PHMSA F7100.1 Incident Report for Gas Pipeline Operators

Incident and Annual Reports for Gas Pipeline Operators

GD_Incident_Report_Form_and_Instructions.clean[1]

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⚠️ Notice: This form may be outdated.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: 2/28/2014

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/library/forms.
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:
5.a ___________________________________________________

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

(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: -

/ - /

/ . /

Form PHMSA F 7100.1 (rev xy-2013)

Page 1 of 17

Reproduction of this form is permitted

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



Other Gas

Propane Gas
Synthetic Gas
Hydrogen Gas
Landfill Gas



*Name: ___________________________

10. Estimated volume of gas released:

/,/

/ Thousand Cubic Feet (MCF)

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 failure

Hour

17.b Local time operator resources arrived on site

/
Hour

Month

/
Month

Day

/
Day

Form PHMSA F 7100.1 (rev xy-2013)

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



Transition Area Specify:  Soil/air interface
 Wall sleeve
 Pipe support or other close contact area
 Other ______________________________________________________

Specify:

4. Did Incident occur in a crossing?
If Yes, specify type below:








Road crossing 
Water crossing 

 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 _______________________________________

 Yes

 No

 Cased

Bridge crossing

Specify:

Railroad crossing

(Select all that apply)
(Select all that apply)
(Select all that apply)

 Uncased
 Cased
 Uncased
 Cased
 Uncased
 Cased
 Uncased

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

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

/,/

Form PHMSA F 7100.1 (rev xy-2013)

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Reproduction of this form is permitted

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




privately owned



Other  Specify: ____________________________________ __

municipally owned

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

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

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
Iron

 Steel
 Other 



Unknown

 Cast/Wrought Iron

 Ductile Iron

 Plastic

 Reconditioned Cast

Specify: __________________________________

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

 Copper

/./



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)

 Pinhole
 Crack

Rupture  Select Orientation:  Circumferential
Leak

Select Type:

 Connection Failure
 Seal or Packing
 Other
 Longitudinal
 Other ________________________________

Approx. size: /__/__/__/__/./__/ in. (widest opening) by /__/__/__/__/__/./__/in. (length circumferentially or axially)



Other



*Describe: ___________________________________________________________________

Form PHMSA F 7100.1 (rev xy-2013)

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Reproduction of this form is permitted

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

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

/,/

2.c Estimated cost of Operator’s emergency response

/,/

2.d Estimated other costs

/,/

Describe: ___________________________________________________
2.e Total estimated property damage (sum of above)
Cost of Gas Released
2.f Estimated cost of gas released
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 xy-2013)

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Reproduction of this form is permitted

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
 Yes
 No
detection of the Incident?
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 xy-2013)

Page 6 of 17

Reproduction of this form is permitted

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 xy-2013)

Page 7 of 17

Reproduction of this form is permitted

PART G – APPARENT CAUSE

Select only one box from PART G in the shaded column on the left representing the APPARENT
Cause of the 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 xy-2013)

Page 8 of 17

Reproduction of this form is permitted

 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  Landslide
 Other ___________________



Heavy Rains/Floods

2. Specify:



Lightning

3. Specify:

 Direct hit  Secondary impact such as resulting nearby fires



Temperature

4. Specify:

 Thermal Stress
 Frozen Components



High Winds



Other Natural Force Damage

 Washouts/Scouring  Flotation  Mudslide  Other ________________

 Frost Heave
 Other ________________________________

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 xy-2013)

Page 9 of 17

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

 Yes  No
 One-Call System

 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 xy-2013)

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Reproduction of this form is permitted

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

13. Did the damage cause an interruption in service?

 No

 Yes

 Data not collected

 Unknown/Other

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 xy-2013)

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Reproduction of this form is permitted

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

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



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

2. Select one or more of the following IF an extreme weather event was a factor:
 Hurricane
 Tropical Storm
 Tornado
 Heavy Rains/Flood
 Other ______________________________



Routine or Normal Fishing or Other
Maritime Activity NOT Engaged in
Excavation



Electrical Arcing from Other
Equipment or Facility



Previous Mechanical Damage NOT
Related to Excavation

 Third Party

Complete 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 xy-2013)

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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  HF ERW  Flash Weld 
 Other ________________________

DSAW



SAW

 Spiral

 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 joined:
 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 xy-2013)

 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 joined:
 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 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: __________________________________
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 xy-2013)

Page 14 of 17

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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
 No

 Most recent year tested: /

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 xy-2013)

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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 xy-2013)

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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

Preparer’s Facsimile Number

Authorized Signer

Authorized Signer Telephone Number

Authorized Signer’s Title

Authorized Signer’s E-mail Address

Form PHMSA F 7100.1 (rev xy-2013)

Page 17 of 17

Reproduction of this form is permitted

Instructions (rev xy-2013) for Form PHMSA F 7100.1 (rev xy-2013)
INCIDENT REPORT – GAS DISTRIBUTION SYSTEMS

