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pdfNOTICE: 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.
Form Approved
OMB NO: 2137-0522
Expires: ????10/31/2018
INCIDENT REPORT –
NATURAL AND OTHER GAS TRANSMISSION
AND GATHERING PIPELINE SYSTEMS
U.S. Department of Transportation
Pipeline and Hazardous Materials
Safety Administration
Report Date
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/library/forms.
PART A – KEY REPORT INFORMATION
Report Type: (select all that apply) Original Supplemental Final
Last Revision Date
1. Operator’s OPS-issued Operator Identification Number (OPID):
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2. Name of Operator: ______________________________________________________________________________________
3. Address of Operator:
3.a _______________________________________________________________________
(Street Address)
3.b ___________________________________________________
(City)
3.c State: /
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3.d Zip Code: /
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4. Local time (24-hr clock) and date of the Incident:
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Hour
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Month
5. Location of Incident:
Latitude:
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Longitude: - / / / / . /
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6. National Response Center Report Number:
Day
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Year
7. Local time (24-hr clock) and date of initial telephonic report to the
National Response Center (if applicable):
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8. Incident resulted from:
Unintentional release of gas
Intentional release of gas
Reasons other than release of gas
9. Gas released: (select only one, based on predominant volume released)
Natural Gas
Propane Gas
Synthetic Gas
Hydrogen Gas
Landfill Gas
Other Gas
Name:
10. Estimated volume of gas released unintentionally:
/
11. Estimated volume of intentional and controlled release/blowdown :
12. Estimated volume of accompanying liquid released:
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/,/
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Form PHMSA F 7100.2 (rev 03/2016)
/
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/ Thousand Cubic Feet (MCF)
/ Thousand Cubic Feet (MCF)
/
/ Barrels
Page 1 of 19
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13. Were there fatalities? Yes No
If Yes, specify the number in each category:
14. Were there injuries requiring inpatient hospitalization?
If Yes, specify the number in each category:
Yes No
13.a Operator employees
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14.a Operator employees
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13.b Contractor employees
working for the Operator
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14.b Contractor employees
working for the Operator
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13.c Non-Operator
emergency responders
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14.c Non-Operator
emergency responders
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13.d Workers working on the
right-of-way, but NOT
associated with this Operator
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14.d Workers working on the
right-of-way, but NOT
associated with this Operator
13.e General public
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14.e General public
13.f Total fatalities (sum of above)
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14.f Total injuries (sum of above)
15. Was the pipeline/facility shut down due to the incident?
Yes No Explain: ______________________________________________________________________________
If Yes, complete Questions 15.a and 15.b: (use local time, 24-hr clock)
15.a Local time and date of shutdown
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Hour
15.b Local time pipeline/facility restarted
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Hour
16. Did the gas ignite?
Yes
No
17. Did the gas explode?
Yes
No
18. Number of general public evacuated: /
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Month
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Year
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Still shut down*
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(*Supplemental Report required)
Year
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19. Time sequence: (use local time, 24-hour clock)
19.a Local time operator identified failure
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Hour
19.b Local time operator resources arrived on site
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Month
Form PHMSA F 7100.2 (rev 03/2016)
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Year
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PART B – ADDITIONAL LOCATION INFORMATION
1. Was the origin of the Incident onshore?
Yes (Complete Questions 2-12)
No (Complete Questions 13-15)
If Onshore:
2. State: /
If Offshore:
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3. Zip Code: /
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13. Approximate water depth (ft.) at the point of the Incident:
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4 ______________________
/ - /
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5______________________
City
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County or Parish
6. Operator designated location: (select only one)
/,/
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14. Origin of Incident:
In State waters
Specify: State: /
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/
Area: ___________________
Milepost/Valve Station (specify in shaded area below)
Survey Station No. (specify in shaded area below)
Block/Tract #: /___/___/___/___/
Nearest County/Parish: ________________
/___/___/___/___/___/___/___/___/___/___/___/___/___/
7. Pipeline/Facility name: ________________________________
/
On the Outer Continental Shelf (OCS)
Specify:
8. Segment name/ID: ___________________________________
9. Was Incident on Federal land, other than the Outer Continental
Shelf (OCS)?
