Form PHMSA F 7100. INCIDENT REPORT GAS DISTRIBUTION SYSTEM

Incident and Annual Reports for Gas Pipeline Operators

GasDistr Incident Form-w-Instructions - PHMSA F 7100-1 (01-2010)

Incident and Annual Reports for Gas Pipeline Operators

OMB: 2137-0522

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 2137-0522 can be found here:

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

OMB NO: 2137-0522
EXPIRATION DATE: 01/31/2013

Report Date

INCIDENT REPORT – GAS DISTRIBUTION
SYSTEM

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

No.
(DOT Use Only)

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

Important: Please read the separate instructions for completing this form before you begin. They clarify the
information requested and provide specific examples. If you do not have a copy of the instructions, you can obtain
one from the PHMSA Pipeline Safety Community Web Page at http://www.phmsa.dot.gov/pipeline.
PART A – KEY REPORT INFORMATION

 Original

**Report Type: (select all that apply)

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

 Supplemental

 Final

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

3.b ___________________________________________________
(City)

3.c State: /

3.d Zip Code: /

/ - /

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

Hour

Month

**6. National Response Center Report Number :
/

Day

Year

**5. Location of Incident:

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

5.a ___________________________________________________

(Street Address or location description)

Hour

/
Month

/
Day

Year

5.b ___________________________________________________
(City)

5.c ___________________________________________________
(County or Parish)

5.d State: /

5.e Zip Code: /

/ . /

5.f Latitude:
Longitude: -

/ - /

/ . /

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

 Natural Gas
 Propane Gas
 Other Gas  Name: ___________________________
**10. Estimated volume of gas released:

/,/

/ Thousand Cubic Feet (MCF)

Form PHMSA F 7100.1 (Rev. 01-2010)

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

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

 Yes  No

11.a Operator employees

12.a Operator employees

11.b Contractor employees
working for the Operator

12.b Contractor employees
working for the Operator

11.c Non-Operator
emergency responders

12.c Non-Operator
emergency responders

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

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

11.e General public

12.e General public

11.f Total fatalities (sum of above)

12.f Total injuries (sum of above)

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

Hour

13.b Local time pipeline/facility restarted

Hour

**14. Did the gas ignite?

 Yes

 No

**15. Did the gas explode?

 Yes

 No

16. Number of general public evacuated: /

/,/

Month

Day

Year

Day

 Still shut down*
(*Supplemental Report required)

Year

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

Hour

17.b Local time operator resources arrived on site

/
Hour

Month

/
Month

Day

/
Day

Form PHMSA F 7100.1 (Rev. 01-2010)

Year

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PART B – ADDITIONAL LOCATION INFORMATION

 Yes

1. Was the Incident on Federal land?

 No

**2. Location of Incident: (select only one)

 Operator-controlled property
 Public property
 Private property
 Utility Right-of-Way / Easement
**3. Area of Incident: (select only one)

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

/,/

 Aboveground Specify:  Typical aboveground facility piping or appurtenance (e.g. valve or regulator station, outdoor meter set)
 Overhead crossing
 In or spanning an open ditch
 Inside a building
 In other enclosed space
 Other _______________________________________
 Transition Area Specify:  Soil/air interface
 Wall sleeve
 Pipe support or other close contact area
 Other ______________________________________________________
**4. Did Incident occur in a crossing?
If Yes, specify type below:








Road crossing 
Water crossing 

 Yes

 No

 Cased

 Uncased
 Cased
 Uncased
(Select all that apply)  Cased
 Uncased
(Select all that apply)  Cased
 Uncased

Bridge crossing

Specify:

Railroad crossing

(Select all that apply)

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

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

/,/

Form PHMSA F 7100.1 (Rev. 01-2010)

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






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






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

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

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

 Unknown

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

4. Material involved in Incident:

 Unknown

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

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

/./

 Plastic

 Unknown

 None or  Unknown

or  Unknown

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

or wall thickness: /

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

/./

 Unknown

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

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

 Other



Describe: ___________________________________________________________________

Form PHMSA F 7100.1 (Rev. 01-2010)

