Form PHMSA F 7000- Form PHMSA F 7000- ACCIDENT REPORT � HAZARDOUS LIQUID PIPELINE SYSTEMS

Transportation of Hazardous Liquids by Pipeline: Recordkeeping and Accident Reporting

CleanProposedHazLiquidAccidentFormWithInstructions

Transportation of Hazardous Liquids by Pipeline: Recordkeeping and Accident Reporting

OMB: 2137-0047

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NOTICE: This report is required by 49 CFR Part 195. 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: 2137-0047.
EXPIRATION DATE: mm/dd/yyyy

Report Date

ACCIDENT REPORT – HAZARDOUS LIQUID
PIPELINE SYSTEMS

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 2137-0047. Public reporting for this
collection of information is estimated to be approximately 10 hours per response (5 hours for a small release), 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. Note: Certain
low consequence accidents only require the information indicated in the shaded fields.
 Original

**Report Type: (select all that apply)

PART A – KEY REPORT INFORMATION

**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 Accident:
/

Hour

Month

**5. Location of Accident:
Latitude:
/ / / . / /
Longitude: - / / / / . /

/
/

Day

/
/

**6. National Response Center Report Number (if applicable):
/

Year

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

Hour

Month

Day

Year

**8. Commodity released: (select only one, based on predominant volume released)




Crude Oil
Refined and/or Petroleum Product (non-HVL) which is a Liquid at Ambient Conditions

 Gasoline (non-Ethanol)
 Diesel, Fuel Oil, Kerosene, Jet Fuel
 Mixture of Refined Products (transmix or other mixture)
 Other  Name: __________________________________


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

 Anhydrous Ammonia
 LPG (Liquefied Petroleum Gas) / NGL (Natural Gas Liquid)
 Other HVL  Name: _______________________________



CO 2 (Carbon Dioxide)
Biofuel / Alternative Fuel (including ethanol blends)

 Fuel Grade Ethanol
 Biodiesel  Blend (e.g. B2, B20, B100): B/___/___/___/
**9.

Estimated volume of commodity released unintentionally:

 Ethanol Blend  % Ethanol: /___/___/
 Other  Name: _______________________
/

/,/

/./

/ Barrels

**10. Estimated volume of intentional and/or controlled release/blowdown:

/,/

/./

/ Barrels

**11. Estimated volume of commodity recovered:

/,/

/./

/ Barrels

Form PHMSA F 7000-1 (Rev. xx-2009 )

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

 Yes  No

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

12.a Operator employees

13.a Operator employees

12.b Contractor employees
working for the Operator

13.b Contractor employees
working for the Operator

12.c Non-Operator
emergency responders

13.c Non-Operator
emergency responders

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

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

12.e General public

13.e General public

12.f Total fatalities (sum of above)

13.f Total injuries (sum of above)

**14. Was the pipeline/facility shut down due to the Accident?
 Yes  No  Explain: ______________________________________________________________________________
If Yes, complete Questions 14.a and 14.b: (use local time, 24-hr clock)
**14.a Local time and date of shutdown

Hour

14.b Local time pipeline/facility restarted

Hour

**15. Did the commodity ignite?

 Yes

 No

**16. Did the commodity explode?

 Yes

 No

17. Number of general public evacuated: /

Month

/,/

Day

Year

Day

 Still shut down*

Year

(*Supplemental Report required)

18. Time sequence: (use local time, 24-hour clock)
18.a Local time Operator identified Accident

Hour

18.b Local time Operator resources arrived on site

/
Hour

Month

Day

Month

Form PHMSA F 7000-1 (Rev. xx-2009 )

/
Day

Year

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PART B – ADDITIONAL LOCATION INFORMATION
**1. Was the origin of the Accident onshore?
 Yes (Complete Questions 2-12)

 No

(Complete Questions 13-15)

If Onshore:
**2. State: /

If Offshore:
/

**3. Zip Code: /

13. Approximate water depth (ft.) at the point of the Accident:
/

**4._______________________

/ - /

**5_______________________

City

County or Parish

6. Operator-designated location: (select only one)
 Milepost/Valve Station (specify in shaded area below)

 Survey Station No.



(specify in shaded area below)

8. Segment name/ID: __________________________________
9. Was Accident on Federal land, other than the Outer Continental
Shelf (OCS)?
 Yes  No
**10. Location of Accident: (select only one)




Totally contained on Operator-controlled property
Originated on Operator-controlled property, but then flowed
or migrated off the property



Pipeline right-of-way

**11. Area of Accident (as found): (select only one)




/,/

In State waters
 Specify: State: / / /
Area: ___________________
Block/Tract #: /___/___/___/___/
Nearest County/Parish: ________________

/___/___/___/___/___/___/___/___/___/___/___/___/___/
7. Pipeline/Facility name: _______________________________

**14. Origin of Accident:



On the Outer Continental Shelf (OCS)
 Specify: Area: ___________________
Block #: /___/___/___/___/

15. Area of Accident: (select only one)

 Shoreline/Bank crossing or shore approach
 Below water, pipe buried or jetted below seabed
 Below water, pipe on or above seabed
 Splash Zone of riser
 Portion of riser outside of Splash Zone, including riser bend
 Platform

Tank, including attached appurtenances
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  Specify:

 Typical aboveground facility piping or appurtenance
 Overhead crossing
 In or spanning an open ditch
 Inside a building
 Inside other enclosed space
 Other ____________________________
 Transition Area  Specify:  Soil/air interface  Wall
sleeve  Pipe support or other close contact area
 Other _________________________
**12. Did Accident occur in a crossing?:  Yes
If Yes, specify type below:
 Bridge crossing  Specify:  Cased




Road crossing



 Cased
Water crossing

 Uncased


 Uncased
 Bored/drilled
(select all that apply)

 Uncased
 Bored/drilled

Railroad crossing

 Cased

 No

(select all that apply)

Specify:  Cased
 Uncased
Name of body of water, if commonly known:
_____________________________________
Approx. water depth (ft) at the point of the Accident:



/,/

(select only one of the following)






Shoreline/Bank crossing
Below water, pipe in bored/drilled crossing
Below water, pipe buried below bottom (NOT in
bored/drilled crossing)
Below water, pipe on or above bottom

Form PHMSA F 7000-1 (Rev. xx-2009 )

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PART C – ADDITIONAL FACILITY INFORMATION
**1. Is the pipeline or facility:
 Interstate
 Intrastate
**2. Part of system involved in Accident: (select only one)
 Onshore Breakout Tank or Storage Vessel, Including Attached Appurtenances 








 Atmospheric or Low Pressure
 Pressurized

Onshore Terminal/Tank Farm Equipment and Piping
Onshore Equipment and Piping Associated with Belowground Storage
Onshore Pump/Meter Station Equipment and Piping
Onshore Pipeline, Including Valve Sites
Offshore Platform/Deepwater Port, Including Platform-mounted Equipment and Piping
Offshore Pipeline, Including Riser and Riser Bend

**3. Item involved in Accident: (select only one)



Pipe



Specify:

 Pipe Body

**3.a Nominal diameter of pipe (in):
3.b Wall thickness (in):



 Pipe Seam
/

/./

/
/

/./

3.c SMYS (Specified Minimum Yield Strength) of pipe (psi):

/,/

3.d Pipe specification: _____________________________
**3.e Pipe Seam

 Specify:  Longitudinal ERW - High Frequency
 Longitudinal ERW - Low Frequency
 Longitudinal ERW – Unknown Frequency
 Spiral Welded ERW
 Spiral Welded SAW
 Lap Welded
 Seamless

 Single SAW
 DSAW

 Flash Welded
 Continuous Welded
 Furnace Butt Welded

 Spiral Welded DSAW
 Other ________________________

3.f Pipe manufacturer: _______________________________
3.g Year of manufacture: /
/
/
/
/
**3.h Pipeline coating type at point of Accident
 Fusion Bonded Epoxy
 Specify:

 Coal Tar
 Asphalt
 Polyolefin
 Extruded Polyethylene  Field Applied Epoxy  Cold Applied Tape  Paint
 Composite
 None
 Other _______________________________
 Weld, including heat-affected zone  Specify:  Pipe Girth Weld  Other Butt Weld  Fillet Weld  Other_____________
 Valve
 Mainline  Specify:  Butterfly  Check  Gate  Plug  Ball  Globe
 Other __________________________
3.i Mainline valve manufacturer: ______________________________
3.j Year of manufacture: /
/
/
/
/
















 Relief Valve
 Auxiliary or Other Valve
Pump
Meter/Prover
Scraper/Pig Trap
Sump/Separator
Repair Sleeve or Clamp
Hot Tap Equipment
Stopple Fitting
Flange
Relief Line
Auxiliary Piping (e.g. drain lines)
Tubing
Instrumentation
Tank/Vessel  Specify:  Single Bottom System

 Double Bottom System
 Tank Shell
 Chime
 Roof Drain System
 Mixer
 Pressure Vessel Head or Wall
 Other ________________________________

 Roof/Roof Seal
 Appurtenance

Other ___________________________________

4. Year item involved in Accident was installed:

Form PHMSA F 7000-1 (Rev. xx-2009 )

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**5. Material involved in Accident: (select only one)
 Carbon Steel
 Material other than Carbon Steel  Specify: ____________________________________________
6. Type of Accident involved: (select only one)
 Mechanical Puncture  Approx. size: /__/__/__/__/./__/in. (axial) by /__/__/__/__/./__/in. (circumferential)

 Crack
 Connection Failure
 Seal or Packing
 Other
 Select Type:  Pinhole
Select
Orientation:

Circumferential

Longitudinal

Other
________________________________

Approx. size: /__/__/__/__/./__/ in. (widest opening) by /__/__/__/__/__/./__/in. (length circumferentially or axially)



Leak




Overfill or Overflow
Other  Describe: _______________________________________________________________________________________

Rupture

Form PHMSA F 7000-1 (Rev. xx-2009 )

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PART D – ADDITIONAL CONSEQUENCE INFORMATION
1. Wildlife impact:
 Yes  No
1.a If Yes, specify all that apply:

 Fish/aquatic
 Birds
 Terrestrial
2. Soil contamination:

 Yes  No

3. Long term impact assessment performed or planned:

 Yes  No

4. Anticipated remediation:  Yes  No (not needed)
4.a If Yes, specify all that apply:

 Surface water
5. Water contamination:

 Groundwater  Soil  Vegetation  Wildlife
 Yes  (Complete 5.a – 5.c below)
 No

5.a Specify all that apply:

 Ocean/Seawater
 Surface
 Groundwater
 Drinking water 

(Select one or both)

 Private Well  Public Water Intake

5.b Estimated amount released in or reaching water:

/,/

/___/./___/___/ Barrels

5.c Name of body of water, if commonly known: __________________________________________
**6. At the location of this Accident, had the pipeline segment or facility been identified as one that “could affect” a High Consequence Area
(HCA) as determined in the Operator’s Integrity Management Program?
 Yes  No

 Yes  No

**7. Did the released commodity reach or occur in one or more High Consequence Area (HCA)?
**7.a If Yes, specify HCA type(s): (select all that apply)



Commercially Navigable Waterway
Was this HCA identified in the “could affect” determination for this Accident site in the Operator’s Integrity Management Program?
 Yes  No



High Population Area
Was this HCA identified in the “could affect” determination for this Accident site in the Operator’s Integrity Management Program?
 Yes  No



Other Populated Area
Was this HCA identified in the “could affect” determination for this Accident site in the Operator’s Integrity Management Program?
 Yes  No



Unusually Sensitive Area (USA) – Drinking Water
Was this HCA identified in the “could affect” determination for this Accident site in the Operator’s Integrity Management Program?
 Yes  No



Unusually Sensitive Area (USA) – Ecological
Was this HCA identified in the “could affect” determination for this Accident site in the Operator’s Integrity Management Program?
 Yes  No

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

/,/

8.b Estimated cost of commodity lost

/,/

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

/,/

8.d Estimated cost of Operator’s emergency response

/,/

8.e Estimated cost of Operator’s environmental remediation

/,/

8.f Estimated other costs

/,/

Describe ___________________________________________________
8.g Estimated total costs (sum of above)

Form PHMSA F 7000-1 (Rev. xx-2009 )

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

/,/

**2. Maximum Operating Pressure (MOP) at the point and time of the Accident (psig) :

/,/

**3. Describe the pressure on the system or facility relating to the Accident: (select only one)
 Pressure did not exceed MOP
 Pressure exceeded MOP, but did not exceed 110% of MOP
 Pressure exceeded 110% of MOP
**4. Not including pressure reductions required by PHMSA regulations (such as for repairs and pipe movement), was the system or facility
relating to the Accident operating under an established pressure restriction with pressure limits below those normally allowed by the MOP?

 No
 Yes  (Complete 4.a and 4.b below)
4.a Did the pressure exceed this established pressure restriction?

 Yes

 No

4.b Was this pressure restriction mandated by PHMSA or the State?

 PHMSA

 State

 Not mandated

**5. Was “Onshore Pipeline, Including Valve Sites” OR “Offshore Pipeline, Including Riser and Riser Bend” selected in PART C, Question 2?

 No
 Yes 

(Complete 5.a – 5.f below)

**5.a Type of upstream valve used to initially isolate release source:

 Manual

 Automatic

 Remotely Controlled

**5.b Type of downstream valve used to initially isolate release source:

 Manual  Automatic
 Check Valve

 Remotely Controlled

**5.c Length of segment initially isolated between valves (ft):

/,/

5.d Is the pipeline configured to accommodate internal inspection tools?




Yes
No  Which physical features limit tool accommodation? (select all that apply)








Changes in line pipe diameter
Presence of unsuitable mainline valves
Tight or mitered pipe bends
Other passage restrictions (i.e. unbarred tee’s, projecting instrumentation, etc.)
Extra thick pipe wall (applicable only for magnetic flux leakage internal inspection tools)
Other  Describe:__________________________________________________________________

5.e For this pipeline, are there operational factors which significantly complicate the execution of an internal inspection tool run?




No
Yes

 Which operational factors complicate execution?






(select all that apply)

Excessive debris or scale, wax, or other wall build-up
Low operating pressure(s)
Low flow or absence of flow
Incompatible commodity
Other  Describe:__________________________________________________________________

**5.f Function of pipeline system: (select only one)
 > 20% SMYS Regulated Trunkline/Transmission
 ≤ 20% SMYS Regulated Trunkline/Transmission
 ≤ 20% SMYS “Unregulated” Trunkline/Transmission

 > 20% SMYS Regulated Gathering
 ≤ 20% SMYS Regulated Gathering
 ≤ 20% SMYS “Unregulated” Gathering

Form PHMSA F 7000-1 (Rev. xx-2009 )

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6. Was a Supervisory Control and Data Acquisition (SCADA)-based system in place on the pipeline or facility involved in the Accident?
 No
 Yes  6.a Was it operating at the time of the Accident?
 Yes
 No
6.b Was it fully functional at the time of the Accident?
 Yes
 No
6.c Did SCADA-based information (such as alarm(s), alert(s), event(s), and/or volume calculations) assist with the
 Yes
 No
detection of the Accident?
6.d Did SCADA-based information (such as alarm(s), alert(s), event(s), and/or volume calculations) assist with the
 Yes
 No
confirmation of the Accident?
7. Was a CPM leak detection system in place on the pipeline or facility involved in the Accident?




No
Yes



7.a Was it operating at the time of the Accident?

 Yes

 No

7.b Was it fully functional at the time of the Accident?
 Yes
 No
7.c Did CPM leak detection system information (such as alarm(s), alert(s), event(s), and/or volume calculations) assist
with the detection of the Accident?
 Yes
 No
7.d Did CPM leak detection system information (such as alarm(s), alert(s), event(s), and/or volume calculations) assist
 Yes
 No
with the confirmation of the Accident?
8. How was the Accident initially identified for the Operator? (select only one)

 CPM leak detection system or SCADA-based information (such as alarm(s), alert(s), event(s), and/or volume 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 Accident
 Other _________________________________________________
8.a If “Controller”, “Local Operating Personnel, including contractors”, “Air Patrol”, or “Ground Patrol by Operator or its contractor” is
selected in Question 8, specify the following: (select only one)

 Operator employee

 Contractor working for the Operator

9. 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
Accident? (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 Accident
 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 7000-1 (Rev. xx-2009 )

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PART F – DRUG & ALCOHOL TESTING INFORMATION
**1. As a result of this Accident, 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 Accident, 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 7000-1 (Rev. xx-2009 )

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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 Accident, and answer the questions on the right. Describe
secondary, contributing, or root causes of the Accident 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 Accident?
 Yes  Year protection started: / / / / /

 No

4.b Was shielding, tenting, or disbonding of coating evident at the point of
the Accident?
 Yes  No
4.c Has one or more Cathodic Protection Survey been conducted at
the point of the Accident?
 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



Internal Corrosion

**6. Results of visual examination:
 Localized Pitting
 General Corrosion
 Not cut open
 Other _______________________________________________
7. Cause of corrosion: (select all that apply)
 Corrosive Commodity  Water drop-out/Acid  Microbiological
 Other ________________________________________________

 Erosion

8. The cause(s) of corrosion selected in Question 7 is based on the following: (select all that
apply)
 Field examination
 Determined by metallurgical analysis
 Other _____________________________________________
9. Location of corrosion: (select all that apply)
 Low point in pipe  Elbow
 Other_____________________________________
**10. Was the commodity treated with corrosion inhibitors or biocides?
**11. Was the interior coated or lined with protective coating?

 Yes  No

**12. Were cleaning/dewatering pigs (or other operations) routinely utilized?
 Not applicable - Not mainline pipe
 Yes
 No
**13. Were corrosion coupons routinely utilized?
 Not applicable - Not mainline pipe
 Yes

 No

Complete the following if any Corrosion Failure sub-cause is selected AND the “Item Involved in Accident” (from PART C, Question 3) is
Tank/Vessel.
**14. List the year of the most recent inspections:
14.a API Std 653 Out-of-Service Inspection
14.b API Std 653 In-Service Inspection

/
/

 No Out-of-Service Inspection completed
 No In-Service Inspection completed

Form PHMSA F 7000-1 (Rev. xx-2009 )

Page 10 of 20

Reproduction of this form is permitted

Complete the following if any Corrosion Failure sub-cause is selected AND the “Item Involved in Accident” (from PART C, Question 3) is
Pipe or Weld.
**15. Has one or more internal inspection tool collected data at the point of the Accident?
 Yes  No
15.a. If Yes, for each tool used, select type of internal inspection tool and indicate most recent year run:

 Magnetic Flux Leakage Tool
 Ultrasonic
 Geometry
 Caliper
 Crack
 Hard Spot
 Combination Tool
 Transverse Field/Triaxial
 Other __________________________

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

 No

**17. Has one or more Direct Assessment been conducted on this segment?
 Yes, and an investigative dig was conducted at the point of the Accident

 Yes, but the point of the Accident was not identified as a dig site
 No

 Most recent year conducted:
 Most recent year conducted:

18. Has one or more non-destructive examination been conducted at the point of the Accident since January 1, 2002?
 Yes  No
18.a If Yes, for each examination conducted since January 1, 2002, select type of non-destructive examination and indicate most recent
year the examination was conducted:

 Radiography
 Guided Wave Ultrasonic
 Handheld Ultrasonic Tool
 Wet Magnetic Particle Test
 Dry Magnetic Particle Test
 Other __________________________

/
/
/
/
/
/

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

Earth Movement, NOT due to
Heavy Rains/Floods

**1. Specify:

 Earthquake  Subsidence  Landslide
 Other ____________________



Heavy Rains/Floods

2. Specify:

 Washout/Scouring  Flotation  Mudslide  Other _________________



Lightning

3. Specify:

 Direct hit



Temperature

**4. Specify:



High Winds



Other Natural Force Damage

 Secondary impact such as resulting nearby fires

 Thermal Stress
 Frozen Components

 Frost Heave
 Other ________________________________

**5. Describe: _________________________________________________

Complete the following if any Natural Force Damage sub-cause is selected.
**6. Were the natural forces causing the Accident 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 7000-1 (Rev. xx-2009 )

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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 Questions 1-5 ONLY IF the “Item Involved in Accident” (from PART C,
Question 3) is Pipe or Weld.
**1. Has one or more internal inspection tool collected data at the point of the Accident?
 Yes  No
1.a If Yes, for each tool used, select type of internal inspection tool and indicate most
recent year run:

 Magnetic Flux Leakage
 Ultrasonic
 Geometry
 Caliper
 Crack
 Hard Spot
 Combination Tool
 Transverse Field/Triaxial
 Other _____________________

2. Do you have reason to believe that the internal inspection was completed BEFORE the
damage was sustained?  Yes  No
**3. Has one or more hydrotest or other pressure test been conducted since original
construction at the point of the Accident?

 Yes Most recent year tested:
Test pressure (psig):

/
/

/
/, /

/
/

 No
**4. Has one or more Direct Assessment been conducted on the pipeline segment?