GENERAL INSTRUCTIONS
Each operator of a gas distribution system 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
detection of the incident. Requirements for submitting reports are in §191.7 and §191.9.
Master meter operators are exempt from filing incident reports per §191.9(c).
The intentional and controlled release of gas for the purpose of maintenance or other routine
operating activities need not be reported if the only reportable criterion is unintentional loss of
gas of 3 million cubic feet or more as described in §191.3 under “Incident” (1)(iii).
Special considerations apply when a gas distribution system failure or release occurs involving
secondary ignition. Secondary ignition is a fire where the origin of the fire is unrelated to the gas
systems subject to Parts 191 or 192, such as electrical fires, arson, etc., and includes events
where fire or explosion not originating from a gas distribution system failure or release was the
primary cause of the gas distribution system failure or release, such as a house fire that
subsequently resulted in – but was not caused by – a gas distribution system failure or release.
An incident caused by secondary ignition is not to be reported unless a release of gas
escaping from facilities subject to regulation under Parts 191 or 192 results in one or more of the
consequences as described in §191.3 under "Incident" (1). The determination of consequences
from a gas distribution system incident caused by secondary ignition, though, is an area of
possible confusion when reporting incidents. This situation is particularly susceptible to
confusion as compared to other Natural or Other Outside Force Damage because it is extremely
difficult in most cases to establish whether and which consequences were attributable to the
initiating fire (that is, the “secondary ignition” source itself) or to a subsequent fire due to a
resulting gas distribution system failure or release. PHMSA is providing the following guidance
for operators to use when secondary ignition is involved (sometimes referred to as “Fire First”
incidents):
• A gas distribution system incident attributed to secondary ignition is to be
reported to PHMSA if any fatalities or injuries are involved unless it can be
established with reasonable certainty that all of the casualties either preceded
the gas distribution system failure or release, or would have occurred whether
or not the gas distribution system failure or release occurred.
• A gas distribution system incident attributed to secondary ignition is NOT to
be reported to PHMSA if the only reportable criterion is unintentional loss of
gas of 3 million cubic feet or more as described in §191.3 under "Incident"
(1)(iii).
• A gas distribution system incident attributed to secondary ignition is NOT to
be reported to PHMSA unless the damage to facilities subject to Parts 191 or
192 equals or exceeds $50,000.
These considerations apply to several gas distribution system incident cause categories as
indicated in pertinent sections of these instructions.
Form PHMSA F 7100.1 and these instructions can be found
on http://phmsa.dot.gov/pipeline/library/forms. The applicable documents are listed in the section
titled Accident/Incident/Annual Reporting Forms.
Page 1 of 23

Instructions (rev xy-2013) for Form PHMSA F 7100.1 (rev xy-2013)
INCIDENT REPORT – GAS DISTRIBUTION SYSTEMS

ONLINE REPORTING REQUIREMENTS
Incident Reports must be submitted online through the PHMSA Portal at
https://portal.phmsa.dot.gov/portal, unless an alternate method is approved (see Alternate
Reporting Methods below). You will not be able to submit reports until you have met all of the
Portal registration requirements –
see http://opsweb.phmsa.dot.gov/portal_message/PHMSA_Portal_Registration.pdf
Completing these registration requirements could take several weeks. Plan ahead and
register well in advance of the report due date.

Use the following procedure for online reporting:
1. Go to the PHMSA Portal at https://portal.phmsa.dot.gov/portal
2. Enter PHMSA Portal Username and Password ; press enter
3. Select OPID; press “continue” button.
4. On the left side menu under “Incident/Accident (2010 to present)” select “ODES 2.0”
1. Under “Create Reports” on the left side of the screen, select “Gas Distribution” and
proceed with entering your data.
2. Click “Submit” when finished with your data entry to have your report uploaded to
PHMSA’s database as an official submission of an Incident Report; or click “Save”
which doesn’t submit the report to PHMSA but stores it in a draft status to allow you to
come back to complete your data entry and report submission at a later time. Note: The
“Save” feature will allow you to start a report and save a draft of it which you can print
out and/or save as a PDF to email to colleagues in order to gather additional
information and then come back to accurately complete your data entry before
submitting it to PHMSA.
3. Once you click “Submit”, the system will check if all applicable portions of the report
have been completed. If portions are incomplete, a listing of these portions will appear
above the row of Parts. If all applicable portions have been completed, the system will
show your Saved Incident/Accident Reports in the top portion of the screen and your
Submitted Incident/Accident Reports in the bottom portion of the screen. Note: To
confirm that your report was successfully submitted to PHMSA, look for it in the bottom
portion of the screen where you can also view a PDF of what you submitted.
Supplemental Report Filing – Follow Steps 1 through 4 above, and double-click a submitted
report from the Submitted Incident/Accident Reports list. The report will default to a “Read
Only” mode that is pre-populated with the data you submitted previously. To create a
supplemental report, click on “Create Supplemental” found in the upper right corner of the
screen. At this point, you can amend your data and make an official submission of the report to
PHMSA as either a Supplemental Report or as a Supplemental Report plus Final Report (see

Page 2 of 23

Instructions (rev xy-2013) for Form PHMSA F 7100.1 (rev xy-2013)
INCIDENT REPORT – GAS DISTRIBUTION SYSTEMS

“Specific Instructions, PART A, Report Type”), or you can use the “Save” feature to create a draft of
your Supplemental Report to be submitted at some future date.