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






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

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

/,/

2.b Estimated cost of gas released

/,/

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

/,/

2.d Estimated cost of Operator’s emergency response

/,/

2.e Estimated other costs

/,/

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

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

/,/

3.b Industrial entities

/,/

3.c Residences

/,/

Form PHMSA F 7100.1 (Rev. 01-2010)

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

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

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

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

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

 Operator employee

 Contractor working for the Operator

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

 Yes, but the investigation of the control room and/or controller actions has not yet been completed by the operator (Supplemental
Report required)

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

Form PHMSA F 7100.1 (Rev. 01-2010)

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

 No
 Yes



1.a Specify how many were tested:

1.b Specify how many failed:

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

 No
 Yes



2.a Specify how many were tested:

2.b Specify how many failed:

Form PHMSA F 7100.1 (Rev. 01-2010)

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PART G – APPARENT CAUSE

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

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

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

 No

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

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

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

 Yes  No

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

Form PHMSA F 7100.1 (Rev. 01-2010)

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 Internal Corrosion

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

 Yes  No

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

Month

Day

Year

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

 No

G2 – Natural Force Damage – **only one sub-cause can be picked from shaded left-handed column
 Earth Movement, NOT due to Heavy
Rains/Floods

**1. Specify:  Earthquake  Subsidence
 Other ___________________

 Heavy Rains/Floods

2. Specify:

 Lightning

3. Specify:

 Temperature

**4. Specify:

 Landslide

 Washouts/Scouring  Flotation  Mudslide  Other ________________
 Direct hit  Secondary impact such as resulting nearby fires
 Thermal Stress
 Frozen Components

 Frost Heave
 Other ________________________________

 High Winds
 Other Natural Force Damage

**5. Describe: _________________________________________________

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

 Yes

 No

 Hurricane  Tropical Storm
 Tornado
 Other ______________________________

Form PHMSA F 7100.1 (Rev. 01-2010)

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G3 – Excavation Damage – **only one sub-cause can be picked from shaded left-hand column
 Excavation Damage by Operator
(First Party)

 Excavation Damage by Operator’s
Contractor (Second Party)

 Excavation Damage by Third Party
 Previous Damage due to Excavation
Activity

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

Month

Day

Year

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

 Yes  No

 One-Call System

3.a If Yes, Notification received from: (select all that apply)

 Excavator

 Contractor

 Landowner

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

Yes

 No

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

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

 Other

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

 Contractor
 Railroad

 County
 State

 Developer
 Utility

 Farmer
 Municipality
 Data not collected

 Occupant
 Unknown/Other

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

 Auger
 Explosives
 Probing Device

 Backhoe/Trackhoe
 Farm Equipment
 Trencher

 Boring
 Grader/Scraper
 Vacuum Equipment

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

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

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

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

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

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

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

Form PHMSA F 7100.1 (Rev. 01-2010)

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

 Yes

9.a If Yes, specify ticket number: /

 No
/

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

 Utility Owner

 Contractor Locator

 Data not collected

 Unknown/Other

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

 No

 Yes

 Data not collected

 Unknown/Other

12. Were facilities marked correctly?

 No

 Yes

 Data not collected

 Unknown/Other

 No

 Yes

 Data not collected

 Unknown/Other

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

/___/___/___/___/ hours

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

 One-Call Notification Practices Not Sufficient: (select only one)
 No notification made to the One-Call Center
 Notification to One-Call Center made, but not sufficient
 Wrong information provided
 Locating Practices Not Sufficient: (select only one)
 Facility could not be found/located
 Facility marking or location not sufficient
 Facility was not located or marked
 Incorrect facility records/maps
 Excavation Practices Not Sufficient: (select only one)
 Excavation practices not sufficient (other)
 Failure to maintain clearance
 Failure to maintain the marks
 Failure to support exposed facilities
 Failure to use hand tools where required
 Failure to verify location by test-hole (pot-holing)
 Improper backfilling
 One-Call Notification Center Error
 Abandoned Facility
 Deteriorated Facility
 Previous Damage
 Data Not Collected
 Other / None of the Above (explain)_____________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________