 Yes, and an investigative dig was conducted at the point of the Accident
 Most recent year conducted: / / / / /
 Yes, but the point of the Accident was not identified as a dig site
 Most recent year conducted: / / / / /
 No
5. Has one or more non-destructive examination been conducted at the point of the Accident
since January 1, 2002?
 Yes  No
5.a If Yes, for each examination conducted since January 1, 2002, select type of nondestructive examination and indicate most recent year the examination was conducted:

 Radiography
 Guided Wave Ultrasonic
 Handheld Ultrasonic Tool
 Wet Magnetic Particle Test
 Dry Magnetic Particle Test
 Other __________________________

Complete the following if Excavation Damage by Third Party is selected as the sub-cause.
**6. Did the Operator get prior notification of the excavation activity?
6.a If Yes, Notification received from: (select all that apply)

 Yes  No

 One-Call System

 Excavator

Form PHMSA F 7000-1 (Rev. xx-2009 )

 Contractor

 Landowner

Page 12 of 20

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

Yes

 No

**8. 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

**9. Type of excavator: (select only one)

 Contractor
 Railroad

 County
 State

 Developer
 Utility

 Farmer
 Municipality
 Data not collected

 Occupant
 Unknown/Other

**10. 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

**11. 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

**12. Was the One-Call Center notified?

 Yes

12.a If Yes, specify ticket number: /

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

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

 No
/

12.b If this is a State where more than a single One-Call Center exists, list the name of the One-Call Center notified:
_____________________________________________________________

 Contract Locator

 Data not collected

 Unknown/Other

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

 No

 Yes

 Data not collected

 Unknown/Other

15. Were facilities marked correctly?

 No

 Yes

 Data not collected

 Unknown/Other

 No

 Yes

 Data not collected

 Unknown/Other

**13. Type of Locator:

 Utility Owner

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

/___/___/___/___/ hours

(This CGA-DIRT section continued on next page with Question 17.)

Form PHMSA F 7000-1 (Rev. xx-2009 )

Page 13 of 20

Reproduction of this form is permitted

17. 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 7000-1 (Rev. xx-2009 )

Page 14 of 20

Reproduction of this form is permitted

G4 - Other Outside Force Damage - **only one sub-cause can be picked from shaded left-hand column


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



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 Questions 3-7 ONLY IF the “Item Involved in Accident” (from PART C,
Question 3) is Pipe or Weld.
**3. Has one or more internal inspection tool collected data at the point of the Accident?
 Yes  No
3.a If Yes, for each tool used, select type of internal inspection tool and indicate most
recent year run:

 Magnetic Flux Leakage
 Ultrasonic
 Geometry
 Caliper
 Crack
 Hard Spot
 Combination Tool
 Transverse Field/Triaxial
 Other _____________________

4. Do you have reason to believe that the internal inspection was completed BEFORE the
damage was sustained?  Yes  No
**5. Has one or more hydrotest or other pressure test been conducted since original
construction at the point of the Accident?

 Yes Most recent year tested:
Test pressure (psig):

/
/

/
/, /

/
/

 No
**6. Has one or more Direct Assessment been conducted on the pipeline segment?

Form PHMSA F 7000-1 (Rev. xx-2009 )

Page 15 of 20

Reproduction of this form is permitted

7. Has one or more non-destructive examination been conducted at the point of the Accident
since January 1, 2002?
 Yes  No
7.a If Yes, for each examination conducted since January 1, 2002, select type of nondestructive examination and indicate most recent year the examination was conducted:
 Radiography
/
/
/
/
/

 Guided Wave Ultrasonic
 Handheld Ultrasonic Tool
 Wet Magnetic Particle Test
 Dry Magnetic Particle Test
 Other __________________________



Intentional Damage

8. Specify:



Other Outside Force Damage

**9. Describe: _________________________________________________________

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

Form PHMSA F 7000-1 (Rev. xx-2009 )

Page 16 of 20

Reproduction of this form is permitted

Use this section to report material failures ONLY IF the “Item Involved in
Accident” (from PART C, Question 3) is “Pipe” or “Weld.”

G5 - Material Failure of Pipe or Weld

**Only one sub-cause can be picked from shaded left-hand column
**1. The sub-cause selected below is based on the following: (select all that apply)

 Field Examination

 Determined by Metallurgical Analysis

 Other Analysis__________________________

 Sub-cause is Tentative or Suspected; Still Under Investigation


Construction-, Installation-, or
Fabrication-related



Original Manufacturing-related
(NOT girth weld or other welds
formed in the field)



Environmental Cracking-related

(Supplemental Report required)

2. List contributing factors: (select all that apply)
 Fatigue- or Vibration-related:
 Mechanically-induced prior to installation (such as during transport of pipe)
 Mechanical Vibration
 Pressure-related
 Thermal
 Other __________________________________
 Mechanical Stress
 Other __________________________________
3. Specify:  Stress Corrosion Cracking
 Sulfide Stress Cracking
 Hydrogen Stress Cracking
 Other ______________________________

Complete the following if any Material Failure of Pipe or Weld sub-cause is selected.
4. Additional factors: (select all that apply)  Dent  Gouge  Pipe Bend
 Lamination
 Buckle
 Wrinkle
 Misalignment
 Other __________________________________

 Arc Burn  Crack
 Burnt Steel

**5. Has one or more internal inspection tool collected data at the point of the Accident?

 Lack of Fusion

 Yes  No

5.a If Yes, for each tool used, select type of internal inspection tool and indicate most recent year run:

 Magnetic Flux Leakage Tool
 Ultrasonic
 Geometry
 Caliper
 Crack
 Hard Spot
 Combination Tool
 Transverse Field/Triaxial
 Other __________________________

**6. Has one or more hydrotest or other pressure test been conducted since original construction at the point of the Accident?
 Yes  Most recent year tested: / / / / /
Test pressure (psig): /
/
/,/
/
/
/

 No

**7. Has one or more Direct Assessment been conducted on the pipeline segment?
 Yes, and an investigative dig was conducted at the point of the Accident  Most recent year conducted:

 Yes, but the point of the Accident was not identified as a dig site
 No



Most recent year conducted:

8. Has one or more non-destructive examination(s) been conducted at the point of the Accident since January 1, 2002?
 Yes  No
8.a If Yes, for each examination conducted since January 1, 2002, select type of non-destructive examination and indicate most recent
year the examination was conducted:

 Radiography
 Guided Wave Ultrasonic
 Handheld Ultrasonic Tool
 Wet Magnetic Particle Test
 Dry Magnetic Particle Test
 Other ________________________________

/
/
/
/
/
/

Form PHMSA F 7000-1 (Rev. xx-2009 )

Page 17 of 20

Reproduction of this form is permitted

G6 - Equipment Failure - **only one sub-cause can be picked from 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
 ESD System Failure
 Other ________________________________________________________



Pump or Pump-related Equipment

**2. Specify:  Seal/Packing Failure
 Body Failure
 Crack in Body
 Appurtenance Failure
 Other ________________________________________________________



Threaded Connection/Coupling
Failure

**3. Specify:

 Pipe Nipple
 Valve Threads
 Mechanical Coupling
 Threaded Pipe Collar  Threaded Fitting
 Other ________________________________________________________



Non-threaded Connection Failure

**4. Specify:

 O-Ring  Gasket
 Seal (NOT pump seal) or Packing
 Other ________________________________________________________



Defective or Loose Tubing or Fitting



Failure of Equipment Body (except
Pump), Tank Plate, or other Material



Other Equipment Failure

**5. Describe: ___________________________________________________________
_______________________________________________________________________

Complete the following if any Equipment Failure sub-cause is selected.
6. Additional factors that contributed to the equipment failure: (select all that apply)
 Excessive vibration

 Overpressurization
 No support or loss of support
 Manufacturing defect
 Loss of electricity
 Improper installation
 Mismatched items (different manufacturer for tubing and tubing fittings)
 Dissimilar metals
 Breakdown of soft goods due to compatibility issues with transported commodity
 Valve vault or valve can contributed to the release
 Alarm/status failure
 Misalignment
 Thermal stress
 Other _______________________________________________________

Form PHMSA F 7000-1 (Rev. xx-2009 )

Page 18 of 20

Reproduction of this form is permitted

G7 - Incorrect Operation - **only one sub-cause can be picked from shaded left-hand column


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



Tank, Vessel, or Sump/Separator
Allowed or Caused to Overfill or
Overflow



Valve Left or Placed in Wrong
Position, but NOT Resulting in a
Tank, Vessel, or Sump/Separator
Overflow or Facility Overpressure

1. Specify:

 Valve misalignment
 Incorrect reference data/calculation
 Miscommunication
 Inadequate monitoring
 Other ____________________________________

 Pipeline or Equipment
Overpressured



Equipment Not Installed Properly



Wrong Equipment Specified or
Installed



Other Incorrect Operation

**2. Describe: __________________________________________________

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

 No

5.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 Accident Cause - **only one sub-cause can be picked from shaded left-hand column


Miscellaneous



Unknown

**1. Describe:
___________________________________________________________________________
___________________________________________________________________________
**2. Specify:

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

Form PHMSA F 7000-1 (Rev. xx-2009 )

Page 19 of 20

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PART H – NARRATIVE DESCRIPTION OF THE ACCIDENT

(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 E-mail Address

Authorized Signature’s Title (type or print)

Form PHMSA F 7000-1 (Rev. xx-2009 )

Page 20 of 20

Reproduction of this form is permitted

INSTRUCTIONS FOR FORM PHMSA F 7000-1 (Rev. xx-2009)
ACCIDENT REPORT - HAZARDOUS LIQUID PIPELINE SYSTEMS

GENERAL INSTRUCTIONS
Each hazardous liquid pipeline operator shall file a written report for an accident that
meets the criteria in 49 CFR §195.50 as soon as practicable but not more than 30 days
after discovery of the accident, using the appropriate form. Hazardous liquid releases
during maintenance activities need not be reported if the spill was less than 5 barrels, not
otherwise reportable under 49 CFR §195.50, did not result in water pollution as described
by 49 CFR §195.52(a)(4), was confined to company property or pipeline right-of-way,
and was cleaned up promptly. Any spill of 5 gallons or more to water shall be reported.
If you need copies of the Form PHMSA F 7000-1 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 PHMSA/OPS Forms
(accidents/incidents/annuals). 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.