Yes No
10. Location of Incident: (select only one)
11. Area of Incident (as found): (select only one)
Belowground storage or aboveground storage vessel,
including attached appurtenances
Underground Specify: Under soil
Under a building
Under pavement
Exposed due to excavation
In underground enclosed space (e.g., vault)
Other ____________________________
/,/
/
Block #: /___/___/___/___/
15. Area of Incident: (select only one)
Operator-controlled property
Pipeline right-of-way
Depth-of-Cover (in): /
Area: ___________________
/
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
/
Aboveground Specify:
Typical aboveground facility piping or appurtenance
Overhead crossing
In or spanning an open ditch
Inside a building
O Inside other enclosed space
O Other ____________________________
Transition Area Specify: Soil/air interface Wall
sleeve Pipe support or other close contact area
Other ____________________________
12. Did Incident occur in a crossing?
If Yes, specify type below:
Yes
No
Bridge crossing Specify: Cased Uncased
Railroad crossing (select all that apply)
Cased
Uncased
Bored/drilled
Road crossing
(select all that apply)
Cased
Uncased
Bored/drilled
Water crossing
Specify: Cased
Uncased
Name of body of water, if commonly known:
_____________________________________
Approx. water depth (ft) at the point of the Incident:
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(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 7100.2 (rev 03/2016)
Page 3 of 19
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PART C – ADDITIONAL FACILITY INFORMATION
1. Is the pipeline or facility:
Interstate
Intrastate
2. Part of system involved in Incident: (select only one)
Belowground Storage, Including Associated Equipment and Piping
Aboveground Storage, Including Associated Equipment and Piping
Onshore Compressor Station Equipment and Piping
Onshore Regulator/Metering Station Equipment and Piping
Onshore Pipeline, Including Valve Sites
Offshore Platform, Including Platform-mounted Equipment and Piping
Offshore Pipeline, Including Riser and Riser Bend
3. Item involved in Incident: (select only one)
Pipe Specify:
Pipe Body
Pipe Seam
3.a Nominal diameter of pipe (in):
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3.b Wall thickness (in):
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3.c SMYS (Specified Minimum Yield Strength) of pipe (psi):
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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: /
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3.h Pipeline coating type at point of Incident
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_____________
If Pipe Girth Weld is selected, complete items 3.a. through h. above. If the values differ on either side of the girth weld, enter one value in
3.a. through h. and list the different value(s) in Part H - Narrative Description of the Incident.
Valve
Mainline Specify: Butterfly Check Gate Plug Ball Globe
Other __________________________
3.i Mainline valve manufacturer:
3.j Year of manufacture: /
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Relief Valve
Auxiliary or Other Valve
Compressor
Meter
Scraper/Pig Trap
Separator/Separator Filter
Strainer/Filter
Dehydrator/Drier/Treater
Regulator/Control Valve
Drip/Drip Collection Device
Pulsation Bottle
Cooler
Repair Sleeve or Clamp
Hot Tap Equipment
Stopple Fitting
Flange
Relief Line
Auxiliary Piping (e.g. drain lines)
Tubing
Instrumentation
Underground Gas Storage or Cavern
Pressure Vessel
Other ___________________________________
4. Year item involved in Incident was installed:
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Form PHMSA F 7100.2 (rev 03/2016)
Page 4 of 19
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5. Material involved in Incident: (select only one)
Carbon Steel
Plastic
Material other than Carbon Steel or Plastic
*Specify: ____________________________________________
6. Type of Incident 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: ___________________________________________________________________
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. Did this Incident occur in a High Consequence Area (HCA)?
No
Yes 2.a Specify the Method used to identify the HCA:
Method 1
3. What is the PIR (Potential Impact Radius) for the location of this Incident?
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/,/
Method 2
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/ feet
Yes
Yes
Yes
4. Were any structures outside the PIR impacted or otherwise damaged by heat/fire resulting from the Incident?
5. Were any structures outside the PIR impacted or otherwise damaged NOT by heat/fire resulting from the Incident?
6. Were any of the fatalities or injuries reported for persons located outside the PIR?
If 2. Is No, answer 6a.
6a. Did this incident occur in a Moderate Consequence Area (MCA)?
Yes
No
No
No
No
If 6a. is Yes, answer 6b.
6b. Select each of the items below that were present within the potential impact circle:
5 or more buildings intended for human occupancy
Occupied site
Road right-of-way for a designated interstate, freeway, expressway, or other principal 4-lane arterial roadway
7. Estimated Property Damage:
7.a Estimated cost of public and non-Operator private property damage
$/
7.b Estimated cost of Operator’s property damage & repairs
7.c Estimated cost of Operator’s emergency response
7.d Estimated other costs
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Describe ___________________________________________________
7.e Total estimated property damage (sum of above)
$/
Cost of Gas Released
7.f Estimated cost of gas released unintentionally
$/
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7.g Estimated cost of gas released during
intentional and controlled blowdown
$/
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7.h Total estimated cost of gas released (sum of 7.f & 7.g above)
$/
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Form PHMSA F 7100.2 (rev 03/2016)
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Page 5 of 19
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PART E – ADDITIONAL OPERATING INFORMATION
1. Estimated pressure at the point and time of the Incident (psig):
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2. Maximum Allowable Operating Pressure (MAOP) at the point and time of the Incident (psig) :
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2a. MAOP established by 49 CFR section:
� 192.619 (a)(1) � 192.619 (a)(2)
� 192.619 (a)(3)
� 192.619 (a)(4)
� 192.624 (c)(1) � 192. 624(c)(2)
� 192.624 (c)(3)
� 192.624 (c)(4)
� Other
Specify Other:
� 192.619 (c)
� 192.619 (d)
� 192.624(c)(5)
� 192.624 (c)(6)
3. Describe the pressure on the system or facility 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
4. Not including pressure reductions required by PHMSA regulations (such as for repairs and pipe movement), was the system or facility
relating to the Incident operating under an established pressure restriction with pressure limits below those normally allowed by the MAOP ?