Form PHMSA F 7100.1 (Rev. 01-2010)

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G4 – Other Outside Force Damage

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

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

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

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

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

 Third Party

**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

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

/
Month

/
Day

Year

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

 Intentional Damage

5. Specify:

 Other Outside Force Damage

**6. Describe: _____________________________________________________

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

Form PHMSA F 7100.1 (Rev. 01-2010)

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

1. Specify:

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

 Butt Weld

2. Specify:

 Pipe  Fabrication  Other ________________________________

 Fillet Weld

3. Specify:

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

 Pipe Seam

4. Specify:

 LF ERW  DSAW  Flash Weld  HF ERW  SAW  Spiral
 Other ________________________

 Threaded Metallic Pipe
 Mechanical Fitting

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

9. Year installed:

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

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

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

 Cat. I

 Cat. II

Form PHMSA F 7100.1 (Rev. 01-2010)

 Cat. III

 DOT 192.283

Page 13 of 17

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 Compression Fitting

13.
14.
15.
16.
17.

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

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

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

19. Specify:

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

20. Year installed:

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

 Other Pipe, Weld, or Joint Failure

**23. Describe:______________________________________________________________

Form PHMSA F 7100.1 (Rev. 01-2010)

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

 Arc Burn  Crack
 Burnt Steel

 Lack of Fusion

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

 Long seam  Other ___________________________________________________

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

 Yes  Most recent year tested: /
 No

Test pressure (psig): /

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

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

 Threaded Connection Failure

**2. Specify:

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

 Non-threaded Connection Failure

**3. Specify:

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

 Valve

4. Specify:

 Manufacturing defect

 Other ________________________________

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

 Other Equipment Failure

**5. Describe: __________________________________________________________________
______________________________________________________________________________

Form PHMSA F 7100.1 (Rev. 01-2010)

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G7 – Incorrect Operation – **only one sub-cause can be selected from the shaded left-hand column
 Damage by Operator or Operator’s
Contractor NOT Related to Excavation
and NOT due to Motorized
Vehicle/Equipment Damage

 Valve Left or Placed in Wrong
Position, but NOT Resulting in an
Overpressure
 Pipeline or Equipment Overpressured

 Equipment Not Installed Properly
 Wrong Equipment Specified or
Installed

 Other Incorrect Operation

**1. Describe: __________________________________________________

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

 No

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

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

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

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

 Unknown

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

Form PHMSA F 7100.1 (Rev. 01-2010)

Page 16 of 17

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PART H – NARRATIVE DESCRIPTION OF THE INCIDENT

(Attach additional sheets as necessary)

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

Preparer's Name (type or print)

Preparer’s Telephone Number

Preparer's Title (type or print)

Preparer's E-mail Address
Authorized Signature

Preparer’s Facsimile Number
Date

Authorized Signature Telephone Number

Authorized Signature’s Name (type or print)

Authorized Signature’s Title (type or print)

Authorized Signature’s E-mail Address

Form PHMSA F 7100.1 (Rev. 01-2010)

Page 17 of 17

Reproduction of this form is permitted

INSTRUCTIONS FOR FORM PHMSA F 7100.1 (Rev. 01-2010)
INCIDENT REPORT – GAS DISTRIBUTION PIPELINE SYSTEMS
GENERAL INSTRUCTIONS
Each gas distribution system operator shall file Form PHMSA F 7100.1 for an incident that
meets the criteria in 49 CFR §191.3 as soon as practicable but not more than 30 days after
discovery of the incident. Please submit reports according to §191.7.
Liquefied natural gas (LNG) facility and master meter operators are exempt from filing reports
(see §191.11(c)).
Release of gas, for the purpose of maintenance need not be reported if the only reportable
criterion is loss of gas of $50,000 or more as described in 49 CFR §191.3 under "Incident"
(1)(ii). Damage from secondary ignition need not be reported unless the damage to facilities
subject to Part 191 exceeds $50,000. Secondary ignition is a gas fire where the origin is
unrelated to the gas facilities, such as electrical fires, arson, etc.
If you need copies of the Form PHMSA F 7100.1 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.
§191.3 Definitions.
*

