PHMSA F 7100.2A Incident Report for Reporting Regulated Gas Gathering Op

NOTICE: This report is required by 49 CFR Part 191. Failure to report can result in a civil penalty as provided in 49
USC 60122.

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

REPORTING-REGULATED NATURAL GAS
GATHERING INCIDENT REPORT

Form Approved ??-????
OMB NO: 2137-0522
Expires: ??/??/????

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
A1. Operator’s OPS-issued Operator Identification Number (OPID):

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A2. Name of Operator: ____ auto-populated based on OPID _______________________________________________
A3. Address of Operator:
A3.a ____ auto-populated based on OPID ___________________________________________________________________
(Street Address)

A3.b _____ auto-populated based on OPID ______________________________________________
(City)

A3.c State: auto-populated based on OPID
A3.d Zip Code: auto-populated based on OPID

A4. Local time (24-hr clock) and date of the Incident:
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Hour

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Month

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A4.a Time Zone for local time (select only one)  Alaska
A4.b Daylight Savings in effect?

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Year

 Eastern  Central  Hawaii-Aleutian

 Mountain  Pacific.

 Yes  No

A5. Location of Incident:
Latitude:
/ / / . / /
Longitude: - / / / / . /

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A6. RESERVED
A7. Estimated volume of gas released unintentionally:

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A8. Estimated volume of intentional and controlled release/blowdown :
A9. Estimated volume of accompanying liquid released:

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A10. Were there fatalities?  Yes  No
If Yes, specify the number in each category:

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/ Thousand Cubic Feet (MCF)
/ Thousand Cubic Feet (MCF)

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/ Barrels

A11. Were there injuries requiring inpatient hospitalization?
If Yes, specify the number in each category:

 Yes  No

A10.a Operator employees

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A11.a Operator employees

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A10.b Contractor employees
working for the Operator

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A11.b Contractor employees
working for the Operator

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A10.c Non-Operator
emergency responders

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A11.c Non-Operator
emergency responders

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A10.d Workers working on the
right-of-way, but NOT
associated with this Operator

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A11.d Workers working on the
right-of-way, but NOT
associated with this Operator

A10.e General public

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A11.e General public

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A10.f Total fatalities (sum of above)

calculated

A11.f Total injuries (sum of above)

calculated

Form PHMSA F 7100.2A (03/2016)

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A12. How was the Incident initially identified by the Operator? (select only one)

 SCADA-based information (such as alarm(s), alert(s), event(s), and/or volume calculations)
 Static Shut-in Test or Other Pressure or Leak Test
 Controller
 Local Operating Personnel, including contractors
 Air Patrol
 Ground Patrol by Operator or its contractor
 Notification from Public
 Notification from Emergency Responder
 Notification from Third Party that caused the Incident
 Other _________________________________________________
A12.a If “Controller”, “Local Operating Personnel, including contractors”, “Air Patrol”, or “Ground Patrol by Operator or its contractor” is
selected in Question 12, specify the following: (select only one)

 Operator employee

 Contractor working for the Operator

A13. Local time Operator identified failure

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Hour

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Month

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Day

If A12. = Notification from Emergency Responder, skip A14.
A14. Did the operator communicate with Local, State, or Federal Emergency Responders about the incident?

Year

 Yes

 No

If No, skip A14.a and b.

 Operator

A14.a Which party initiated communication about the accident?

 Local/State/Federal Emergency Responder

A14.b Local time of initial Operator and Local/State/Federal Emergency Responder communication
/ / / / /
/
Hour

A15 Local time operator resources arrived on site

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Hour

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Month

A16. Local time operator confirmed discovery of the accident

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Month

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Hour

Month

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Year

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Year

A17. Local time (24-hr clock) and date of initial operator report to the National Response Center :
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Hour

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Month

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A17.a Initial Operator National Response Center Report Number OR

 NRC Notification Required But Not Made

A17.b Additional NRC Report numbers submitted by the operator:_____________________
A18. Did the gas ignite?

 Yes

 No

If A18 = Yes, then answer A18.a through d:
A18.a

Local time of ignition

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Hour

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Month

A18.b How was the fire extinguished?
 Operator/Contractor  Local/State/Federal Emergency Responder
A18.c. Volume of gas consumed by fire (mcf):

 Yes

A18.d Did the gas explode?

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Day

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Year

 Allowed to burn out  Other, specify:_________

(must be less than or equal to A7.)

 No

A19. Number of general public evacuated: /

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A24. Average length of evacuation (hours):

PART B – ADDITIONAL LOCATION INFORMATION
B1. State: /

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B2. Zip Code: /

B3 ______________________

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B4______________________

City

County or Parish

B5. Was Incident on Federal land, other than the Outer Continental Shelf (OCS)?
B6. Location of Incident: (select only one)
B7. Did Incident occur in a crossing?

