition: (if offshore do not complete a through i, go to item 5)
(a)___________________________ (b) ___________________ (c) ___________________
(Street address)
(nearest City)
(County)
(d) /__/__/ (e) /__/__/__/__/__/ (f) ___________________________ or
(State)
(Zip code)
(Milepost)
(g)____________________________________________ or (h)_______________________
(Landmark)
(Survey Station Number)
(i): Latitude:
Longitude:

/

/

/ . /

/

/

/

/

/

- /

/

/ . /

/

/

/

/

/

Form PHMSA F####.# (rev. mm/yyyy)

Reproduction of this form is permitted

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5. Offshore Location of Condition: … OCS waters

… State waters

(a) State or nearest State: ____________________ (b) If on Platform, name of Platform: __________________
(c): Block/Tract #: /___/___/___/___/___/___/___
(d): Latitude:
Longitude:

/

/

/ . /

/

/

/

/

/

- /

/

/ . /

/

/

/

/

/

Part D – Description of Condition:

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1. Reason for Reporting Safety Related Condition (per §191.23/195.55): (select only one)
… General corrosion pitting (not a choice for an LNG Facility)
… Unintended movement or abnormal loading
… Material defect or physical damage (not a choice for an LNG Facility)
… Malfunction or operating error
… Leak that constitutes an emergency
… Condition that could lead to an imminent hazard
… Crack or material defect of an LNG facility (not a choice for Natural and Other Gas or Hazardous Liquid
Pipelines)
… Inner tank leakage, ineffective insulation of an LNG storage tank (not a choice for Natural and Other Gas or
Hazardous Liquid Pipelines)

2. Further Description of Condition selected above: __________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

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3. Commodity Transported or Stored: (select only one of the three primary categories shown and – for Natural and
Other Gas or Hazardous Liquid Pipeline Facilities, only one sub-category based on the predominant commodity
involved)
… LNG (for LNG Facility only)
… For Natural and Other Gas Pipeline Facility
… Natural Gas
… Propane Gas
… Synthetic Gas
… Hydrogen Gas
… Other Gas Æ Name:
__________________
… For Hazardous Liquid Pipeline Facility
… Crude Oil
… Refined and/or Petroleum Product (non-HVL) which is a Liquid at Ambient Conditions
… HVL or Other Flammable or Toxic Fluid which is a Gas at Ambient Conditions
… CO2 (Carbon Dioxide)
… Biofuel (including ethanol blends)

4. Describe the Circumstances Leading to the Discovery of the Condition: ________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

5. Describe the Significant Effects of the Condition on Safety: __________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Form PHMSA F####.# (rev. mm/yyyy)

Reproduction of this form is permitted

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Part E – Corrective Action Taken:
1. Corrective Action Taken Before the Report was Submitted: (select all that apply)
… Reduction of pressure
… Shutdown
… Other ÖDescribe: __________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
2. Describe the Planned Follow-up or Future Corrective Action: __________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
a): Anticipated Date for Start of Follow-up or Future Corrective Action: / / / / / / / (mm/dd/yy)

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b): Anticipated Date for Conclusion of Follow-up or Future Corrective Action:
(mm/dd/yy)

/

/

/

/

/

/

/

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Form PHMSA F####.# (rev. mm/yyyy)

Reproduction of this form is permitted

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INSTRUCTIONS FOR FORM PHMSA F XXXX.XX
SAFETY-RELATED CONDITION REPORT

GENERAL INSTRUCTIONS

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Reporting requirements are in Part 191 of Title 49 of the Code of
Federal Regulations (CFR) Transportation of Natural and Other Gas by
Pipeline: Annual Reports, Incident Reports, and Safety-Related
Condition Reports and Part 195 Transportation of Hazardous Liquids by
Pipeline, Subpart B – Annual, Accident, and Safety-Related Condition
Reporting.
As stipulated in §191.25 for natural gas pipelines and §195.56 for
hazardous liquid pipelines, filing safety-related condition reports
are required of each operator reporting safety-related conditions per
§191.23(a) or §195.55(a). Each operator within 5 working days after
the day a representative of the operator first determines that the
condition exists, but not later than 10 working days after the day a
representative of the operator discovers the condition. Separate
conditions may be described in a single report if they are closely
related.