195.50 Reporting accidents.
An accident report is required for each failure in a pipeline system subject to this
part in which there is a release of the hazardous liquid or carbon dioxide
transported resulting in any of the following:
(a) Explosion or fire not intentionally set by the operator.
(b) Release of 5 gallons (19 liters) or more of hazardous liquid or carbon
dioxide, except that no report is required for a release of less than 5 barrels (0.8
cubic meters) resulting from a pipeline maintenance activity if the release is:
(1) Not otherwise reportable under this section;
(2) Not one described in §195.52(a)(4);
(3) Confined to company property or pipeline right-of-way; and
(4) Cleaned up promptly;
(c) Death of any person;
(d) Personal injury necessitating hospitalization;
(e) Estimated property damage, including cost of clean-up and recovery,
value of lost product, and damage to the property of the operator or others, or both,
exceeding $50,000.

195.52 Telephonic Notice of Certain Accidents.
(a) At the earliest practicable moment following discovery of a release of the
hazardous liquid or carbon dioxide transported resulting in an event
described in §195.50, the operator of the system shall give notice, in
accordance with paragraph (b) of this section, of any failure that:
(1) Caused a death or a personal injury requiring hospitalization;
(2) Resulted in either a fire or explosion not intentionally set by the
operator;
(3) Caused estimated property damage, including cost of cleanup and
recovery, value of lost product, and damage to the property of the
operator or others, or both, exceeding $50,000;
(4) Resulted in pollution of any stream, river, lake, reservoir, or other
similar body of water that violated applicable water quality
standards, caused a discoloration of the surface of the water or
adjoining shoreline, or deposited a sludge or emulsion beneath the
surface of the water or upon adjoining shorelines; or
(5) In the judgment of the operator was significant even though it did
not meet the criteria of any other paragraph of this section.
(b) Reports made under paragraph (a) of this section are made by telephone to
800-424-8802 (for those without 800 access: 202-267-2675) and must include the
following information:
(1) Name and address of the operator.
(2) Name and telephone number of the reporter.
(3) The location of the failure.
(4) The time of the failure.
(5) The fatalities and personal injuries, if any.
(6) All other significant facts known by the operator that are relevant
to the cause of the failure or extent of the damages.

Telephonic reports are assigned an NRC number, which operators should note. When
applicable, National Response Center call information must be reported in Question
6 of the Form PHMSA F 7000-1.
§ 195.54 Accident reports.

(a) Each operator that experiences an accident that is required to be reported
under §195.50 shall as soon as practicable, but not later than 30 days after
discovery of the accident, prepare and file an accident report on DOT Form
7000–1, or a facsimile.
(b) Whenever an operator receives any changes in the information reported
or additions to the original report on DOT Form 7000–1, it shall file a
supplemental report within 30 days.

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.

1. Online:
a. Go to the PHMSA website at the following URL:
http://opsweb.rspa.dot.gov/cfdocs/opsapps/pipes/main.cfm.
(Alternatively, go to the Pipeline Safety Community main page
http://phmsa.dot.gov/pipeline, click the ONLINE DATA ENTRY link listed in the
third column of hyperlinks, click on the Hazardous Liquid or Carbon Dioxide
Systems Accident Report link)
b. 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.]
c. Click “add” to begin
d. Click “submit” when finished. NOTE: For supplemental reports use steps 1a and
1b then click on the report ID to make corrections. Click “save” when finished.
e. A confirmation page will appear for you to print and save for your records.
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. 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

3. Fax to: Information Resources Manager at (202) 366-4566.
3

RESCINDING A REPORT
An operator who reports an accident and upon subsequent investigation determines that
the event did not meet the criteria in 49 CFR 195.50 may request that its report be
rescinded. Requests for rescission should be submitted on operator letterhead and mailed
or faxed to the Information Resources Manager at the address/fax number above.
Requests may also be submitted by email to [email protected]. Requests
should include the following information:
a: The Report ID, the unique 8-digit identifier assigned by PHMSA,
b. Operator name,
c: PHMSA-issued operator ID number,
d. The number assigned by the National Response Center when telephonic report
was made in accordance with 49 CFR 192.52 (if telephonic report was required),
e. Date of the accident,
f. Location of the accident (e.g., for onshore accidents: city, county, state), and
g. A brief statement as to why the report should be rescinded.

SPECIAL INSTRUCTIONS
1. Certain data fields must be completed before an Original Report will be accepted.
The data fields that must be completed for an Original Report to be accepted are
indicated on the form by a double asterisk (**). If filing a hardcopy of this report, the
report will not be accepted by PHMSA unless all of these fields have been completed.
If filing on-line, your Original Report will not be able to be submitted until the
required information has been provided, although your partially completed form can
be saved on-line so that you can return at a later time to provide the missing
information.
2. An entry should be made in each applicable space or check box, unless otherwise
directed by the section instructions.
3. If the data is unavailable, enter “unknown” for text fields and leave numeric fields
and fields using check boxes or “radio” buttons blank.
4. If possible, provide an estimate in lieu of answering a question with “unknown” or
leaving the field blank. Estimates should be based on best-available information and
reasonable effort.
5. For unknown or estimated data entries, the operator should file a supplemental report
when additional information becomes available to finalize the report.
6. If the question is not applicable, please enter “N/A” for text fields and leave numeric
fields and fields using check boxes or “radio” buttons blank.

7. For questions requiring numeric answers, all data fields should be filled in using
zeroes when appropriate. When decimal points are required, the decimal point
should be placed in a separate block in the data field.
Examples:
(Part C, item 3.a, ) Nominal diameter of pipe (in):
(Part C, item 3.b), Wall thickness (in)
(Part C, item 3.c), SMYS

/0/0/2/4/
/3/./5/
/0/./3/1/2/
/0/5/2/,/0/0/0/

(24 inches)
(3.5 inches)
(0.312 inches)
(52,000 psi)

8. If OTHER is checked for any answer to a question, please include an explanation or
description on the line provided next to the item checked.
9. Pay close attention to each question for the phrase:
a. (select all that apply)
b. (select only one)
If the phrase does not exist for a given question, then “select only one” is the
default instruction. “Select all that apply” means that you should choose all
answers that are applicable. “Select only one” means that you should select the
single, primary or most applicable answer. DO NOT SELECT MORE
ANSWERS THAN REQUESTED.
10. Date format = mm/dd/yy or for year = /yyyy/
11. Time format: All times are reported as a 24-hour clock:
Time format Examples:
a. (0000) = midnight =
b. (0800) = 8:00 a.m. =
c. (1200) = Noon
=
d. (1715) = 5:15 p.m. =
e. (2200) = 10:00 p.m. =

/0/0/0/0/
/0/8/0/0/
/1/2/0/0/
/1/7/1/5/
/2/2/0/0/

12. Local time always refers to time at the site of the accident.

SPECIFIC INSTRUCTIONS
PART A – GENERAL REPORT INFORMATION
Report Type: (select all that apply)
Check the appropriate report box or boxes to indicate the type of report being filed.
Depending on the descriptions below, the following combinations of boxes may be
5

selected:
 Original Report only
 Original Report plus Final Report
 Supplemental Report only
 Supplemental Report plus Final Report
 Original Report
Select this type of report if this is the FIRST report filed for this accident.
If all of the information requested is known and provided at the time the initial report is
filed, including final property damages and accident cause information, check the box for
“Final Report” as well as the box for “Original Report,” indicating that no further
information will be forthcoming.
 Supplemental Report
Select this type of report only if you have already filed an “Original Report” AND you
are now providing new, updated, and/or corrected information. Multiple supplements are
to be submitted as needed in order to provide new, updated, and/or corrected information
as it becomes available.
For Supplemental Reports filed by fax or mail, please check the Supplemental Report
box, complete Part A, Items 1 through 6, and then enter information that has changed or
is being added. Please do not enter previously submitted information that has not
changed other than Items 1-6, which are needed to provide a way to identify previously
filed reports.
For Supplemental Reports filed online, all data previously submitted will automatically
populate in the form. Page through the form to make edits and additions where needed.
Operators are encouraged to file supplemental reports within one year in those instances
where the supplemental report is used to update information from investigations that were
still ongoing when the prior report was filed.
 Final Report
Select this type of report if you are filing an “Original Report” for which no further
information will be forthcoming (as described under “Original Report” above) or if you
have already filed an “Original Report” AND you are now providing new, updated,
and/or corrected information via a “Supplemental Report” AND you are reasonably
certain that no further information will be forthcoming. (Note: If an Operator files one
of the two types of “Final” Reports and then subsequently finds that new information
needs to be provided, it should submit another “Supplemental Report” and select the
appropriate box or boxes – “Supplemental + Final” (if appropriate) – for the newly
submitted report and include an explanation in the PART H Narrative.)
Supplemental reports must be filed within 30 days following the Operator’s awareness of
new, additional, or updated information. Failure to comply with these requirements can
result in enforcement actions, including the assessment of civil penalties not to exceed
$100,000 for each violation for each day that such violation persists up to a maximum of
$1,000,000
6

Required Fields for Small Releases:
If the release is at least 5 gallons but is less than 5 barrels with no additional
consequences (see below), complete only the fields indicated by light-grey shading. If
the spill is to water as described in 49 CFR §195.52(a)(4) or is otherwise reportable under
§195.50, then the entire Form F 7000-1 must be completed.
The entire form must be completed for any releases that
 Involve death or personal injury requiring hospitalization; or
 Involve fire or explosion; or
 Are 5 barrels or more; or
 Have property damage greater than $50,000: or
 Result in pollution of a body of water.
 In the judgment of the operator was significant even though it did not meet these
criteria.
If any of these events occurred, complete the entire Form F 7000-1.

In Part A, answer questions from 1 thru 18 by providing the requested
information or by checking the appropriate box.
1. Operator’s OPS -Issued Operator Identification Number (OPID):
The Pipeline and Hazardous Materials Safety Administration (PHMSA) assigns the
operator's identification number. Most OPIDs are 5 digits. Older OPIDs may contain
fewer digits. If your OPID contains fewer than 5 digits, insert leading zeros to fill all
blanks. Contact us at (202) 366-8075 if you need assistance with an identification
number during our business hours of 8:30 AM to 5:00 PM Eastern Time.
2. Name of Operator
This is the company name used when registering for an Operator ID and PIN in the
Online Data Entry System. For online entries, the Name of Operator should be
automatically filled in based on the Operator Identification Number entered in question 1.
If the name that appears does not coincide with the Operator ID, contact PHMSA at the
number provided in Question 1.
3. Address of Operator
Enter the address of the operator’s business office to which any correspondence related to
the accident report should be sent.
4. Local time (24-hour clock) and date of the Accident.
For pipeline systems crossing multiple time zones, enter the time at the location of the
accident.