 Yes

 Yes

 Operator-controlled property
 No

 No

 Pipeline right-of-way

If Yes, specify type:

 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
Specify:  Cased
 Uncased
 Water crossing
Name of body of water, if commonly known: ______________________
Approx. water depth (ft) at the point of the Incident: / /,/ / / /
(select only one of the following)
 Shoreline/Bank/Marsh 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 7100.2A (03/2016)

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PART C – ADDITIONAL FACILITY INFORMATION
C1. Material involved in Incident: (select only one)

 Carbon Steel
 Plastic
 Material other than Carbon Steel or Plastic



*Specify: ____________________________________________

If C1. is Carbon Steel, answer C1.a:
C1.a % SMYS caused by operating pressure at the time of failure:

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C2. Item involved in Incident: (select only one)

 Pipe  Specify:

 Pipe Body

 Pipe Seam

 Joint, including heat-affected zone  Specify:  Pipe Girth Joint  Other Butt Joint  Fillet Joint
 Other ______ _____________________________ mandatory text field ____________________
If C2. is Pipe or Pipe Girth Joint, answer C2.a:
C2.a Nominal Pipe Size:

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C6. 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
D1. Class Location of Incident: (select only one)
 Class 1 Location

 Class 2 Location
D2. Estimated Property Damage:
D2.a Estimated cost of public and non-Operator private property damage

$/

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D2.b Estimated cost of Operator’s property damage & repairs

$/

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D2.c Estimated cost of Operator’s emergency response

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D2.d Estimated other costs

$/

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Describe: _______________________________
D2.e Total estimated property damage (sum of above)

$ calculated

Cost of Gas Released
Cost of Gas in $ per thousand standard cubic feet (mcf):______________
D2.f Estimated cost of gas released unintentionally

$ calculated

D2.g Estimated cost of gas released during intentional and controlled blowdown

$ calculated

D2.h Total estimated cost of gas released (sum of 2.f & 2.g above)

$ calculated

D2.i Total Cost (sum of D2.e and D2.h)

$ calculated

Injured Persons not included in A11 The number of persons injured, admitted to a hospital, and remaining in the hospital for at least one
overnight are reported in A11. If a person is included in A11, do not include them in D3.
D3. Number of persons with injuries requiring treatment by EMTs at the site of incident:
If a person is included in D3, do not include them in D4.
D4. Number of persons with injuries requiring treatment in a medical facility but not requiring overnight in-patient hospitalization:
Buildings Affected
D5. Number of residential buildings affected:
D6. Number of business buildings affected:
D7. Wildlife impact:
 Yes  No
D7.a If Yes, specify all that apply:
 Fish/aquatic

 Birds
 Terrestrial
Form PHMSA F 7100.2A (03/2016)

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Reproduction of this form is permitted

PART E – APPARENT CAUSE

Select only one box from PART E in the shaded column on the left representing the
APPARENT Cause of the Accident. Describe secondary, contributing, or root causes of
the Accident in the narrative (PART F).

E1 - Corrosion Failure – *only one sub-cause can be picked
 External Corrosion
 Internal Corrosion

E2 - Natural Force Damage - *only one sub-cause can be picked
 Earth Movement, NOT due to Heavy Rains/Floods
 Heavy Rains/Floods
 Lightning
 Temperature
 High Winds
 Tree/Vegetation Root
 Other Natural Force Damage

E3 – Excavation Damage - *only one sub-cause can be picked
 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

E4 - Other Outside Force Damage - *only one sub-cause can be picked
 Nearby Industrial, Man-made, or Other Fire/Explosion as Primary Cause of Accident
 Damage by Car, Truck, or Other Motorized Vehicle/Equipment NOT Engaged in Excavation
 Damage by Boats, Barges, Drilling Rigs, or Other Maritime Equipment or Vessels Set Adrift or Which Have
Otherwise Lost Their Mooring

 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
 Intentional Damage
 Other Outside Force Damage

Form PHMSA F 7100.2A (03/2016)

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E5 - Material Failure of Pipe or Weld *Only one sub-cause can be picked
 Design-, Construction-, Installation-, or Fabrication-related
 Original Manufacturing-related (NOT girth weld or other welds formed in the field)
 Environmental Cracking-related

E6 - Equipment Failure - *only one sub-cause can be picked
 Malfunction of Control/Relief Equipment
 Pump or Pump-related Equipment
 Threaded Connection/Coupling Failure
 Non-threaded Connection Failure
 Defective or Loose Tubing or Fitting
 Failure of Equipment Body (except Pump), Tank Plate, or other Material
 Other Equipment Failure

E7 - Incorrect Operation - *only one sub-cause can be picked
 Damage by Operator or Operator’s Contractor NOT Related to Excavation and NOT due to Motorized
Vehicle/Equipment Damage

 Tank, Vessel, or Sump/Separator Allowed or Caused to Overfill or Overflow
 Valve Left or Placed in Wrong Position, but NOT Resulting in a Tank, Vessel, or Sump/Separator Overflow or
Facility Overpressure
 Pipeline or Equipment Overpressured

 Equipment Not Installed Properly
 Wrong Equipment Specified or Installed
 Other Incorrect Operation

E8 – Other Accident Cause - *only one sub-cause can be picked from shaded left-hand column
 Miscellaneous
 Unknown

Form PHMSA F 7100.2A (03/2016)

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PART F – NARRATIVE DESCRIPTION OF THE ACCIDENT
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PART G – PREPARER

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

Local Contact Name: optional
Local Contact Email: optional
Local Contact Phone: optional

Form PHMSA F 7100.2A (03/2016)

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Reproduction of this form is permitted