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Note: Per §191.23(b) A report is not required for any safety-related
condition that—
(1) Exists on a master meter system or a customer-owned service line;
(2) Is an incident or results in an incident before the deadline for
filing the safety-related condition report;

(3) Exists on a pipeline (other than an LNG facility) that is more
than 220 yards (200 meters) from any building intended for human
occupancy or outdoor place of assembly, except that reports are
required for conditions within the right-of-way of an active railroad,
paved road, street, or highway; or
(4) Is corrected by repair or replacement in accordance with
applicable safety standards before the deadline for filing the safetyrelated condition report, except that reports are required for
conditions under paragraph (a)(1) of this section other than localized
corrosion pitting on an effectively coated and cathodically protected
pipeline.
(see Part D of these instructions for a listing of conditions noted in
the above paragraph)

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Note: Per §195.55(b) A report is not required for any safety-related
condition that—
(1) Exists on a pipeline that is more than 220 yards (200 meters) from
any building intended for human occupancy or outdoor place of
assembly, except that reports are required for conditions within the
right-of-way of an active railroad, paved road, street, or highway, or
that occur offshore or at onshore locations where a loss of hazardous
liquid could reasonably be expected to pollute any stream, river,
lake, reservoir, or other body of water;

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(2) Is an accident that is required to be reported under §195.50 or
results in such an accident before the deadline for filing the safetyrelated condition report; or
(3) Is corrected by repair or replacement in accordance with
applicable safety standards before the deadline for filing the safetyrelated condition report, except that reports are required for all
conditions under paragraph (a)(1) of this section other than localized
corrosion pitting on an effectively coated and cathodically protected
pipeline.

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(see Part D of these instructions for a listing of conditions noted in
the above paragraph)

If you need copies of the Form PHMSA F XXXX.XX and/or instructions
they can be found on the Pipeline Safety Community main page,
http://phmsa.dot.gov/pipeline, by clicking the Forms hyperlink and
scrolling down to the section entitled “Accident/Incident/Annual
Reporting Forms.” If you have questions about this report or these
instructions, please call (202) 366-8075. Please type or print all
entries when submitting forms by mail or Fax.

REPORTING METHODS

Use one of the following methods to submit your report. We prefer
online reporting over hardcopy submissions. If you prefer, you can
mail or fax your completed reports to DOT/PHMSA.
Note: Submit a copy of your report directly to the State Regulatory
Agency in addition to submitting to DOT/PHMSA, if that is the
requirement in your state.
1.

Online:
a. Navigate to the Pipeline Safety Community main page
http://phmsa.dot.gov/pipeline, click the ONLINE DATA ENTRY link
listed in the fourth column of hyperlinks

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b. Click on the Safety-Related Condition Report link
c. Enter Operator ID and PIN [If an operator does not have an
Operator ID or a PIN, the website
(http://opsweb.rspa.dot.gov/cfdocs/opsapps/pipes/main.cfm)
includes directions on how to obtain one.]
d. Click “add” to begin
e. Click “submit” when finished. A confirmation page will appear
for you to print and save for your records

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If you submit your report online, PLEASE DO NOT MAIL OR FAX the
completed report to DOT as this may result in duplicate entries.
2.

3.

Mail to:
DOT/PHMSA Office of Pipeline Safety
Information Resources Manager,
1200 New Jersey Ave., SE
East Building, 2nd Floor, (PHP-10)
Room Number E22-321
Washington, DC 20590

Fax to: Information Resources Manager at (202) 366-4566.

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SPECIFIC INSTRUCTIONS
Check Initial Report if this is the original filing for this safetyrelated condition. Check Supplemental Report if this is a follow-up
to a previously filed safety-related condition report to amend or
correct information. On Supplemental Reports, please complete Part A
and only amended, revised, or added information for Parts B, C, D and
E.

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PART A - OPERATOR INFORMATION

Complete the next four items to finish Part A

1. Pipeline Type/Facility Type – Please select the type of pipeline
system/facility this safety-related condition report is being
submitted for (i.e., is this a natural gas pipeline system that you
file annual reports for using the “Natural or Other Gas Transmission &
Gathering System” annual report form; is this an LNG facility that you
file annual reports for using the “Liquefied Natural Gas” annual
report form; or is this a hazardous liquid pipeline system which you
file annual reports for using the “Hazardous Liquid or Carbon Dioxide
System” annual report form).

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2. Operator’s 5 Digit Identification Number _/ _/ _/ _/ _/.

(Note: Depending on when your ID was issued, it may not contain five digits)

3. Operator Name - This is the company name used when registering for an Operator ID and PIN in the
Online Data Entry System.

The Pipeline and Hazardous Materials Safety Administration (PHMSA)
assigns the operator's five-digit identification number. Contact us at
(202) 366-8075 if you need assistance with an identification number.
A company may submit separate reports for subsidiaries or affiliate
operations under the appropriate operator name and ID number.
4. Operator Address – This should be the operator location office
filing the safety-related condition report. If there is no location
office, please use the headquarters address of the operator as
submitted on the annual reports.