See page 5 for examples of Date format and Time format expressed as a 24hour clock
5. Location of Accident:
The latitude and longitude of the accident are to be reported as Decimal Degrees with a
minimum of 5 decimal places (e.g. Lat: 38.89664 Long: -77.04327), using the NAD83 or
WGS84 datums.
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°
All locations in the United States will have a negative longitude coordinate, which has
already been printed on the form.
If you cannot locate the accident with a GPS or some other means, the U.S. Census
Bureau provides a tool for determining latitude and longitude,
(http://tiger.census.gov/cgi-bin/mapbrowse-tbl). You can use the online tool to identify
the geographic location of the accident. 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 Amy Nelson
(202.493.0591 or [email protected]).
6. National Response Center (NRC) Report Number
Accidents meeting the criteria outlined in §195.52 are to be reported directly to the 24hour National Response Center (NRC): at 1-800-424-8802 at the earliest practicable
moment (generally within 2 hours). The number of that telephonic report is to be entered
in Question 6.
7. Local time (24-hr clock) and date of initial telephonic report to the National
Response Center:
Enter the time (local time at site of the accident) and date of the telephonic report of
accident. The time should be shown by 24-hour clock notation (see page 5 for
examples).
8. Commodity Released
Select only one primary description of the commodity and then, where applicable, the
secondary description of the commodity, based on the predominant volume released.
Only releases of transported commodities are reportable.
 Crude Oil
 Refined and/or Petroleum Product (non-HVL) which is a Liquid at Ambient
Conditions
8

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 the name of the
commodity (e.g., “propylene”) in the space provided.
 HVL or Other Flammable or Toxic Fluid which is a Gas at Ambient Conditions
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.
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 (NH 3 ) 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 (e.g.,
“ethane” or “ethylene”) in the space provided.
 CO 2 (Carbon Dioxide)
 Biofuel/Alternate Fuel (including ethanol blends)
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.
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.
Blends greater than 95% ethanol should be reported as Fuel Grade Ethanol.
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. For pure biodiesel, report 100.
9. Estimated volume of commodity released unintentionally:
An estimate of the volume released may be based on a variety and/or combination of
inputs, including
 calculations made by hydraulic engineers
 volume added to the pipeline segment to repack the line when the line is placed
back in service
 measured volume of free phase commodity recovered, with allowances for
commodity that is not recovered.
 volume calculated to be absorbed by soil or water
 volume calculated to have been lost to evaporation (e.g., for gasoline spills)
9

Report all estimated volumes in BARRELS. Barrel means a unit of measurement
equal to 42 U.S. standard gallons. The table below converts gallons to barrels.

If
estimated
volume is
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23

Report

gallons
gallons
gallons
gallons
gallons
gallons
gallons
gallons
gallons
gallons
gallons
gallons
gallons
gallons
gallons
gallons
gallons
gallons
gallons

0.12
0.14
0.17
0.19
0.21
0.24
0.26
0.29
0.31
0.33
0.36
0.38
0.41
0.43
0.45
0.48
0.50
0.52
0.55

barrels
barrels
barrels
barrels
barrels
barrels
barrels
barrels
barrels
barrels
barrels
barrels
barrels
barrels
barrels
barrels
barrels
barrels
barrels

If
estimated
volume is
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42

Report

gallons
gallons
gallons
gallons
gallons
gallons
gallons
gallons
gallons
gallons
gallons
gallons
gallons
gallons
gallons
gallons
gallons
gallons
gallons

0.57
0.60
0.62
0.64
0.67
0.69
0.71
0.74
0.76
0.79
0.81
0.83
0.86
0.88
0.91
0.93
0.95
0.98
1.000

barrels
barrels
barrels
barrels
barrels
barrels
barrels
barrels
barrels
barrels
barrels
barrels
barrels
barrels
barrels
barrels
barrels
barrels
barrels

10. Estimated volume of intentional and/or controlled release/blowdown:
Estimate the amount of commodity that was released during any intentional release or
controlled blowdown conducted as part of responding to or recovering from the incident.
Intentional and controlled blowdown implies a level of control of the site and situation by
the Operator such that the area and the public are protected during the controlled release.
11. Estimated volume of commodity recovered:
Recovered means the commodity is no longer in the environment. The commodity could
have been removed by: absorbent pads or similar mechanisms; transferring to temporary
storage such as a vacuum truck, a frac tank, or similar vessel; soil removal; bioremediation; or other similar means of removal or recovery. The volume can be
estimated based on a variety or combination of the measurement of free phase
commodity recovered, the amount calculated to be absorbed by soil or water that was
removed from the environment, measurement of oil extracted from absorbent pads, etc.
Report all estimated volumes in BARRELS. See conversion table above to convert
from gallons to barrels.
12. Were there fatalities?
If a person dies at the time of the accident or within 30 days of the initial accident date
due to injuries sustained as a result of the accident, report as a fatality. If a person dies
subsequent to an injury more than 30 days past the accident date, report as an injury. This
aligns with the Department of Transportation's general guidelines for all modes for
reporting deaths and injuries.
11

Contractor employees working for the operator means people hired to work for or on
behalf of the operator of the pipeline.
Non-operator emergency responders means people responding to render professional
aid at the accident scene including on-duty fire fighters, rescue workers, EMTs, police
officers, etc. “Good Samaritans” that stop to assist should be reported as “General
public.”
Workers Working on the Right of Way, but NOT Associated with this Operator
means people authorized to work in or near the right-of-way, but not hired by or
working on behalf of the operator of the pipeline. This includes all work conducted
within the right of way including work associated with other underground facilities
sharing the right of way, building/road construction in or across the right of way, or
farming. This category most often includes employees of other pipelines or
underground facilities operators, or their contractors, working in or near a shared
right-of-way. Workers performing work near, but not on, the right of way and who
are affected should be reported as general public.
13. Were there injuries requiring inpatient hospitalization?
Injuries requiring inpatient hospitalization mean injuries sustained as a result of the
accident which require both hospital admission and at least one overnight stay.
14. Was the pipeline/facility shut down due to the Accident?
Report any shutdowns that occur as a result of the accident (including but not limited to
those required for damage assessment, repair, and clean-up). Instances in which an
accident was caused by a release that did not involve damage to the pipeline (e.g.,
incorrect operations) and in which no need for repairs resulted need not be reported as
being shutdown, even though the pipeline may have been shutdown as a precautionary
measure to inspect for damages.
If No is selected, explain the reason that no shutdown was needed in the blank provided.
If Yes is selected, complete questions 14.a and 14.b.
14.a. Local time (24hr clock) and date of shutdown
For pipeline systems crossing multiple time zones, enter the time at the location of the
accident.
14.b. Local time pipeline/facility restarted
Report the time the pipeline/facility was restarted (if applicable). If the pipeline or
facility has not been restarted at the time of reporting, check “Still shut down” and then
include the restart time in a future Supplemental Report.
15. Did the Commodity Ignite?
Ignite means the commodity caught fire.
16. Did the Commodity Explode?
12

Explode means the release of the transported commodity resulted in a sudden and violent
release of energy, whether accompanied by a fire involving the released commodity or
not.
17. Number of General Public Evacuated:
The number of people evacuated should be estimated based on operator knowledge, or
police, fire or other emergency responder reports or estimates. If there was no evacuation
involving the general public, report “0.” If an estimate is not possible for some reason,
leave blank but include an explanation of why it was not possible in the Part H Narrative.
18. Time sequence (use local time, 24-hour clock)
Enter the time the operator became aware that an event constituted an accident (i.e.,
identified the accident) and the time operator personnel or contract resources (i.e.,
personnel and/or equipment) arrived on site. All times should be local times at the
location of the accident.

PART B – ADDITIONAL LOCATION INFORMATION
1. Was the origin of the Accident onshore?
Answer Yes or No as appropriate and complete only the designated questions.
For onshore pipelines
2 – 5. Accident Location
Provide the state, zip code, city, and county/parish in which the accident occurred.
6. Operator-Designated Location:
This is intended to be the designation that the operator would use to identify the location
of the accident on its pipeline system. Enter the appropriate milepost/valve station or
survey station number. This designator is intended to allow PHMSA personnel to both
return to the physical location of the accident using the operator’s own maps and
identification systems as well as to identify the “paper” location of the accident when
reviewing operator maps and records.
7. Pipeline/Facility Name
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 “Wooster Terminal”.
8. Segment name/ID
Within a given pipeline system and/or facility, there are typically multiple segment or
station identifiers, names, or ID’s which are commonly used by the operator. The
13

information reported here helps locate and/or record the more precise accident location,
for example, “Segment 4-32”, or “MP 4.5 to Wayne County Line”, or “Dublin Pump
Station”, or “Witte Meter Station”.
9. Was the Accident on Federal Lands other than Outer Continental Shelf?
Federal Lands other than Outer Continental Shelf means all lands the United States owns,
including military reservations, except lands in National Parks and lands held in trust for
Native Americans. Accidents at Federal buildings, such as Federal Court Houses, Custom
Houses, and other Federal office buildings and warehouses, are NOT to be reported as
being on Federal Lands.
10. Location of Accident
Operator-controlled Property would normally apply to an operator’s facility, which
may or may not have controlled access, but which is often fenced or otherwise marked
with discernible boundaries. This “operator-controlled property” does not refer to the
pipeline right-of-way, which is a separate choice for this question.
11. Area of Accident (as found)
Underground means pipe, components or other facilities installed below the natural
ground level, road bed, or below the underwater natural bottom.
Under pavement includes under streets, sidewalks, paved roads, driveways and parking
lots.
Exposed due to Excavation means that a normally buried pipeline had been exposed by
any party (operator, operator’s contractor, or third party) preparatory to or as a result of
excavation. The cause of the release, however, may or may not necessarily be related to
excavation damage. This category could include a corrosion leak not previously
evidenced by stained vegetation, but found during an ILI dig, or a release caused by a
non-excavation vehicle where contact happened to occur while the pipeline was exposed
for a repair or examination. Natural forces might also damage a pipeline that happened to
be temporarily exposed. In each case, the cause should be appropriately reported in
section G of this form.
Aboveground means pipe, components or other facilities that are above the natural
grade.
Typical aboveground facility piping includes any pipe or components installed
aboveground such as those at pump stations, valve sites, and breakout tank farms.
Transition area means the junction of differing material or media between pipes,
components, or facilities such as those installed at a belowground-aboveground junction
(soil/air interface), another environmental interface, or in close contact to supporting
elements such as those at water crossings, pump stations and break out tank farms.
12. Did Accident occur in a crossing?
14

Use Bridge Crossing if the pipeline is suspended above a body of water or roadway,
railroad right-of-way, etc., either on a separately designed pipeline bridge or as a part of
or connected to a road, railroad, or passenger bridge.
Use Railroad Crossing or Road Crossing, as appropriate, if the pipeline is buried
beneath rail bed or road bed.
Use Water Crossing if the pipeline is in the water, beneath the water, in contact with the
natural ground of the lake bed, etc., or buried beneath the bed of a lake, reservoir, stream
or creek, whether the crossing happens to be flowing water at the time of the accident or
not. The name of the body of water should be provided if it is commonly known and
understood among the local population. (The purpose of this information is to allow
persons familiar with the area in which the accident occurred to identify the location and
understand it in its local context. Research to identify names that are not commonly used
is not necessary since such names would not fulfill the intended purpose. If a body of
water does not have a name that is commonly used and understood in the local area, this
field should be left blank).
For Approximate Water Depth (ft) of the lake, reservoir, etc., estimate the typical water
depth at the location of the accident, allowing for seasonal, weather-related and other
factors which may affect the water depth from time to time.
For offshore pipelines
13. Approximate Water Depth (ft.), at the point of the Accident:
This should be the estimated depth from the surface of the water to the seabed at the point
of the accident regardless of whether the pipeline is below/on the bottom, underwater but
suspended above the bottom, or above the surface (e.g., on a platform).
14. Origin of the Accident
Area and Tract/Block numbers should be provided for either State or OCS waters,
whichever is applicable.
For Nearest County/Parish, as with the name of an onshore body of water (see question
12 above), the data collected is intended to allow persons familiar with the area in which
the accident occurred to identify the location and understand it in its local context.
Accordingly, it is not necessary to take measurements to determine which county/parish
is “nearest” in cases where the accident location is approximately equidistant from two
(or more). In such cases, the name of one of the nearby counties/parishes should be
provided.