Alternate Reporting Methods
Operators for whom electronic reporting imposes an undue burden and hardship may submit a
written request for an alternate reporting method. Operators must follow the requirements in
§191.7(d) to request an alternate reporting method and must comply with any conditions
imposed as part of PHMSA’s approval of an alternate reporting method.

RETRACTING A 30-DAY WRITTEN REPORT
An operator who reports an incident in accordance with §191.9 (oftentimes referred to as a 30day written report) and upon subsequent investigation determines that the event did not meet the
criteria in §191.3 may request that their report be retracted. Requests to retract a 30-day written
report are to be emailed to [email protected]. Requests are to include the
following information:
a. The Report ID (the unique 8-digit identifier assigned by PHMSA)
b. Operator name
c. PHMSA-issued OPID number
d. The number assigned by the National Response Center (NRC) when an immediate
notice was made in accordance with §191.5. If Supplemental Reports were made to the
NRC for the event, list all NRC report numbers associated with the event.
e. Date of the event
f. Location of the event
g. A brief statement as to why the report should be retracted.
Note: PHMSA no longer requests that operators rescind erroneously reported “Immediate
Notices” filed with the NRC in accordance with §191.5 (oftentimes referred to as “Telephonic
Reports”).

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Instructions (rev xy-2013) for Form PHMSA F 7100.1 (rev xy-2013)
INCIDENT REPORT – GAS DISTRIBUTION SYSTEMS

SPECIAL INSTRUCTIONS
All applicable data fields must be completed before an Original Report will be accepted. Your
Original Report cannot be submitted online until the required information has been provided,
although your partially completed report can be saved online so that you can return at a later time
to provide the missing information.
1. An entry should be made in each applicable space or check box, unless otherwise directed by
the section instructions.
2. If the data is unavailable, enter “Unknown” for text fields and leave numeric fields and fields
using check boxes or “radio” buttons blank.
3. Estimate data only if necessary. 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.
4. For unknown or estimated data entries, the operator should file a Supplemental Report when
additional or more accurate information becomes available.
5. If the question is not applicable, enter “N/A” for text fields and leave numeric fields and
fields using check boxes or “radio” buttons blank. Do not enter zero unless this is the actual
value being submitted for the data in question.
6. If OTHER is checked for any answer to a question, include an explanation or description in
the text field provided, making it clear why “Other” was the necessary selection.
7. Pay close attention to each question for the phrase:
a. (select all that apply)
b. (select only one)
If the phrase is not provided for a given question, then “select only one” applies. “Select
only one” means that you should select the single, primary, or most applicable answer. DO
NOT SELECT MORE ANSWERS THAN REQUESTED. “Select all that apply” requires
that all applicable answers (one or more than one) be selected.
8. Date format = mm/dd/yyyy
9. 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/

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Instructions (rev xy-2013) for Form PHMSA F 7100.1 (rev xy-2013)
INCIDENT REPORT – GAS DISTRIBUTION SYSTEMS

Local time always refers to time at the site of the incident. Note that time zones at
the incident site may be different than the time zone for the person discovering or
reporting the event. For example, if a release occurs at an gas distribution system
facility in Denver, Colorado at 2:00 pm MST, but a supervisor located in Houston is
filing the report after having been notified at 3:00 pm CST, the time of the incident
should be reported as 1400 hours based on the time in Denver, which is the physical
site of the incident.

SPECIFIC INSTRUCTIONS
PART A – KEY 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 – and only one of these
combinations - may be selected:
•
•
•
•

Original Report only
Original Report plus Final Report
Supplemental Report only
Supplemental Report plus Final Report

 Original Report
Select if this is the FIRST report filed for this incident and you expect that additional or
updated information will be provided later.
 Original Report

plus

 Final Report

Select both Original Report and Final Report if ALL of the information requested is known and
can be provided at the time the initial report is filed, including final property damage costs and
apparent failure cause information. If new, updated, and/or corrected information becomes
available, you are still able to file a Supplemental Report.
 Supplemental Report
Select only if you have already filed an Original Report AND you are now providing new,
updated, and/or corrected information. Multiple Supplemental Reports are to be submitted, as
necessary, in order to provide new, updated, and/or corrected information when it becomes
available and, per §191.9(b), each Supplemental Report containing new, updated, and/or
corrected information is to be filed as soon as practicable. Submission of new, updated, and/or

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Instructions (rev xy-2013) for Form PHMSA F 7100.1 (rev xy-2013)
INCIDENT REPORT – GAS DISTRIBUTION SYSTEMS

corrected information is NOT to be delayed in order to accumulate “enough” to “warrant” a
Supplemental Report, or to complete a Final Report. Supplemental Reports must be filed as
soon as practicable following the Operator’s awareness of new, updated, and/or corrected
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.

For Supplemental Reports filed online, all data previously submitted will automatically populate
in the form. Page through the form to make edits and additions where needed.
 Supplemental Report

plus

 Final Report

If an Original Report has already been filed AND new, updated, and/or corrected information is
now being submitted via a Supplemental Report, AND the operator is reasonably certain that no
further information will be forthcoming, then Final Report is to also be selected along with
Supplemental Report. (See also the requirements stated above under “Supplemental Report”.)