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PART B – Reporter Information
For the items in this section, please provide the specific information
related to the person submitting the safety-related condition report.
1. Date of Report – refers to the actual date the safety-related
condition report is submitted to PHMSA.

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2. Name of Person Submitting Report – Please provide the name of the
person submitting the safety-related condition report.
a): Job Title – Please provide the official job title of the
person submitting the safety-related condition report.
b): Phone Number – Please provide the business telephone number
of the person submitting the safety-related condition report.
c): Email Address – Please provide the email address of the
person submitting the safety-related condition report.
3. Name of Person who Determined the Condition Exists – Please
provide the name of the person who made the determination that the
safety-related condition exists.
a): Job Title – Please provide the official job title of the
person who made the determination that the safety-related condition
exists.
b): Phone Number – Please provide the business telephone number
of the person who made the determination that the safety-related
condition exists.

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PART C – Condition Information

1. Name of Pipeline or Facility – Multiple pipeline systems and/or
facilities are often operated by a single operator. This information
identifies the particular pipeline system or pipeline facility name
commonly used by the operator on which the accident occurred, for
example, the “West Line 24” Pipeline”, or “Gulf Coast Pipeline” or
“Yankee Gas Services peak shaving plant”.
2. Date Condition was Discovered – Provide the date in mm/dd/yyyy
format for when the operator discovered the condition.

3. Date Condition was First Determined to Exist – Provide the date in
mm/dd/yyyy format for when the operator first determined the condition
to exist. Note: The dates for item 2 and 3 will usually be the same,
but may be different.
4. Onshore Location of Condition – For onshore locations (items a-i),
provide the street address, nearest city, state, zip code, and either
one of the following [milepost or landmark or survey station number]
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and the latitude and longitude of where the safety-related condition
is located. (see guidance below on determining latitude and
longitude)
5. Offshore Location of Condition – For offshore locations (items ad), select whether the condition is located in OCS waters or State
waters and then provide the state or nearest state of the offshore
area, the offshore platform name, block/tract number, and/or latitude
and longitude of the location of the safety-related condition.

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Note: Block/Tract numbers should be provided for either State or Outer
Continental Shelf (OCS) waters, whichever is applicable.
Please follow the guidance below when determining the GPS coordinates.
The latitude and longitude of the offshore pipeline condition
are to be reported as Decimal Degrees with a minimum of 5
decimal places (e.g. Lat: 38.89664 Long: -77.04327). If you
have coordinates in degrees/minutes or degrees/minutes/seconds,
use the formula below to convert to decimal degrees:
degrees + (minutes/60) + (seconds/3600) = decimal degrees
e.g. 38° 53' 47.904" = 38 + (53/60) + (47.904/3600) =
38.89664°

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All locations in the United States will have a negative
longitude coordinate. Be sure a negative (-) sign precedes your
longitude coordinate on your report. If you cannot locate the
incident with a GPS or some other means, the U.S. Census Bureau
provides a tool for determining them at the following URL
http://tiger.census.gov/cgi-bin/mapbrowse-tbl. You can use the
online tool to identify the geographic location of the incident.
The tool displays the latitude and longitude in decimal degrees
below the map. Any questions regarding the required format,
conversion or how to use the tool noted above can be directed to
PHMSA’s GIS Manager at (202)493-0591.

PART D – Description of Condition

1. Reason for Reporting Safety-Related Condition: For item 1, select
the corresponding regulation in either A or B which dictated your
reason for submitting the safety-related condition report. Note: If
you selected as your pipeline type in Part A natural gas or LNG
facility, you should select item A; however, if you selected hazardous
liquid as your pipeline type in Part A, then you should check item B.
After selecting the appropriate regulation governing your safetyrelated condition report submission, select all applicable conditions
listed under the corresponding regulation.
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Conditions Per §191.23/§195.55 – Reporting Safety-Related Conditions
(select only one)
… In the case of a pipeline (other than an LNG facility) that
operates at a hoop stress of 20 percent or more of its specified
minimum yield strength, general corrosion that has reduced the wall
thickness to less than that required for the maximum allowable
operating pressure, and localized corrosion pitting to a degree where
leakage might result.

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… Unintended movement or abnormal loading by environmental causes,
such as an earthquake, landslide, or flood, that impairs the
serviceability of a pipeline or the structural integrity or
reliability of an LNG facility that contains, controls, or processes
gas or LNG.