Incident means any of the following events:
(1) An event that involves a release of gas from a pipeline or of liquefied natural gas
or gas from an LNG facility and
(i) A death, or personal injury necessitating in-patient hospitalization; or
(ii) Estimated property damage, including cost of gas lost, of the operator or
others, or both, of $50,000 or more.
(2) An event that results in an emergency shutdown of an LNG facility.
(3) An event that is significant, in the judgment of the operator, even though it did
not meet the criteria of paragraphs (1) or (2).
§191.5 Telephonic notice of certain incidents.
Instructions:

Incident Report – Gas Distribution Pipeline Systems

Form PHMSA F 7100.1 (Rev. 01-2010)

Page 1 of 20

(a) At the earliest practicable moment following discovery, each operator shall give
notice in accordance with paragraph (b) of this section of each incident as defined in
§191.3.
(b) Each notice required by paragraph (a) of this section shall be made by telephone
to 800-424-8802(in Washington, DC, 267-2675) and shall include the following information:
(1) Names of operator and person making report and their telephone
numbers.
(2) The location of the incident.
(3) The time of the incident.
(4) The number of fatalities and personal injuries, if any.
(5) All other significant facts that are known by the operator that are
relevant to the cause of the incident or extent of the damages.
§191.9 Distribution system: Incident report.
(a) Except as provided in paragraph (c) of this section, each operator of a
distribution pipeline system shall submit Department of Transportation Form RSPA F
7100.1 as soon a practicable but not more than 30 days after detection of an incident
required to be reported under §191.5.
(b) When additional relevant information is obtained after the report is submitted
under paragraph (a) of this section, the operator shall make supplementary reports as
deemed necessary with a clear reference by date and subject to the original report.
(c) The incident report required by this section need not be submitted with respect
to master meter systems or LNG
facilities.

Telephonic reports are assigned an NRC number, which operators should note. National
Response Center call information must be reported in Question 6 of the Form PHMSA F 7100.1.

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.
Instructions:

Incident Report – Gas Distribution Pipeline Systems

Form PHMSA F 7100.1 (Rev. 01-2010)

Page 2 of 20

Note: Submit a copy of your report directly to the State Regulatory Agency in addition to
submitting to DOT/PHMSA, if that is the requirement in your state.

1. Online:
a. Navigate to the ONLINE DATA ENTRY SYSTEM at http://opsweb.phmsa.dot.gov/
and click on the Incident Report – Gas Distribution Systems link
b. Enter Operator ID and PIN (the name that appears is the operator name assigned to the
operator ID and PIN and is automatically populated by our database and cannot be
changed by the operator at the time of filing).
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.

RESCINDING A REPORT
An operator who reports an incident and upon subsequent investigation determines that the event
did not meet the criteria in 49 CFR 191.3 may request that their report be rescinded. Requests
for rescission should be submitted on company 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: Operator name,
b: PHMSA-issued operator ID number,
c. The number assigned by the National Response Center when telephonic report was
made in accordance with 49 CFR 191.5,
d. Date of the incident,
e. Location of the incident (city, county, state), and
f. A brief statement as to why the report should be rescinded.

SPECIAL INSTRUCTIONS
Instructions:

Incident Report – Gas Distribution Pipeline Systems

Form PHMSA F 7100.1 (Rev. 01-2010)

Page 3 of 20

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 and leave numeric fields and field suing
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 and “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 4.b) Wall Thickness

/ 0 / 0 /0/ 8 / (8 inches)
/1/./5/0/ (1.5 inches)
/./5/0/0/ inches (0.5 inches)

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/.
Instructions:

Incident Report – Gas Distribution Pipeline Systems

Form PHMSA F 7100.1 (Rev. 01-2010)

Page 4 of 20

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/

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 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 incident.
If all of the information requested is known and provided at the time the initial report is filed,
including final property damages and failure 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
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 is needed to provide a way to identify previously filed reports.
For Supplemental Reports filed online, all data previously submitted will automatically populate
Instructions:

Incident Report – Gas Distribution Pipeline Systems

Form PHMSA F 7100.1 (Rev. 01-2010)

Page 5 of 20

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 as soon as practicable 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.