In PART A, answer Questions 1 thru 17 by providing the requested
information or by making- the appropriate selection.
1. Operator’s OPS -Issued Operator Identification Number (OPID)
For online entries, the OPID will automatically populate based on the selection you made when
entering the Portal. If you have log-in credentials for multiple OPID, be sure the report is being
created for the appropriate OPID. Contact PHMSA’s Information Resources Manager at 202-3668075 if you need assistance with an OPID. Business hours are 8:30 AM to 5:00 PM Eastern Time.

2. Name of Operator
This is the company name associated with the OPID. For online entries, the name will automatically
populate based on the OPID entered in A1. If the name that appears is not correct, you need to submit
an Operator Name Change (Type A) Notification.

3. Address of Operator
For online entries, the headquarters address will automatically populate based on the OPID entered in
A1. If the address that appears is not correct, you need to change it in the online Contacts module.

4. Local time (24-hour clock) and date of the Incident
Enter the earliest local date/time an incident reporting criteria was met. In some cases, this date/time
must be estimated based on information gathered during the investigation.
See “Special Instructions”, numbers 8 and 9 for examples of Date format and Time format
expressed as a 24-hour clock.

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Instructions (rev xy-2013) for Form PHMSA F 7100.1 (rev xy-2013)
INCIDENT REPORT – GAS DISTRIBUTION SYSTEMS

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. If the incident did not occur
within a municipality, select Not Within Municipality in the City field.
c. Provide the name of the county or parish where the incident occurred.
d. Enter the 2-digit state abbreviation where the incident occurred.
e. Enter the zip code where the incident occurred.
f. The latitude and longitude of the incident 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 included on the data entry form so that operators do not have to enter
the negative sign.
If you cannot locate the incident with a GPS or some other means, there are online tools that
may assist you at http://viewer.nationalmap.gov/viewer/. Any questions regarding the
required format, conversion, or how to use the tools 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
assigned to that Immediate Notice (sometimes referred to as the “Telephonic Report”) is to be
entered in Question 6. When there is more than one NRC report for the incident, enter the first
report in this field and remaining NRC report numbers in Part H – Narrative. If a NRC report
was not made, select the option that best describes why: NRC Notification Not Required, NRC
Notification Required But Not Made, Do Not Know NRC Report Number.
7. Local time (24-hr clock) and date of initial telephonic report to the National Response
Center
Enter the time and date of the initial Immediate Notice of incident to the NRC. The time is to be
shown by 24-hour clock notation, and is to reflect the time in the time zone where the incident
was physically located. (See “Special Instructions”, numbers 8 and 9.)

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Instructions (rev xy-2013) for Form PHMSA F 7100.1 (rev xy-2013)
INCIDENT REPORT – GAS DISTRIBUTION SYSTEMS

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:
Select the type of gas released. An example of Synthetic Gas is manufactured gas based on
naphtha. Landfill Gas includes biogas.
10. Estimated volume of gas released
Estimate the amount of gas that was released (in thousands of standard cubic feet, MCF) from
the beginning of the incident until such time as gas is no longer being released from the gas
distribution system or until intentional and controlled blowdown has commenced. Estimates are
to be based on best-available information. Important Note: Volumes consumed by fire and/or
explosion are to be included in the estimated volume reported.
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. (Note: This aligns with the
Department of Transportation's general guidelines for all jurisdictional modes for reporting
deaths and injuries.)
Contractor employees working for the operator are individuals hired to work for or on behalf
of the operator of the gas distribution system. These individuals are not to be reported as
“Operator employees”.
Non-Operator emergency responders are individuals responding to render professional aid at
the incident scene including on-duty and volunteer fire fighters, rescue workers, EMTs, police
officers, etc. “Good Samaritans” that stop to assist are to 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 gas distribution system. This includes all work conducted
within the right-of-way including work associated with other underground facilities sharing
the right-of-way, building/road construction in or across the right-of-way, or farming. This
category most often includes employees of other 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.

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12. Were there injuries requiring inpatient hospitalization?

Injuries requiring inpatient hospitalization are injuries sustained as a result of the incident and
requiring hospital admission and at least one overnight stay.
See Question 11 for additional definitions that apply.
13. Was the pipeline/facility shut down due to the Incident?
Report any shutdowns that occur as a result of the incident, including but not limited to those
required for damage assessment, temporary repair, permanent repair, and clean-up.
If No is selected, explain the reason that no shutdown was needed in the space provided.
If Yes is selected, complete questions 13.a and 13.b.
13.a. Local time (24hr clock) and date of shutdown
13.b. Local time pipeline/facility restarted
The time is to be shown by 24-hour clock notation, and is to reflect the time in the
time zone where the incident was physically located. (See “Special Instructions”,
numbers 9 and 10.) Enter the time and date of the shutdown that is associated with
the onset or occurrence of the incident in 13.a and the time and date of restart in
13.b. The intent with this data is to capture the total time that the gas distribution
system or facility is shutdown due to the incident. If the gas distribution system or
facility has not been restarted at the time of reporting, select “Still shut down” for
Question 13.b and then include the restart time and date in a future Supplemental
Report.
14. Did the Gas Ignite?
Ignite means the released gas caught fire.
15. Did the Gas Explode?
Explode means the ignition of the released gas occurred with a sudden and violent release of
energy.
16. Number of general public evacuated
The number of people evacuated is to be estimated based on operator knowledge, or police, fire
department, or other emergency responder reports. If there was no evacuation involving the
general public, report zero (0). If an estimate is not possible for some reason, leave the field
blank but include an explanation of why it was not possible to provide a number in PART H –
Narrative Description of the Incident.