PART C – ADDITIONAL FACILITY INFORMATION
1. Is the pipeline or facility [Interstate or Intrastate]?
15

As defined in section 195.2, “Interstate pipeline means a pipeline or that part of a
pipeline that is used in transportation of hazardous liquids or carbon dioxide in interstate
or foreign commerce.”
As defined in section 195.2, “Intrastate pipeline means a pipeline or that part of a
pipeline to which [part 195] applies that is not an interstate pipeline.
Operators may refer to Appendix A of Part 195 for further guidance.
3. Item involved in Accident
Pipe (whether pipe body or pipe seam) means the pipe through which the commodity is
transported, not including auxiliary piping, tubing or instrumentation.
Nominal diameter of pipe is also called Nominal pipe size. It is the diameter in whole
number inches (except for pipe less than 4”) used to describe the pipe size; for example,
8-5/8 pipe has a nominal pipe size of 8”. Decimals are unnecessary for this measure
(except for pipe less than 4”).
Enter pipe wall thickness in inches. Wall thickness is typically less than one inch, and is
standard among different pipeline types and manufacturers. Accordingly, use three
decimal places to report wall thickness: 0.312, 0.281, etc.
SMYS means specified minimum yield strength and is the yield strength prescribed by
the specification under which the material is purchased from the manufacturer.
Pipe Specification is the specification to which the pipe was manufactured, such as API
5L or ASTM A106.
Pipe seam means the longitudinal seam (longitudinal weld) created during manufacture
of the joint of pipe.
Pipe Seam Type Abbreviations
SAW means submerged arc weld
ERW means electric-resistance weld
DSAW means double submerged arc weld
Auxiliary piping means piping, usually small in diameter that supports the operation of
the mainline or facility piping and does not include tubing. Examples of auxiliary piping
include discharge and drain lines, sample lines, etc.
If the accident occurred on an item not provided in this section, check the OTHER box
and specify in the space provided the item that failed.
6. Type of Accident involved (select only one):
Mechanical puncture means a puncture of the pipeline, typically by a piece of
equipment such as would occur if the pipeline were pierced by directional drilling or a
backhoe bucket tooth. Not all excavation-related damage will be a “mechanical
16

puncture.” (Precise measurement of size – e.g., micrometer – is not needed.
Approximate measurements can be provided in inches and one decimal.)
Leak means a failure resulting in an unintentional release of the transported commodity
that is often small in size, usually resulting in a low flow release of low volume, although
large volume leaks can and do occur on occasion.
Rupture means a loss of containment that immediately impairs the operation of the
pipeline. Pipeline ruptures often result in a higher flow release of larger volume. The
terms “circumferential” and “longitudinal” refer to the general direction or orientation of
the rupture relative the pipe’s axis. They do not exclusively refer to a failure involving a
circumferential weld such as a girth weld, or to a failure involving a longitudinal weld
such as a pipe seam. (Precise measurement of size – e.g., micrometer – is not needed.
Approximate measurements can be provided in inches and one decimal.)

PART D – ADDITIONAL CONSEQUENCE INFORMATION
Per 195.450, High Consequence Area means:
1. A commercially navigable waterway, which means a waterway where a
substantial likelihood of commercial navigation exists;
2. A high population area, which means an urbanized area as defined and
delineated by the Census Bureau that contains 50,000 or more people and
has a population density of at least 1,000 people per square mile;
3. An other populated area, which means a place as defined and delineated by
the Census Bureau that contains a concentrated population, such as an
incorporated or unincorporated city, town, village, or other designated
residential or commercial area;
4. An unusually sensitive area, as defined in § 195.6
5.b Estimated amount released in or reaching water
An estimate of the volume released in or reaching water may be based on a variety and/or
combination of inputs, including those mentioned above for Part A, Questions 9 and 10.
5.c Name of body of water, if commonly known:
The name of the body of water should be provided if it is commonly known and
understood among the local population. (The purpose of this information is to allow
persons familiar with the area in which the accident occurred to identify the location and
understand it in its local context. Research to identify names that are not commonly used
is not necessary since such names would not fulfill the intended purpose. If a body of
water does not have a name that is commonly used and understood in the local area, this
field should be left blank).
6. At the location of this Accident, had the pipeline segment or facility been
identified as one that “could affect” a High Consequence Area (HCA) as determined
in the Operator’s Integrity Management Program?
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This question should be answered based on the classification of the involved segment in
the operator’s integrity management (IM) program at the time of the accident, whether or
not consequences to an HCA ensued. It is possible that a release on a pipeline segment
that “could affect” an HCA might not actually affect an HCA. It is also possible that
releases from segments thought not able to affect an HCA might have such an affect.
This could indicate a deficiency in the operator’s IM program for identifying segments
that can affect HCAs, and all of this information is useful for PHMSA’s overall
evaluations concerning the efficacy of IM regulation.
7. Did the released commodity reach or occur in one or more High Consequence
Area (HCA)?
Guidance available from the pipeline industry for its own spill reporting system is
pertinent here. Please see
http://committees.api.org/pipeline/ppts/docs/Advisories/20041AdvisoryHCAReporting.pdf
Generally, a spilled commodity will have “reached” an HCA if the spill zone intersects
the boundaries of the HCA polygon as mapped by the National Pipeline Mapping
System. The HCA maps should be available as a part of each operator’s Integrity
Management Program as per Part 195.452.
7.a. HCA Type (select all that apply)
Refer to the definitions in 192.450, reproduced above. Leave this question blank if the
released commodity did not reach or occur in a High Consequence Area.
8. Estimated cost to Operator:
All relevant costs to the operator must be included on the initial written accident report as
well as supplemental reports. This includes (but is not limited to) costs due to property
damage to the operator’s facilities and to the property of others, commodity lost, facility
repair and replacement, and environmental cleanup and damage. Do not report costs
incurred for facility repair, replacement, or change that is not related to the accident and
done solely for convenience. An example of doing work solely for convenience is
working on non-leaking facilities unearthed because of the accident. Litigation and other
legal expenses related to the accident are not reportable.
Operators should report costs based on the best estimate available at the time a report is
submitted. It is likely that an estimate of final repair costs may not be available when the
initial report must be submitted (30 days, per Section 195.54). The best available
estimate of these costs should be included in the initial report. For convenience, this
estimate can be revised, if needed, when supplemental reports are filed for other reasons,
however, when no other changes are forthcoming, supplemental reports should be filed as
new cost information becomes available. If supplemental reports are not submitted for
other reasons, a supplemental report should be filed for the purpose of correcting the
estimated cost if these costs differ from those already reported by 20 percent or $20,000,
whichever is greater.
18

Public and Non-operator private property damage estimates generally include
physical damage to the property of others, the cost of environmental investigation and
remediation of a site not owned or operated by the Operator, laboratory costs, third party
expenses such as engineers or scientists, and other reasonable costs, excluding litigation
and other legal expenses related to the accident.
Paid/reimbursed means that the entity experiencing the property damage was
compensated by the operator or operator’s representative for the damage or the cost to
repair the damage.
Cost of commodity lost includes the cost of the commodity not recovered and/or the cost
of recovered commodity downgraded to a lower value or re-processed, and should be
based on the volume reported in Part A, Questions 9 and 10.
Operator’s property damage estimates generally include physical damage to the
property of Operator or Owner Company such as the estimated installed value of the
damaged pipe, coating, component, materials or equipment due to the accident, excluding
litigation and other legal expenses related to the accident.
When estimating the Cost of repairs to company facilities, the standard shall be the cost
necessary to safely restore property to its predefined level of service. These costs may
include the cost of repair sleeves or clamps, re-routing of piping, or the removal from
service of an appurtenance, tank, or pipeline component. When more comprehensive
repairs or improvements are justified but not required for continued operation, the cost of
such repairs or replacement is not attributable to the accident. Costs associated with
improvements to the pipeline to mitigate the risk of future failures are not included.
The following examples are provided for clarity and guidance:
Tank accident - Property damage estimates would include the cost to remove the
tank from service, sufficiently clean the tank, repair the tank to a standard operating
capability, and then return the tank to service. Costs associated with improvements
to the tank to mitigate the risk of future failures are not included.
Pipeline accident - Property damage estimates include the cost to access, excavate
and repair the pipeline using methods, materials, and labor necessary to re-establish
operations at a predetermined level. Costs associated with improvements to the
pipeline to mitigate the risk of future failures are not included.
Estimated costs of Operator’s emergency response include emergency response
operations necessary to return the accident site to a safe state, actions to minimize the
volume of commodity released and conduct reconnaissance, and actions to identify the
extent of accident impacts and contain, control, mitigate, recover, and remove the
commodity from the environment, to the maximum extent practicable. They include
materials, supplies, labor, and benefits. Costs related to stakeholder outreach, media
response, etc. should not be included. The estimated costs of long-term remediation
activities should be included in Environmental Remediation estimates.

Environmental remediation includes the estimated cost to remediate a site such as those
associated with engineering, scientists, laboratory costs, installation of long-term
recovery systems, etc.
Other costs should not include estimated cost categories separately listed above.
Costs should be reported in only one category and should not be double-counted. Costs
can be split between two or more categories when they overlap more than one reporting
category.