… Any material defect or physical damage that impairs the
serviceability of a pipeline that operates at a hoop stress of 20
percent or more of its specified minimum yield strength. (Note: Not a
choice for LNG)

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… Any malfunction or operating error that causes the pressure of a
pipeline or LNG facility that contains or processes gas or LNG to rise
above its maximum allowable operating pressure (or working pressure
for LNG facilities) plus the build-up allowed for operation of
pressure limiting or control devices.

… A leak in a pipeline or LNG facility that contains or processes gas
or LNG that constitutes an emergency.
… Any crack or other material defect that impairs the structural
integrity or reliability of an LNG facility that contains, controls,
or processes gas or LNG.
… Inner tank leakage, ineffective insulation, or frost heave that
impairs the structural integrity of an LNG storage tank.
… Any safety-related condition that could lead to an imminent hazard
and causes (either directly or indirectly by remedial action of the
operator), for purposes other than abandonment, a 20 percent or more
reduction in operating pressure or shutdown of operation of a pipeline
or an LNG facility that contains or processes gas or LNG.
2. Further Description of Condition selected above: For item 2,
provide additional description of the safety-related condition
selected in item 1 above.

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3. Commodity Transported or Stored: For item 3, select only one of
the three primary categories shown and – for Natural and Other Gas or
Hazardous Liquid Pipeline Facilities, only one sub-category based on
the predominant commodity involved)

LNG (for LNG Facility only)
For Natural and Other Gas Pipeline Facility
… Natural Gas
… Propane Gas
… Synthetic Gas
… Hydrogen Gas
… Other Gas Æ Name:
__________________
… For Hazardous Liquid Pipeline Facility
… Crude Oil
… Refined and/or Petroleum Product (non-HVL) which is a Liquid
at Ambient Conditions

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Note: Refined and/or Petroleum Product includes gasoline, diesel,
jet fuel, kerosene, fuel oils, or other refined or petroleum
products which are a liquid at ambient conditions. They are
flammable, toxic, or corrosive products obtained from distilling or
processing of crude oil, unfinished oils, natural gas liquids,
blend stocks, and other miscellaneous hydrocarbon compounds. For a
non-HVL petrochemical feedstock such as propylene report as “other”
and specify “propylene” in the space provided.

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… HVL or Other Flammable or Toxic Fluid which is a Gas at
Ambient Conditions

Note: Highly Volatile Liquids (HVLs) are hazardous liquids or
liquid mixtures which will form a vapor cloud when released to the
atmosphere and have a vapor pressure exceeding 276 kPa at 37.8 C.

Note: Other Flammable or Toxic Fluids are those defined under 49
CFR 173.120 Class 3—Definitions
Other flammable or toxic fluids which fall under this category
include gases at ambient conditions, such as anhydrous ammonia (NH3)
and propane. For a petrochemical feedstock such as ethane or
ethylene which is also classified as a highly volatile liquid,
report as “Other HVL” and specify the appropriate name (“ethane” or
“ethylene”) in the space provided.

CO2 (Carbon Dioxide)
Biofuel (including ethanol blends)

Note: Fuel Grade Ethanol is denatured ethanol before it has been
mixed with a petroleum product or other hydrocarbon; sometimes also
referred to as neat ethanol.
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Ethanol Blend is ethanol plus a petroleum product such as gasoline.
Such mixtures may be referred to as E10 or E85, for example,
representing a 10% or 85% blend respectively. In the space
provided, specify the percentage of ethanol in the mixture.
Biodiesel is a diesel liquid distilled from biological feedstocks
vs. crude oil. Biodiesel is typically shipped as a blend mixed with
a petroleum product. Report the percentage biodiesel in the blend
as shown.

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4. Describe the Circumstances Leading to the Discovery of the
Condition: For item 4, please describe the circumstances that lead to
the discovery of the condition.
5. Describe the Significant Effects of the Condition on Safety: For
item 5, please describe any significant effects the condition will
have on safety.

PART E – Corrective Action Taken

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1. Describe the Corrective Action Taken Before the Report was
Submitted: For item 1, select all applicable corrective actions taken
by the operator before the safety-related condition report was
submitted. If you select other, please describe in complete detail
the corrective actions taken prior to the safety-related condition
report was submitted.

2. Describe the Planned Follow-up or Future Corrective Action: For
item 2, please describe in complete detail the planned follow-up or
future corrective action for the condition in this safety-related
condition report. In addition, under item (a) include the anticipated
start date of follow-up or future corrective action for the condition
in this safety-related condition report. Finally, under item (b),
include the anticipated date for conclusion of follow-up or future
corrective action for the condition in this safety-related condition
report. Note: Date format for items (a) and (b) should be
mm/dd/yyyy.

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