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17. Time sequence (use local time, 24-hour clock)

In 17a, enter the date/time the operator became aware of the failure. The earliest date/time that
an incident reporting criteria was met is reported in item A4. In some cases, the operator may
become aware of a failure before an incident reporting criteria is met. In other cases, one or
more incident reporting criteria may be met before the operator becomes aware of the failure. In
17b, enter the date/time operator responders, company or contract, arrived on site. These times
are to be shown by 24-hour clock notation and reported in the time in the time zone where the
incident occurred. (See “Special Instructions”, numbers 8 and 9 and 10.) PHMSA will use this
data to calculate incident response times.

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 gas distribution system at which gas was released, resulting in
the incident. It does not refer to adjacent locations in which released gas may have accumulated
or ignited.
Underground means pipe, components, or other facilities installed below the natural ground
level, road bed, or below the underwater natural bottom.
Under pavement includes under streets, sidewalks, paved roads, driveways, and parking lots.
Exposed due to Excavation means that a normally buried facility had been exposed by any
party (operator, operator’s contractor, or third party) preparatory to or as a result of excavation.
The cause of the release, however, may or may not necessarily be related to excavation damage.
This category could include a corrosion leak not previously evidenced by stained vegetation, but
found during excavation, or a release caused by a non-excavation vehicle where contact
happened to occur while the facility was exposed for excavation repair or examination. Natural

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forces might also damage a facility that happened to be temporarily exposed. In each case, the
cause is to be appropriately reported in PART 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 and meter stations.
4. Did 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 or Road Crossing, as appropriate, if the pipeline is buried beneath rail
bed or road bed.
Use Water Crossing if the pipeline is in the water, beneath the water, in contact with the natural
ground of the lake bed, etc., or buried beneath the bed of a lake, reservoir, stream, or creek,
whether the crossing happens to be flowing water at the time of the incident or not.. The name
of the body of water is to 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 may 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, ignoring 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 gas distribution 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, select “Other” and specify in the space provided the item involved in the incident.
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 facility, typically by a piece of equipment such as
would occur if the facility 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. Approximate measurements can be provided in inches and one
decimal.)
Leak means a failure resulting in an unintentional release of gas that is often small in size,
usually resulting a low flow release of low volume, although large volume leaks can and do
occur on occasion.
Rupture means a loss of containment that immediately impairs the operation of the gas
distribution system or facility. Facility ruptures often result in a higher flow release of larger
volume. The terms “circumferential” and “longitudinal” refer to the general direction or
orientation of the rupture relative the pipe’s axis. They do not exclusively refer to a failure
involving a circumferential weld such as a girth weld, or to a failure involving a longitudinal
weld such as a pipe seam. (Precise measurement of size – e.g., micrometer – is not needed.
Approximate measurements can be provided in inches and decimals.)

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PART D – ADDITIONAL CONSEQUENCE INFORMATION
2. Estimated Property Damage
All relevant costs available at the time of submission must be included in the initial written
Incident Report as well as being updated as needed on 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, facility repair and replacement, gas distribution service restoration and relighting, leak
locating, and environmental cleanup and damage. Do NOT include cost of gas lost.
Additionally, do NOT include costs incurred for facility repair, replacement, or changes that are
NOT related to the incident and which are typically done solely for convenience. An example of
doing work solely for convenience is working on non-leaking facilities unearthed because of the
incident. Litigation and other legal expenses related to the incident are not reportable.
Operators are to 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 is to
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 are to be filed as new cost information becomes available. If
Supplemental Reports are not submitted for other reasons, a Supplemental Report is to be filed
for the purpose of updating or correcting the estimated cost if these costs differ from those
already reported by 20 percent or $20,000, whichever is greater.
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.
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 the cost of any gas lost. Also
to be excluded are litigation and other legal expenses related to the incident.
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. Property damage estimates
include the cost to access, excavate, and repair the facility using methods, materials, and labor
necessary to re-establish operations at a predetermined level. These costs may include the cost
of repair sleeves or clamps, re-routing of piping, or the removal from service of an appurtenance
or facility 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 gas distribution system to mitigate the risk
of future failures are not included.
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

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released, conduct reconnaissance, and to identify the extent of incident impacts. They include
materials, supplies, labor, and benefits. Costs related to stakeholder outreach, media response,
etc. are not to be included.
Other costs are to include any and all costs which are not included above. Cost of any gas lost
is NOT to be reported here, but is to be reported under Cost of Gas Released. Operators are to
NOT use this category to report any costs which belong in cost categories separately listed
above.
Costs are to be reported in only one category and are not to be double-counted. Costs can be
split between two or more categories when they overlap more than one reporting category.
Cost of Gas Released
Cost of gas released is to be based on the volume reported in PART A, Question 10.
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 designed or used 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 incident?
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 incident? If no, describe functions that
were not operational in PART H – Narrative Description of the Incident.