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.e below)
5.a Type of upstream valve used to initially isolate release source:
Manual
5.b Type of downstream valve used to initially isolate release source:
Manual Automatic
Check Valve
5.c Length of segment isolated between valves (ft):
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Automatic
Remotely Controlled
Remotely Controlled
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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)
Transmission System
Transmission Line of Distribution System
Type A, Area 1 Gathering
Type B, Area 1 Gathering
Type A, Area 2 Gathering
Type B, Area 2 Gathering
Storage Gathering
Offshore Gathering
Form PHMSA F 7100.2 (rev 03/2016)
Page 6 of 19
Reproduction of this form is permitted
6. Was a Supervisory Control and Data Acquisition (SCADA)-based system in place on the pipeline or facility involved in the Incident?
No
Yes 6.a Was it operating at the time of the Incident?
Yes
No
Yes
No
6.b Was it fully functional at the time of the Incident?
6.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
6.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
7. 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 _________________________________________________
7.a If “Controller”, “Local Operating Personnel, including contractors”, “Air Patrol”, or “Ground Patrol by Operator or its contractor” is
selected in Question 7, specify the following: (select only one)
Operator employee
Contractor working for the Operator
8. 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 7100.2 (rev 03/2016)
Page 7 of 19
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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:
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*1.b Specify how many failed:
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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:
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*2.b Specify how many failed:
/
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Form PHMSA F 7100.2 (rev 03/2016)
Page 8 of 19
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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?
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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 Erosion
Other ____________ ________________________________________________
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 Drop-out
Other ____________________________________________________________
10. Was the gas/fluid treated with corrosion inhibitors or biocides?
11. Was the interior coated or lined with protective coating?
Yes No
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
Form PHMSA F 7100.2 (rev 03/2016)
No
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Complete the following if any Corrosion Failure sub-cause is selected AND the “Item Involved in Incident” (from PART C, Question 3) is
Pipe or Weld.
14. Has one or more internal inspection tool collected data at the point of the Incident?
Yes No
14.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 __________________________
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15. Has one or more hydrotest or other pressure test been conducted since original construction at the point of the Incident?
Yes Most recent year tested: / / / / /
Test pressure (psig): /
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No
16. Has one or more Direct Assessment been conducted on this segment?
Yes, and an investigative dig was conducted at the point of the Incident
Yes, but the point of the Incident was not identified as a dig site
No
Most recent year conducted: /
Most recent year conducted: /
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17. Has one or more non-destructive examination been conducted at the point of the Incident since January 21, 2002?
Yes No
17.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 __________________________
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G2 - Natural Force Damage - *only one sub-cause can be picked from shaded left-hand column
Earth Movement, NOT due to
1. Specify:
Earthquake Subsidence Landslide
Other __________________
Heavy Rains/Floods
2. Specify:
Washout/Scouring Flotation Mudslide Other _______________
Lightning
3. Specify:
Direct hit Secondary impact such as resulting nearby fires
Temperature
4. Specify:
Thermal Stress
Frozen Components
Heavy Rains/Floods
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 7100.2 (rev 03/2016)
Page 10 of 19
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 Incident” (from PART C,
Question 3) is Pipe or Weld.
1. Has one or more internal inspection tool collected data at the point of the Incident?
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 _____________________
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/
/
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 Incident?
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 Incident
Most recent year conducted: / / / / /
Yes, but the point of the Incident 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 Incident
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 __________________________
/
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/
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
Form PHMSA F 7100.2 (rev 03/2016)
Excavator
Contractor
Landowner
Page 11 of 19
Reproduction of this form is permitted
Complete the following mandatory CGA-DIRT Program questions if any Excavation Damage sub-cause is selected.
Yes
7. Do you want PHMSA to upload the following information to CGA-DIRT (www.cga-dirt.com)?
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
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/
*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:
_____________________________________________________________
13. Type of Locator:
Utility Owner
Contract Locator
Data not collected
Unknown/Other
No
Data not collected
Unknown/Other
14. Were facility locate marks visible in the area of excavation?
No
15. Were facilities marked correctly?
No
16. Did the damage cause an interruption in service?
16.a If Yes, specify duration of the interruption:
Yes
Yes
Yes
Data not collected
Data not collected
Unknown/Other
Unknown/Other
/___/___/___/___/ hours
(This CGA-DIRT section continued on next page with Question 17.)