PART E – ADDITIONAL OPERATING INFORMATION
4. Not including pressure reductions required by PHMSA regulations (such as for
repairs and pipe movement), was the system or facility relating to the Accident
operating under an established pressure restriction with pressure limits below those
normally allowed by the MOP?
Consider both voluntary and mandated pressure restrictions. A pressure restriction
should be considered mandated by PHMSA or a state regulator if it was directed by an
order or other formal correspondence. Pressure reductions imposed by the operator as a
result of regulatory requirements, e.g., a pressure reduction taken because an anomaly
identified during an IM assessment could not be repaired within the required schedule
(195.452(h)(3)), should not be considered mandated by PHMSA.
5.a. Type of upstream valve used to initially isolate release source
Identify the type of valve used to initially isolate the release on the upstream side. In
general, this will be the first upstream valve selected by the Operator to minimize the
release volume but may not be the closest to the accident site.
5.b. Type of downstream valve used to initially isolate release source
Identify the type of valve used to initially isolate the release on the downstream side. In
general, this will be the first downstream valve selected by the Operator to minimize the
release volume but may not be the closest to the accident site.
5.c. Length of segment isolated between valves (ft):
Identify the length in feet between the valves identified in item 5.a and 5.b that were
initially used to isolate the spill area.
5.f. Function of pipeline system
Gathering means a crude oil pipeline 8 5/8 inches or less nominal outside diameter that
transports petroleum from a production facility.
Trunkline/Transmission means all other pipeline assets not meeting the gathering
definition.
SMYS means specified minimum yield strength and is the yield strength prescribed by
the specification under which the material is purchased from the manufacturer.
20

Not all rural pipelines or gathering lines operating at less than 20% of SMYS are subject
to part 195 safety requirements. Reporting requirements in part 195 subpart B, however,
are applicable to all rural low-stress pipelines beginning January 5, 2009 (rule change
published in the Federal Register June 3, 2008, 73FR31646). The purpose of this rule
change was to allow PHMSA to collect data that might be used to determine whether
rural low-stress pipelines and gathering lines not now subject to other regulations should
be made subject to them. Low-stress rural pipelines and low-stress rural gathering lines
that are not subject to the safety requirements of part 195 are considered unregulated, for
purposes of this question, even though accidents on these pipelines are required to be
reported.
Accidents reported on “UNregulated” rural low-stress pipelines and “Unregulated” rural
low-stress gathering lines must be identified so that the data may be separated out to be
used for the purpose intended. Accordingly, for accidents occurring on pipelines
operating at less than or equal to 20% SMYS, Operators should indicate whether that
pipe is “Regulated” (i.e., subject to all part 195 requirements; this includes pipe in nonrural areas and regulated rural pipelines) or “UNregulated.”
6. Was a Supervisory Control and Data Acquisition (SCADA)-based system in
place on the pipeline or facility involved in the Accident?
This does not mean a system exclusively for leak detection.
6.a. Was it operating at the time of the Accident?
Was the SCADA system in operation at the time of the accident?
6.b. Was it fully functional at the time of the Accident?
Was the SCADA system capable of performing all of its functions, whether or not it was
actually in operation at the time of the accident? If no, describe functions that were not
operational in the Narrative Part H
6.c and d. Did SCADA-based information (such as alarm(s), alert(s), event(s),
and/or volume calculations) assist with the detection (or confirmation) of the
Accident?
Check yes if SCADA-based information was used to confirm the accident even if the
initial report or identification may have come from other sources. Use of SCADA data
for subsequent estimation of amount of commodity lost, etc. is not considered use to
confirm the accident.
Check No if data from SCADA was not used to assist with identification of the accident.
7. Was a CPM leak detection system in place on the pipeline or facility involved in
the Accident?
This means a system exclusively for leak detection.
Follow instructions for question 6 (SCADA) above,
21

8. How was the Accident initially identified for the Operator? (select only one)
Controller per the definition in API RP 1168 means a qualified individual whose
function within a shift is to remotely monitor and/or control the operations of entire or
multiple sections of pipeline systems via a SCADA system from a pipeline control room,
and who has operational authority and accountability for the daily remote operational
functions of pipeline systems.
Local Operating Personnel including contractors means employees or contractors
working on behalf of the operator outside the control room.
9. 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 Accident?
Check only one of the boxes to indicate whether an investigation was/is being conducted
(Yes) or was not conducted (No). If an investigation has been completed, select all the
factors that apply in describing the results of the investigation.
Cause means an action or lack of action that directly led to or resulted in the pipeline
accident.
Contributing factor means an action or lack of action that when added to the existing
pipeline circumstances heightened the likelihood of the release and/or added to the
impact of the release.
Controller Error means that the controller failed to identify a circumstance indicative of
a release event, such as an abnormal operating condition, alarm, pressure drop, change in
flow rate, or other similar event.
Incorrect Controller action means that the controller errantly operated the means for
controlling an event. Examples include opening or closing the wrong valve, or hitting the
wrong switch or button.

PART F – DRUG & ALCOHOL TESTING INFORMATION
Requirements for post-accident drug and alcohol tests are in 49 CFR 199.105 and 225
respectively. If the accident circumstances were such that tests were not required by
these sections, and if no tests were conducted, check no. If tests were administered,
check yes and report separately the number of operator employees and contractors
working for the operator who were tested and who failed.

PART G – APPARENT CAUSE
In PART G – Apparent Cause
Complete only one of the eight Sections listed under G1 thru G8
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After identifying the main cause category as designated by G1 thru G8, select the
one, single sub-cause that best describes the proximate cause of the accident in the
shaded column on the left. Answer the corresponding questions that accompany
your selected sub-cause.
G1 – Corrosion Failure
Corrosion includes a leak or failure caused by galvanic, atmospheric, stray current,
microbiological, or other corrosive action, and, for the purposes of this reporting,
includes selective seam corrosion. 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 deteriorates or becomes loose
and leaks due to corrosion or failure of bolts, it is classified as Corrosion. (If the bonnet,
packing, or other gasket has deteriorated to failure before the end of its expected life but
not due to corrosive action, it is classified as an Equipment Failure – G6.)
External Corrosion
4.a. Under cathodic protection means cathodic protection in accordance with
Paragraphs 195.563 or 195.573(b). Recognizing that older pipelines may have had
cathodic protection added over a number of years, provide an estimate if the exact year
cathodic protection started is unknown.
Internal Corrosion
9. Location of corrosion
A low point in pipe includes portions of the pipe contour in which water might settle out.
This includes, but is not limited to, the low point of vertical bends at a crossing of a
foreign line or road/railroad, etc., an elbow, a drop out or low point drain.
10. Was the commodity treated with corrosion inhibitors or biocides?
Answer yes if corrosion inhibitors or biocides were included in the commodities
transported.
12. Were cleaning/dewatering pigs (or other operations) routinely utilized?
13. Were corrosion coupons routinely utilized?
For purposes of these questions, “routinely” refers to an action that is performed on more
than a sporadic or one-time basis as part of a regular program with the intent to ensure
that water build-up and/or settling and internal corrosion do not occur.
Either External or Internal Corrosion
14. List the year of the most recent inspections:
Complete this question only when any corrosion failure sub-cause is selected and the
item involved in the accident (as reported in Part C, Question 3) is tank/vessel. Do not
complete if the item involved is pipe or weld.
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15.a. If Yes, for each tool used, select type of internal inspection tool and indicate
most recent year run:
Magnetic Flux Leakage Tool is an in-line inspection tool using an imposed magnetic
flux to detect instances of pipe wall loss from corrosion. Includes low- and highresolution MFL tools. Does not include transverse flux MFL tools, which are a separate
choice in this question.
Ultrasonic refers to an in-line inspection tool that uses ultrasonic technology to measure
wall thickness and detect instances of wall loss.
Transverse Field/Triaxial tools are specialized magnetic flux leakage tools that use a
flux oriented to improve ability to detect crack anomalies.
Combination Tool refers to any in-line inspection tool that uses a combination of these
inspection technologies in a single tool.
16. Has one or more hydrotest or other pressure test been conducted since original
construction at the point of the Accident?
Information from the initial post-construction hydrostatic test need not be reported.
17. Has one or more Direct Assessment been conducted on this segment?
This refers to direct assessment as defined in 49 CFR 195.553. Instances in which one or
more indirect monitoring tools (e.g., close interval survey, DCVG) have been used that
might be used as part of direct assessment but which were not used as part of the direct
assessment process defined in 195.553 do not constitute a Direct Assessment for
purposes of this question.
G2 – Natural Force Damage
This category includes all outside forces attributable to causes NOT involving humans.
Earth Movement, NOT due to Heavy Rains/Floods refers to accidents caused by land
shifts such as earthquakes, subsidence, or landslides, but not mudslides which are
presumed to be initiated by heavy rains or floods.
Heavy Rains/Floods refer to all water-related accident causes. While mudslides involve
earth movement, report them here since typically they are an effect of heavy rains or
floods.
Lightning includes both damage and/or fire caused by a direct lighting strike and damage
and/or fire as a secondary effect from a lightning strike in the area. An example of such a
secondary effect would be a forest fire started by lightning that results in damage to a
pipeline system asset which results in an accident.
Temperature refers to those causes that are related to ambient temperature effects, either
heat or cold, where temperature was the initial cause.
24

Thermal stress refers to mechanical stress induced in a pipe or component when some or
all of its parts are not free to expand or contract in response to changes in temperature.
Frozen components would include accidents where components are inoperable because
of freezing and those due to cracking of a piece of equipment due to expansion of water
during a freeze cycle.
High Winds includes damage caused by wind-induced forces. Select this category if the
damage is due to the force of the wind itself. Damage caused by impact from objects
blown by wind would be reported as Section G4, “Other Outside Force Damage.”