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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?
Select 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.
Select No if SCADA-based information was not used to assist with identification of
the incident.
6. How was the Incident initially identified for the Operator? (select only one)
Controller means a qualified individual whose function within a shift is to remotely monitor
and/or control the operations of entire or multiple sections of distribution pipelines or systems
via a SCADA system from a control room, and who has operational authority and accountability
for the daily remote operational functions of gas distribution 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?
Select only one of the choices 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 gas distribution system
incident.
Contributing factor means an action or lack of action that when added to the existing
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.

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PART F – DRUG & ALCOHOL TESTING INFORMATION
Requirements for post-accident drug and alcohol tests are in 49 CFR §199.105 and §199.225
respectively. If the incident circumstances were such that tests were not required by these
sections, and if no tests were conducted, select No. If tests were administered, select Yes and
report separately the number of operator employees and contractors working for the operator
who were tested and the number of each that failed such tests.

PART G – APPARENT CAUSE
PART G – Apparent Cause
Select the one, single sub-cause listed under sections G1 thru G8 that best describes the
apparent cause of the Incident. These sub-causes are contained in the shaded column on
the left under each main cause category. Answer the corresponding questions that
accompany your selected sub-cause, and describe any secondary, contributing, or root
causes of the Incident in PART H – Narrative Description of the Incident.

G1 – Corrosion Failure
Corrosion includes a release or failure caused by galvanic, atmospheric, stray current,
microbiological, or other corrosive action. A corrosion release or failure is not limited to a hole
in the pipe or other piece of equipment. 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. (Note: If the bonnet, packing, or other gasket has deteriorated to failure,
whether before or after the end of its expected life, but not due to corrosive action, report it under
a different cause category, such as G4 Incorrect Operation for improper installation or G6 Equipment Failure if the gasket failed.)
External Corrosion
4.a. Under cathodic protection means cathodic protection in accordance with §192.455,
§192.457, and §192.463. Recognizing that older facilities may have had cathodic protection
added over a number of years, provide an estimate if exact year cathodic protection started is
unknown.

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Internal Corrosion

10. Location of corrosion
A low point in pipe includes portions of the pipe contour in which water might settle out. This
includes, but is not limited to, the low point of vertical bends at a crossing of a foreign line or
road/railroad, etc., an elbow, a drop out or low point drain.
11. Was the gas/fluid treated with corrosion inhibitors or biocides?
Select Yes if corrosion inhibitors or biocides were included in the gas/fluid transported.
Either External or Internal Corrosion
14. Has one or more hydrotest or other pressure test been conducted since original
construction at the point of the Incident?
Information from the initial post-construction hydrostatic test is not to be reported.
G2 – Natural Force Damage
Natural Force Damage includes a release or failure resulting from earth movement,
earthquakes, landslides, subsidence, lightning, heavy rains/floods, washouts, flotation, mudslide,
scouring, temperature, frost heave, frozen components, high winds, or similar natural causes.
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 natural force causes. While mudslides involve
earth movement, report them here since typically they are an effect of heavy rains or floods.
Lightning includes both damage and/or fire caused by a direct lighting strike and damage and/or
fire as a secondary effect from a lightning strike in the area. An example of such a secondary
effect would be a forest fire started by lightning that results in damage to a gas distribution
system asset which results in an incident. (See also the discussion of “secondary ignition” under
the General Instructions.)
Temperature includes weather-related temperature and thermal stress effects, either heat or
cold, where temperature was the initiating 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 are
to be reported under section G4 - Other Outside Force Damage.
Other Natural Force Damage. Select this sub-cause for types of Natural Force Damage not
included otherwise, and describe in the space provided. If necessary, provide additional
explanation in PART H – Narrative Description of the Incident.
Answer Questions 6 and 6.a if the incident occurred in conjunction with an extreme weather
event such as a hurricane, tropical storm, or tornado. If an extreme weather event related to
something other than a hurricane, tropical storm, or tornado was involved, indicate Other and
describe the event in the space provided.
G3 – Excavation Damage
Excavation Damage includes a release or failure resulting directly from excavation damage by
operator's personnel (oftentimes referred to as “first party” excavation damage) or by the
operator’s contractor (oftentimes referred to as “second party” excavation damage) or by people
or contractors not associated with the operator (oftentimes referred to as “third party” excavation
damage). Also, this section includes a release or failure determined to have resulted from
previous damage due to excavation activity. For damage from outside forces OTHER than
excavation which results in a release, use G2 - Natural Force Damage or G4 - Other Outside
Force, as appropriate. Also, for a strike, physical contact, or other damage to a gas distribution
system or facility that apparently was NOT related to excavation and that results in a delayed or
eventual release, report the incident under G4 as “Previous Mechanical Damage NOT related to
Excavation.”
Excavation Damage by Operator (First Party) refers to incidents caused as a result of
excavation by a direct employee of the operator.
Excavation Damage by Operator’s Contractor (Second Party) refers to incidents 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 refers to incidents 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 refers to incidents that were apparently caused
by prior excavation activity and that then resulted in a delayed or eventual release. Indications of
prior excavation activity might come from the condition of the pipe when it is examined, or from
records of excavation at the site, or through metallurgical analysis or other inspection and/or
testing methods. Dents and gouges in the 10:00-to-2:00 o’clock positions on the pipe, for