In Part A, answer questions 1 thru 16 by providing the requested information
or by checking the appropriate box.
1. Operator’s OPS -Issued five Digit Operator Identification Number (OPID):
The Pipeline and Hazardous Materials Safety Administration (PHMSA) assigns the operator's
five-digit 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
incident report should be sent.
4. Local time (24-hour clock) and date of the Incident.
Instructions:

Incident Report – Gas Distribution Pipeline Systems

Form PHMSA F 7100.1 (Rev. 01-2010)

Page 6 of 20

See page 5 for examples of Date format and Time format expressed as a 24-hour clock
5. Location of Incident:
a. Provide the street address of the incident (enter “unknown” if no street address)
b. Provide the name of the city where the incident occurred.
c. Provide the name of the county or Parish where the incident occurred.
d. Enter the state where the incident occurred.
e. Enter the zip code where the incident occurred.
f. 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/cgibin/mapbrowse-tbl). You can use the online tool to identify the geographic location of the
incident. The tool displays the latitude and longitude in decimal degrees below the map. Any
questions regarding the required format, conversion or how to use the tool noted above can be
directed to Amy Nelson (202.493.0591 or [email protected]).
6. National Response Center (NRC) Report Number
§ 191.5 requires that incidents meeting the criteria outlined in §191.3 be reported directly to the
24-hour National Response Center (NRC): at 1-800-424-8802 at the earliest practicable
moment (generally within 2 hours). The NRC assigns numbers to each call. 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. Incident resulted from:
Indicate whether the incident resulted from intentional or unintentional release of gas or from
reasons other than release of gas.
9. Gas released:
Instructions:

Incident Report – Gas Distribution Pipeline Systems

Form PHMSA F 7100.1 (Rev. 01-2010)

Page 7 of 20

Report the type of gas released.
10. Estimated volume of gas released
Estimate the amount of gas that was released (in thousands of cubic feet) from the beginning of
the incident until the time product flow was terminated. Estimates should be based on bestavailable information.
11. Were there fatalities?
If a person dies at the time of the incident or within 30 days of the initial incident date due to
injuries sustained as a result of the incident, report as a fatality. If a person dies subsequent to an
injury more than 30 days past the incident date, report as an injury. This aligns with the
Department of Transportation's general guidelines for all modes for reporting deaths and injuries.
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
incident 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 category most often includes employees of
other underground facilities operators, or their contractors, working in or near a shared
right-of-way. For distribution pipelines not located in a defined right of way, this category
should be left blank.
12. Were there injuries requiring inpatient hospitalization?
Injuries requiring inpatient hospitalization means injuries sustained as a result of the incident and
requiring hospital admission and at least one overnight stay.
13. Was the pipeline/facility shut down due to the incident?
Report any shutdowns that occur because of damage incurred during the incident or to make
repairs necessitated by the incident. Instances in which an incident 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 13.a and 13.b.
14. Did the Gas Ignite?
Ignite means the gas caught fire.
Instructions:

Incident Report – Gas Distribution Pipeline Systems

Form PHMSA F 7100.1 (Rev. 01-2010)

Page 8 of 20

15. Did the Gas Explode?
Explode means the ignition of the gas with a sudden and violent release of energy.
16. 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, if available. If there was no evacuation involving the
general public, report “0”. If estimate is not possible for some reason, leave blank but include an
explanation of why it was not possible in the Part H Narrative.
17. Time sequence (use local time, 24-hour clock)
Enter the time the operator became aware of the incident, the time operator personnel or contract
resources arrived on site, and the time normal operations resumed (i.e., when immediate
response activities ended, not including subsequent replacement/repairs that could be deferred
until after the immediate response).