G3 – Excavation Damage
This section covers damage caused by the operator, operator’s contractor, or entities
unrelated to the operator during excavation and which results in an immediate release of
the transported commodity. For damage from forces OTHER than excavation which
results in an immediate release, use “Natural Force Damage”, Section G2, or “Other
Outside Force Damage”, Section G4, as appropriate. For a strike or other damage to a
pipeline or facility that results in a later release, report the accident in Section G4 as
“Rupture or Failure Due to Previous Mechanical Damage.”
Excavation Damage by Operator (First Party)
Check this item if the accident was caused as a result of excavation by a direct employee
of the operator.
Excavation Damage by Operator’s Contractor (Second Party)
Check this item if the accident was caused as a result of excavation by the operator’s
contractor or agent or other party working for the operator.
Excavation Damage by Third Party
Check this item if the accident was caused by excavation damage resulting from actions
by personnel or other third parties not working for or acting on behalf of the operator or
its agent.
Previous Damage due to Excavation Activity
1.a. If Yes, for each tool used, select type of internal inspection tool and indicate
most recent year run:
Magnetic Flux Leakage Tool is an in-line inspection tool using an imposed magnetic
flux to detect instances of pipe wall loss from corrosion. Includes low- and highresolution MFL tools. Does not include transverse flux MFL tools, which are a separate
choice in this question.
Ultrasonic refers to an in-line inspection tool that uses ultrasonic technology to measure
wall thickness and detect instances of wall loss.
25

Transverse Field/Triaxial tools are specialized magnetic flux leakage tools that use a
flux oriented to improve ability to detect crack anomalies.
Combination Tool refers to any in-line inspection tool that uses a combination of these
inspection technologies in a single tool.
3. Has one or more hydrotest or other pressure test been conducted since original
construction at the point of the Accident?
Information from the initial post-construction hydrostatic test need not be reported.
4. Has one or more Direct Assessment been conducted on this segment?
This refers to direct assessment as defined in 49 CFR 195.553. Instances in which one or
more indirect monitoring tools (e.g., close interval survey, DCVG) have been used that
might be used as part of direct assessment but which were not used as part of the direct
assessment process defined in 195.553 do not constitute a Direct Assessment for
purposes of this question.
7. – 17. Complete these questions for any excavation damage sub-cause. Instructions for
answering these questions can be found at CGA’s web site,
https://www.damagereporting.org/dr/control/userGuide.do.

G4 – Other Outside Force Damage
This section covers accidents caused by outside force damage, other than excavation
damage or natural forces. Check the most appropriate one sub-cause in this section that
applies and answer any accompanying questions.
Nearby Industrial, Man-made or other Fire/Explosion as Primary Cause of
Accident applies to situations where the fire occurred before and caused the release. An
example of such an accident would be an explosion or fire at a neighboring facility or
installation (chemical plant, tank farm, other industrial facility) that results in a release at
the operator’s facility. (Note that an accident report is required only if the release
resulted in reportable consequences, per 195.50). This section should not be used if the
release occurred first and then the hydrocarbon ignited. If the fire is known to have been
started as a result of a lightning strike, the accident’s cause should be classified under
Section G2, “Natural Force Damage.” Arson events directed at harming the pipeline or
the operator should be reported as “Intentional Damage” in this section. Forest fires that
are caused by human activity and result in a release should be reported in this section.
Damage by Car, Truck, or Other Motorized Vehicle/Equipment NOT Engaged in
Excavation. An example of this sub-cause would be a stopple tee that releases
commodity when damaged by a pickup truck maneuvering near the pipeline. Other
motorized vehicles or equipment include tractors, backhoes, bulldozers and other tracked
vehicles, and heavy equipment that can move. Include under this sub-cause accidents
caused by vehicles operated by the pipeline operator, the pipeline operator’s contractor,
or a third party, and specify the vehicle/equipment operator’s affiliation. Pipeline
26

accidents resulting from vehicular traffic loading or other contact should also be reported
in this category. If the activity that caused the release involved digging, drilling, boring,
grading, cultivation or similar activities, report in Section G3, “Excavation Damage”.
Damage by Boats, Barges, Drilling Rigs, or Other Maritime Equipment or Vessels
Set Adrift or Which Have Otherwise Lost Their Mooring. This sub-cause includes
impacts by maritime equipment or vessels (including their anchors or anchor chains or
other attached equipment) that have lost their moorings and are carried into the pipeline
facility by the current. This sub-cause also includes maritime equipment or vessels set
adrift as a result of severe weather events and carried into the pipeline facility by waves,
currents, or high winds. In such cases, also indicate the type of severe weather event. Do
not report in this sub-cause accidents which are caused by the impact of maritime
equipment or vessels while they are engaged in their normal or routine activities; such
accidents should be reported as “Routine or Normal Fishing or Other Maritime Activity
NOT Engaged in Excavation” so long as those activities are not excavation activities. If
those activities are excavation activities such as dredging or bank stabilization or
renewal, the accident should be reported in Section G3, “Excavation Damage”.
Routine or Normal Fishing or Other Maritime Activity NOT Engaged in
Excavation. This sub-cause includes accidents due to shrimping, purseining, oil drilling,
or oilfield workover rigs, including anchor strikes, and other routine or normal maritimerelated activities UNLESS the movement of the maritime asset was due to a severe
weather event (this type of accident should be reported under “Damage by Boats, Barges,
Drilling Rigs, or Other Maritime Equipment or Vessels Set Adrift or Which Have
Otherwise Lost Their Mooring”) or the accident was caused by excavation activity such
as the dredging of waterways or bodies of water (this type of accident should be reported
under Section G3, “Excavation Damage”).
Previous Mechanical Damage NOT Related to Excavation. This sub-cause covers
accidents where damage occurred at some time prior to the release, and would include
prior excavation damage, prior outside force damage of an unknown nature, prior natural
force damage, and prior damage from other outside forces. Accidents resulting from
damage sustained during construction, installation, or fabrication of the pipe or a weld
should be reported under Section G5, “Material Failure of Pipe or Weld.”
Is there reason to believe that the damage resulted from excavation activity? The
answer to this question might come from the condition of the pipe when it is examined or
from records of excavation at the site. Dents and gouges in the 10:00-to-2:00 o’clock
positions on the pipe, for instance, may indicate an earlier strike, as might marks from the
bucket or tracks of an earth moving machine or similar pieces of equipment.
Intentional Damage
Vandalism means willful or malicious destruction of the operator’s pipeline facility or
equipment. This category would include pranks, systematic damage inflicted to harass
the operator, motor vehicle damage that was inflicted intentionally, and a variety of other
intentional acts.

Terrorism, per 28 C.F.R. § 0.85 General Functions, includes the unlawful use of force
and violence against persons or property to intimidate or coerce a government, the
civilian population, or any segment thereof, in furtherance of political or social
objectives. Operators selecting this item are encouraged to also notify the FBI.
Theft means damage by any individual or entity, by any mechanism, specifically to steal,
or attempt to steal, the transported commodity or pipeline equipment.
Other
Describe in the space provided and, if necessary, provide additional explanation in Part
H.

G5 – Material Failure of Pipe or Weld
Use this section to report material failures only if “Item Involved in accident” (Part C,
Question 3) is “Pipe” (whether pipe body or pipe seam) or “Weld.”
This section includes leaks, ruptures or other failures from defects within the material of
the pipe body or within the pipe seam or other weld due to faulty manufacturing
procedures, defects resulting from poor construction/installation/fabrication practices,
and in-service stresses such as vibration, fatigue and environmental cracking.
Construction-, Installation-, or Fabrication-related includes leaks in or failures of
originally sound material due to force being applied during construction or installation
that caused a dent, gouge, excessive stress, or some other defect that eventually failed
resulting in an accident. Included are leaks in or failures of wrinkle bends, field welds,
and damage sustained in transportation to the construction or fabrication site. Not
included are failures due to seam defects.
Original Manufacturing-related (NOT girth weld or other welds formed in the field)
means an inherent flaw in the material or weld that occurred in the manufacture or at a
point prior to construction, fabrication or installation. Therefore, this option is not
appropriate for wrinkle bends, field welds, girth welds, or other joins fabricated in the
field. Use this option for failures such as those due to defects of the longitudinal weld or
inclusions in the pipe body.
If Construction, Installation, Fabrication-related or Original Manufacturing-related
is selected, then select the failure mechanism.
Examples of Mechanical Stress include failures related to overburden or loss of support.
G6 – Equipment Failure
This section applies to failures of items other than Pipe Body, Pipe Seam, or Welds.
Malfunction of Control/Relief Equipment
28

Examples of this type of accident cause include: overpressurization resulting from
malfunction of a control or alarm device; relief valve malfunction; valves failing to open
or close on command; or valves which opened or closed when not commanded to do so.
If overpressurization or some other aspect of this accident was caused by incorrect
operation, the accident should be reported under Section G7, “Incorrect Operation.”
ESD System Failure means failure of an emergency shutdown system.

G7 – Incorrect Operation
These types of accidents most often occur during operating, maintenance, or repair
activities. Some examples of this type of accident are tank overfills, improper valve
selection or operation, inadvertent overpressurization, or improper selection or
installation of equipment. The unintentional ignition of the transported commodity
during a welding or maintenance activity would also be included in this sub-cause. These
types of accidents often involve training or judgment errors.

G8 – Other Accident Cause
This section is provided for accident causes that do not fit in any of the main cause
categories listed in Sections G1 through G7.
If the accident cause is known but doesn’t fit in any category in Sections G1 through G7,
check the Miscellaneous box and enter a description of the accident and continue in Part
H - Narrative Description of the Accident, if more space is needed.
If the accident cause is unknown at the time of filing this report, check the Unknown box
in this section and select one reason from the accompanying two choices. If the
investigation is not completed and the cause of the incident is thus still to be determined,
file a supplemental report once the investigation is completed to report the apparent
cause.

PART H – NARRATIVE DESCRIPTION OF THE ACCIDENT
(Attach additional sheets as necessary)

Concisely describe the accident, including the facts, circumstances, and conditions that
may have contributed directly or indirectly to causing the accident. Include secondary
and contributing causes when possible, or any other factors associated with the cause that
are deemed pertinent. Use this section to clarify or explain unusual conditions, to provide
sketches or drawings, and to explain any estimated data. Operators submitting reports
on-line will be afforded the opportunity to attach/upload files containing sketches,
drawings, or additional data.

If you checked the Miscellaneous block in Section G8, the narrative should describe the
accident in detail, including all known or suspected causes and possible contributing
factors.
Operators should use the narrative to describe any secondary causes that they consider
important but which could not be reported in section G since only the primary cause is
reported there.

PART I – PREPARER AND AUTHORIZED SIGNATURE
The Preparer is the person who compiled the data and prepared the responses to the
report and who is to be contacted for more information (preferably the person most
knowledgeable about the information in the report or who knows how to contact the
person most knowledgeable). Please enter the Preparer’s e-mail address if the Preparer
has one, and the phone and fax numbers used by the Preparer.
An Authorized Signature must be obtained from an officer, manager, or other person
whom the operator has designated to review and approve (and sign and date) the report.
This individual is responsible for assuring the accuracy and completeness of the reported
data. In addition to their title, a phone number and email address are to be provided for
the individual signing as the Authorized Signature.

File Type	application/pdf
File Title	NOTICE: This report is required by 49 CFR Part 195
Author	Debbie
File Modified	2009-12-15
File Created	2009-12-15