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instance, may indicate an earlier strike, as might marks from the bucket or tracks of an earth
moving machine or similar pieces of equipment.
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 is not to 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
Other Outside Force Damage includes, but are not limited to, a release or failure resulting from
non-excavation-related outside forces, such as nearby industrial, man-made, or other fire or
explosion; damage by vehicles or other equipment; failures due to mechanical damage; and,
intentional damage including vandalism and terrorism.
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. (See also the
discussion of “secondary ignition” under the General Instructions.) Examples of such an
incident would be an explosion or fire that originated at a house or neighboring installation
(chemical plant, tank farm, or other industrial facility) or structure, debris, or brush/trees that
results in a release at the operator’s gas distribution system or facility. This includes forest,
brush, or ground fires that are caused by human activity. If the fire, however, is known to have
been started as a result of a lightning strike, the incident’s cause is to be classified under G2 Natural Force Damage. Arson events directed at harming the gas distribution system or the
operator are to be reported as G4 - Intentional Damage (see below). This sub-cause is NOT to be
used if the release occurred first and then the gas released from the gas distribution system or
facility ignited.
Damage by Car, Truck, or Other Motorized Vehicle/Equipment NOT Engaged in
Excavation. An example of this sub-cause would be damage to a meter set caused by vehicle
impact. Other motorized vehicles or equipment include 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 gas distribution system operator, the gas distribution system’s
contractor, or a third party and specify the vehicle/equipment operator’s affiliation from one of
these three groups. Gas distribution system incidents resulting from vehicular traffic loading or
other contact are to also be reported in this category. If the activity that caused the incident
involved digging, drilling, boring, grading, cultivation, or similar excavation activities, report
under G3 - Excavation Damage.
Damage by Boats, Barges, Drilling Rigs, or Other Maritime Equipment or Vessels Set
Adrift or Which Have Otherwise Lost Their Mooring. This sub-cause includes impacts by
maritime equipment or vessels (including their anchors or anchor chains or other attached
equipment) that have lost their moorings and are carried into the gas distribution system or

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facility by the current. This sub-cause also includes maritime equipment or vessels set adrift as a
result of severe weather events and carried into the gas distribution system or facility by waves,
currents, or high winds. In such cases, also indicate the type of severe weather event. Do NOT
report in this sub-cause incidents which are caused by impact of maritime equipment or vessels
while they are engaged in their normal or routine activities; such incidents are to be reported as
“Routine or Normal Fishing or Other Maritime Activity NOT Engaged in Excavation” under this
section G4 (see below) so long as those activities are not excavation activities. If those activities
are excavation activities such as dredging or bank stabilization or renewal, the incident is to be
reported under 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 inadvertent and due to a severe weather event (this type of
incident is to be reported under “Damage by Boats, Barges, Drilling Rigs, or Other Maritime
Equipment or Vessels Set Adrift or Which Have Otherwise Lost Their Mooring” in this section
G4); or, the incident was caused by excavation activity such as dredging of waterways or bodies
of water (this type of incident is to be reported under G3 - Excavation Damage”).
Electrical Arcing from Other Equipment or Facility such as a pole transformer or adjacent
facility’s electrical equipment.
Previous Mechanical Damage NOT Related to Excavation. This sub-cause covers incidents
where damage occurred at some time prior to the release that was apparently NOT related to
excavation activities, and would include prior outside force damage of an unknown nature, prior
natural force damage, prior damage from other outside forces, and any other previous
mechanical damage other than that which was apparently related to prior excavation. Incidents
resulting from previous damage sustained during construction, installation, or fabrication of the
pipe, weld, or joint from which the release eventually occurred are to be reported under G5 –
Pipe, Weld, or Joint Failure. (See this sub-cause for typical indications of previous construction,
installation, or fabrication damage.) Incidents resulting from previous damage sustained as a
result of excavation activities should be reported under G3 – Previous Damage due to Excavation
Activity. (See this sub-cause for typical indications of prior excavation activity.)
Intentional Damage
Vandalism means willful or malicious destruction of the operator’s gas distribution
system or facility or equipment. This category would include arson, pranks,
systematic damage inflicted to harass the operator, motor vehicle damage that was
inflicted intentionally, and a variety of other intentional acts. (See also the
discussion of “secondary ignition” under the General Instructions.)
Terrorism, per 28 CFR §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.