PART B – ADDITIONAL LOCATION INFORMATION
1. Was the incident on Federal Land?
Federal Lands means all lands the United States owns, including military reservations, except
lands in National Parks and lands held in trust for Native Americans. Incidents 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.
2. Location of incident
Operator-controlled property would normally apply to an operator’s facility, which may or
may not have controlled access, but which is oftentimes fenced or otherwise marked with
discernible boundaries. This “operator-controlled property” does not refer to the pipeline rightof-way/easement, which is a separate choice for this question.
3. Area of incident
This refers to the location on the pipeline at which gas was released, resulting in the incident. It
does not refer to adjacent locations in which released gas may have accumulated and ignited,
resulting in adverse consequences.
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.
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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, is not necessarily excavation damage (but may be). This
category could include a corrosion leak not previously evidenced by stained vegetation, but
found during excavation, or a release caused by a non-excavation vehicle where contact
happened to occur while the pipeline was exposed for an excavation. 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 regulating stations or valve sites.
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.
4. Did the incident occur in a crossing?
Use Bridge Crossing if the pipeline is suspended above a body of water or roadways, 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 if the pipeline is buried beneath rail bed, whether paralleling or crossing
the track.
Use Road Crossing if the pipeline crosses a road (e.g., at an intersection). Road Crossing does
not refer to situations in which pipelines are buried under roadways and parallel the direction of
the road.
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 incident 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 incident 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 and time of the incident, allowing for seasonal, weather-related and other factors
which may affect the water depth from time to time.

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PART C – ADDITIONAL FACILITY INFORMATION
1. Indicate the type of pipeline system:
Designate the type of distribution pipeline system on which the incident occurred.
2. Part of system involved in Incident
This should be the part of the system principally involved in the incident, from which gas
was released resulting in reportable consequences. If the failure occurred on an item not
provided in this section, check the OTHER box and specify in the space provided the
item that failed.
3. When “Main” or “Service” is selected as the “Part of system involved in incident,”
(from PART C, Question 2), provide the following:
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”).
Pipe Specification is the specification to which the pipe or component was manufactured, such
as API 5L or ASTM A106.
4. Material involved in incident:
Identify the type of material involved and provide additional information as indicated.
5. Type of release involved:
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 puncture.” (Precise measurement of
size – e.g., micrometer – is not needed. Measurements can be provided in inches and one
decimal.)
Leak means a failure resulting in an unintentional release of gas which is often small in size,
usually resulting a low volume release, although large volume leaks can and do occur on
occasion. Leaked gas may accumulate in nearby structures where subsequent ignition can result
in consequences.
Rupture means a loss of containment event that immediately impairs the operation of the
pipeline. Pipeline ruptures have the potential to be severely detrimental to safety and the
environment. 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
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weld such as a pipe seam. (Precise measurement of size – e.g., micrometer – is not needed.
Measurements can be provided in inches and decimals.)

PART D – ADDITIONAL CONSEQUENCE INFORMATION
2. Estimated Cost to Operator:
All relevant costs must be included in the initial written incident 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, gas lost, facility repair and replacement, gas distribution
service restoration and relighting, leak locating, and environmental cleanup and damage. Do not
report costs incurred for facility repair, replacement, or change that are not related to the incident
done solely for convenience. An example of doing work solely for convenience is working on
leaking facilities unearthed because of the incident. Litigation and other legal expenses related
to the incident 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 § 191.9). 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.
Costs incurred by the operator prior to gas being shut off should be included as part of operator
emergency response. Costs incurred thereafter should be included with repair costs.
Public and non-operator private property damage estimates generally include physical
damage to the property of others, the cost of investigation and remediation of a site not owned or
operated by the Company, laboratory costs, third party expenses such as engineers or scientists,
and other reasonable costs, excluding litigation and other legal expenses related to the incident.
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.
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, reinstallation of a service line, or the
removal from service of an appurtenance 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 incident. Costs associated with improvements to
the pipeline to mitigate the risk of future failures are not included.
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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 incident, excluding litigation and other legal
expenses related to the incident.
Estimated cost of Operator’s emergency response includes emergency response operations
necessary to return the incident site to a safe state, actions to minimize the volume of gas
released, and to identify the extent of accident impacts. They include materials, supplies, labor,
and benefits. Costs related to stakeholder outreach, media response, etc. should not be included.
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.
3. Estimated number of customers out of service:
Count number of individual services in each category that were affected, not number of persons
served.