Form PHMSA F 7100.2 (rev 03/2016)
Page 12 of 19
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 7100.2 (rev 03/2016)
Page 13 of 19
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 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 Questions 3-7 ONLY IF the “Item Involved in Incident” (from PART C,
Question 3) is Pipe or Weld.
3. Has one or more internal inspection tool collected data at the point of the Incident?
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
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/
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 Incident?
Yes
Most recent year tested:
Test pressure (psig):
/
/
/
/
/
/,/
/
/
/
/
/
No
6. Has one or more Direct Assessment been conducted on the pipeline segment?
Yes, and an investigative dig was conducted at the point of the Incident
Most recent year conducted: / / / / /
Yes, but the point of the Incident was not identified as a dig site
Most recent year conducted: / / / / /
No
(This section continued on next page with Question 7.)
Form PHMSA F 7100.2 (rev 03/2016)
Page 14 of 19
Reproduction of this form is permitted
7. Has one or more non-destructive examination been conducted at the point of the Incident
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 __________________________
/
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/
Intentional Damage
8. Specify:
Other Outside Force Damage
9. Describe: _________________________________________________________
Vandalism
Terrorism
Theft of transported commodity Theft of equipment
Other ________________________________________
Form PHMSA F 7100.2 (rev 03/2016)
Page 15 of 19
Reproduction of this form is permitted
Use this section to report material failures ONLY IF the “Item Involved in
Incident” (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 (Supplemental Report required)
Construction-, Installation-, or
Fabrication-related
Original Manufacturing-related
(NOT girth weld or other welds
formed in the field)
Environmental Cracking-related
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 Incident?
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 __________________________ /
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6. Has one or more hydrotest or other pressure test been conducted since original construction at the point of the Incident?
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 Incident
Yes, but the point of the incident was not identified as a dig site
No
Most recent year conducted:
Most recent year conducted:
/
/
/
/
/
/
/
/
/
/
8. Has one or more non-destructive examination(s) been conducted at the point of the Incident 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 ________________________________
/
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/
Form PHMSA F 7100.2 (rev 03/2016)
Page 16 of 19
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
Compressor or Compressor-related
Equipment
Threaded Connection/Coupling
1. Specify: (select all that apply)
Control Valve
Instrumentation
SCADA
Communications Block Valve
Check Valve
Relief Valve
Power Failure
Stopple/Control Fitting
Pressure Regulator
ESD System Failure
Other ________________________________________________________
2. Specify: Seal/Packing Failure
Body Failure
Crack in Body
Appurtenance Failure
Pressure Vessel Failure
Other _______________________________________________________
3. Specify:
Pipe Nipple
Valve Threads
Mechanical Coupling
Threaded Pipe Collar Threaded Fitting
Other _______________________________________________________
4. Specify:
O-Ring
Gasket
Seal (NOT compressor seal) or Packing
Other_______________________________________________________
Failure
Non-threaded Connection Failure
Defective or Loose Tubing or Fitting
Failure of Equipment Body (except
Compressor), Vessel 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 gas/fluid
Valve vault or valve can contributed to the release
Alarm/status failure
Misalignment
Thermal stress
Other _______________________________________________________
Form PHMSA F 7100.2 (rev 03/2016)
Page 17 of 19
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
Underground Gas Storage, Pressure
1. Specify:
Vessel, or Cavern Allowed or
Caused to Overpressure
Valve Misalignment
Incorrect Reference Data/Calculation
Miscommunication
Inadequate Monitoring
Other ____________________________________
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
2. Describe: __________________________________________________
Complete the following if any Incorrect Operation sub-cause is selected.
3. Was this Incident 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 Incident:
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 Incident 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 Incident Cause - *only one sub-cause can be picked from 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 7100.2 (rev 03/2016)
Page 18 of 19
Reproduction of this form is permitted
PART H – NARRATIVE DESCRIPTION OF THE INCIDENT
(Attach additional sheets as necessary)
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
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__________________________________________________________________________________________________________________
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
Preparer’s Facsimile Number
_______
Date
Authorized Signer Name
Authorized Signer Title
Authorized Signer Telephone Number
Authorized Signer E-mail Address
Form PHMSA F 7100.2 (rev 03/2016)
Page 19 of 19
Reproduction of this form is permitted
| File Type | application/pdf |
| File Title | NOTICE: This report is required by 49 CFR Part 191 |
| Author | PHMSA |
| File Modified | 2016-04-06 |
| File Created | 2016-04-06 |