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Theft of commodity or Theft of equipment means damage by any individual or
entity, by any mechanism, specifically to steal, or attempt to steal, the transported
gas or gas distribution system equipment.
Other Describe in the space provided and, if necessary, provide additional
explanation in PART H – Narrative Description of the Incident.
Other Outside Force Damage. Select this sub-cause for types of Other Outside Force Damage
not included otherwise, and describe in the space provided. If necessary, provide additional
explanation in PART H – Narrative Description of the Incident.
G5 – Pipe, Weld, or Joint Failure
Use this section to report failures only for main or service pipe, or welds, joints, or
connections joining main pipe or service pipe.
This section includes releases in or failures of main or service pipe, or welds, joints, or
connections joining main pipe or service pipe due to faulty manufacturing procedures, defects
resulting from poor construction, installation, or fabrication practices, and in-service stresses
such as vibration, fatigue, and environmental cracking.
Mechanical Fitting, Question 7, Manufacturer
Compression Fitting, Question 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.
14. Has one or more hydrotest or other pressure test been conducted since original
construction at the point of the Incident?
Information from the initial post-construction hydrostatic test is not to be reported. Records of
test pressure from past pressure tests may not be available. In such cases, the operator is to
estimate the test pressure using best available information.

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Instructions (rev xy-2013) for Form PHMSA F 7100.1 (rev xy-2013)
INCIDENT REPORT – GAS DISTRIBUTION SYSTEMS

G6 – Equipment Failure
This section applies to failures of items other than main or service pipe, or welds, joints, or
connections joining main pipe or service pipe.
Equipment Failure includes a release or failure resulting from: malfunction of control/relief
equipment including valves, regulators, or other instrumentation; failures of compressors, or
compressor-related equipment; failures of various types of connectors, connections, and
appurtenances; failures of the body of equipment, vessel plate, or other material (including those
caused by construction, material, or design defects or anomalies); and, all other equipmentrelated failures.
Malfunction of Control/Relief Equipment. Examples of this type of incident cause include:
overpressurization resulting from malfunction of control or alarm device; malfunction of relief
valve; 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 is to be reported under G7 - Incorrect Operation.
ESD System Failure means failure of an emergency shutdown system.
Other Equipment Failure. Select this sub-cause for types of Equipment Failure not included
otherwise, and describe in the space provided. If necessary, provide additional explanation in
PART H – Narrative Description of the Incident.
G7 – Incorrect Operation
Incorrect Operation includes a release or failure resulting from operating, maintenance, repair,
or other errors by facility personnel, including, but not limited to, improper valve selection or
operation, inadvertent overpressurization, improper selection of procedures, incorrect
installation of equipment, and failure to follow manufacturer instructions.
Other Incorrect Operation. Select this sub-cause for types of Incorrect Operation not included
otherwise, and describe in the space provided. If necessary, provide additional explanation in
PART H – Narrative Description of the Incident.
G8 – Other Incident Cause
This section is provided for incidents whose cause is currently unknown, or where investigation
into the cause has been exhausted and the final judgment as to the cause remains unknown, or
where a cause has been determined which does not fit into any of the main cause categories
listed in sections G1 thru G7.
If the incident cause is known but doesn’t fit in any category in sections G1 through G7, select
Miscellaneous and enter a description of the incident cause, continuing with a more thorough
explanation in PART H - Narrative Description of the Incident.

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Instructions (rev xy-2013) for Form PHMSA F 7100.1 (rev xy-2013)
INCIDENT REPORT – GAS DISTRIBUTION SYSTEMS

If the incident cause is unknown at time of filing this report, select Unknown in this section and
select one reason from the accompanying two choices. Once the operator’s investigation into the
incident cause is completed, the operator is to file a Supplemental Report as soon as practicable
either reporting the apparent cause or stating definitively that the cause remains Unknown, along
with any other new, updated, and/or corrected information pertaining to the incident. This
Supplemental Report is to include all new, updated, and/or corrected information pertaining to
all portions of the report form known at this time, and not only that information related to the
apparent cause.
Important Note: Whether the investigation is completed or not, or if the cause continues to be
unknown, Supplemental Reports are to be filed reflecting new, updated, and/or corrected
information as and when this information becomes available. In those cases in which
investigations are ongoing for an extended period of time, operators are to file a Supplemental
Report within one year of their last report for the incident even in those instances where no new,
updated, and/or corrected information has been obtained, with an explanation that the cause
remains under investigation in PART H – Narrative Description of the Incident. Additionally,
final determination of the apparent cause and/or closure of the investigation does NOT preclude
the need for the operator’s filing of additional Supplemental Reports as and when new, updated,
and/or corrected information becomes available.

PART H – NARRATIVE DESCRIPTION OF THE INCIDENT
Concisely describe the incident, including the facts, circumstances, and conditions that may have
contributed directly or indirectly to causing the incident. Include secondary, contributing, or root
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 (in PDF or JPG format only) containing sketches, drawings, or additional
data.
If you selected Miscellaneous in section G8, the narrative is to describe the incident in detail,
including all known or suspected causes and possible contributing factors.

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 or persons most
knowledgeable). Enter the Preparer’s e-mail address if the Preparer has one, and the phone and
fax numbers used by the Preparer.
The Authorized Signer 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
Authorized Signer.

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File Type	application/pdf
Author	PHMSA
File Modified	2014-09-18
File Created	2013-11-25