PART E – ADDITIONAL OPERATING INFORMATION
2. Normal operating pressure at point and time of the incident (psig)
If the normal operating pressure of a distribution system varies throughout the year (e.g.,
seasonally), report the normal operating pressure at the time the incident occurred.
5. Was a Supervisory Control and Data Acquisition (SCADA)-based system in place on the
pipeline or facility involved in the incident?
This does not mean a system exclusively for leak detection.
5.a. Was it operating at the time of the Incident?
Was the SCADA system in operation at the time of the accident?
5.b. Was it fully functional at the time of the Incident?
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
5.c and d. Did SCADA-based information (such as alarm(s), alert(s), event(s), and/or
volume or pack calculations) assist with the detection or confirmation of the Incident?

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Check yes if SCADA-based information was used to confirm the incident even if the initial
report or identification may have come from other sources. Use of SCADA data for subsequent
estimation of amount of gas lost, etc. is not considered use to confirm the incident.
Check No if data from SCADA was not used to assist with identification of the incident.
6. How was the Incident initially identified for the Operator?
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.
7. Was an investigation initiated into whether or not the controller(s) or control room
issues were the cause of or a contributing factor to the Incident?
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 resulted in the pipeline incident.
Contributing factor means an action or lack of action that when added to the existing pipeline
circumstances heightened the likelihood of the release 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, report separately
the number of operator employees and contractors working for the operator who were tested and
who failed.

PART G – APPARENT CAUSE
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In PART G – Apparent Cause
Complete only one of the eight sections listed under G1 thru G8
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. 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 and failure of bolts, it is classified as Corrosion. (If the bonnet, packing, or other
gasket has deteriorated before the end of its expected life but not due to corrosive action, it is
classified as a Material Defect.)
External Corrosion
Under cathodic protection means cathodic protection in accordance with Sections 192.455,
192.457, and 192.463. Recognizing that older pipelines may have had cathodic protection added
over a number of years, provide an estimate if exact year cathodic protection started is unknown.

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 incidents caused by land shifts
such as earthquakes, landslides, or subsidence, but not mudslides which are presumed to be
initiated by heavy rains or floods.
Heavy Rains/Floods refer to all water related incident. 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 incident.
Temperature refers to those causes that are related to ambient temperature effects, either heat or
cold, where temperature was the initial cause.
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.
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Frozen components would include incidents 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 inflicted by the operator, operator’s contractor, or entities unrelated
to the operator during excavation that results in an immediate release of gas. Damage from
outside forces OTHER than excavation that results in an immediate release, use G2 “Natural
Force Damage” or G4 “Other Outside Force” as appropriate. For a strike or other damage to a
pipeline or facility that results in a later release, report the incident in Section G4 as “Rupture or
Failure Due to Previous Mechanical Damage.”
Excavation Damage by Operator (First Party)
Check this item if the incidnet 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 incident 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 incident 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
2. Has one or more pressure test been conducted since original construction at the point of
the incident?
Information from the initial post-construction hydrostatic test need not be reported.
4. – 14. 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 incidents 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 questions.

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Nearby Industrial, Man-made or Other Fire/Explosion as Primary Cause of Incident
applies to situations where the fire occurred before and caused the release. An example of such a
failure would be an explosion/fire at a neighboring facility or structure that results in a release at
the location of the incident. (Note that an incident report is required only if damage to facilities
subject to Part 192 exceeded $50,000). This section should not be used if the release occurred
first and then the gas ignited. If the fire is known to have been started as a result of a lightning
strike, the incident’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 would be damage to a meter set caused by vehicle impact. Other
motorized vehicles/equipment includes tractors, backhoes, bulldozers and other tracked vehicles,
and heavy equipment that can move. Include under this sub-cause incidents 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 as appropriate. Pipeline incidents resulting from
vehicular traffic loading or other contact should also be reported in this category. If the activity
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 that have lost their moorings and are carried into the pipeline 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 by current or high winds. In such cases, also
indicate the type of severe weather event. Do not report in this sub-cause incidents which are
caused by impact of maritime equipment or vessels while they are engaged in their normal or
routine activities; such incidents 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 incidents due to shrimping, purseining, oil drilling, or oilfield workover rigs,
including anchor strikes, and other routine or normal maritime-related activities UNLESS the
movement of the maritime asset was due to a severe weather event (this type of damage 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 incident was caused by
excavation activity such as dredging of waterways or bodies of water (this type of incident
should be reported under Section G3, “Excavation Damage.”).
Previous Mechanical Damage NOT Related to Excavation. This sub-cause covers incidents
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. Incidents resulting from damage sustained during
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construction, installation, or fabrication of the pipe or a weld should be reported under Section
G5, “Material Failure of Pipe or Weld.”
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 gas or pipeline equipment.
Other
Describe in the space provided and, if necessary, provide additional explanation in Part H.
G5 – Pipe, Weld, or Joint Failure
This section includes leaks, ruptures or other failures from a defect within the material of the
pipe, component or joint due to faulty manufacturing procedures, defects resulting from poor
construction/installation practices, and in-service stresses such as vibration, fatigue and
environmental cracking.
Mechanical Fitting, Question 7, Manufacturer
Compression Fitting, Qustion 14, Manufacturer
Operators should take care in identifying the manufacturer. Some types of fittings are commonly
referred to as “Dresser fittings” (for example) even though the particular fitting may have been
manufactured by a different company. Operators should report here the company that actually
manufactured the involved fitting.
Fitting means a device, usually metal, for joining lengths of pipe into various piping systems. It
includes couplings, ells, tees, crosses, reducers, unions, caps and plugs.
Material defect means an inherent flaw in the material or weld that occurred in the manufacture
or at a point prior to construction, fabrication or installation.
Design defect means an aspect inherent in a component to which a subsequent failure has been
attributed that is not associated with errors in installation, i.e., is not a construction defect.” This
could include, for example, errors in engineering design.

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Records of test pressure from past pressure tests may not be available. In such cases, the
operator should estimate the test pressure using best available information.
G6 – Equipment Failure
This section includes malfunctions of control and relief equipment (typically the result of failed
and leaking valves), failures of threaded components and broken pipe couplings, including ORing failures, Gasket failures, thread failures, and failures in packing.
Malfunction of Control/Relief Equipment
Examples of this type of failure include failures on compressors, meters, or regulator stations
where the failure resulted from a crack in a component or threads of a component such as
nipples, flanges, valve connections, line pipe collars, etc. Include a description of the nature of
the failure and apparent cause in the narrative (PART H).
Examples of this type of failure cause also include: overpressurization resulting from
malfunction of control or alarm device; relief valve malfunction: and 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 incident was caused by incorrect operation, the
incident should be reported under Section G7, “Incorrect Operation.”
G7 – Incorrect Operation
These types of incidents most often occur during operating, maintenance or repair activities.
Some examples of this type of failure are improper valve selection or operation, inadvertent
overpressurization, or improper selection or installation of equipment. The unintentional ignition
of the transported gas during a welding or maintenance activity would also be included in this
sub-cause. These types of incidents often involve training or judgment errors.
G8 – Other Incident Cause
This section is provided for incident causes that do not fit in any of the main cause categories in
Sections G1 through G7.
If the incident 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 incident and continue in Part H, Narrative
Description of the Incident, if more space is needed.
Leaks resulting from materials deteriorating after the expected life of the materials are classified
as “Other Cause”. Describe under Miscellaneous.
If the incident cause is unknown at 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.
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PART H – NARRATIVE DESCRIPTION OF THE INCIDENT
(Attach additional sheets as necessary)

Concisely describe the incident, including the facts, circumstances, and conditions that may have
contributed directly or indirectly to causing the incident. 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 box in Section G8, the narrative should describe the incident 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.

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File Type	application/pdf
File Title	NOTICE: This report is required by 49 CFR Part 191
Author	PHMSA
File Modified	2010-02-19
File Created	2010-02-19