PHMSA F7100.1 Incident Report - Gas Distribution Systems

Incident Reports for Natural Gas Pipeline Operators

2019 GD Incident Form and Instructions - PHMSA F 7100.1

Incident Reports for Gas Pipeline Operators

OMB: 2137-0635

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 2137-0635 can be found here:

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?????
EXPIRATION DATE: ??/??/20??

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

OMB NO:

INCIDENT REPORT – GAS DISTRIBUTION
SYSTEM

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

Report Date
No.

(DOT Use Only)

A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to
comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a

????

current valid OMB Control Number. The OMB Control Number for this information collection is 2137. Public reporting for this collection
of information is estimated to be approximately 12 hours per response, including the time for reviewing instructions, gathering the data needed,
and completing and reviewing the collection of information. All responses to this collection of information are mandatory. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information
Collection Clearance Officer, PHMSA, Office of Pipeline Safety (PHP-30) 1200 New Jersey Avenue, SE, Washington, D.C. 20590.
INSTRUCTIONS

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

Report Type: (select all that apply)

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

 Original
/

 Supplemental

 Final

A2. Name of Operator: _____auto-populated based on OPID________________________________________
A3. Address of Operator:
A3a. _____ auto-populated based on OPID __________________________________________________________________
(Street Address)

A3b. _____ auto-populated based on OPID ______________________________________________
(City)

A3c. State: auto-populated based on OPID /

A3d. Zip Code: auto-populated based on OPID /

/ - /

A4. Earliest local time (24-hr clock) and date an incident reporting criteria was met:
/

Hour

Month

Day

Year

A4a. Time Zone for local time (select only one)  Alaska

 Eastern  Central  Hawaii-Aleutian

 Mountain  Pacific.

 Yes  No

A4b. Daylight Saving in effect?
A5. Location of Incident:

A5a. ___________________________________________________ (Street Address or location description)
A5b. ___________________________________________________ (City)
A5c. ___________________________________________________ (County or Parish)
A5d. State: /

A5e. Zip Code: /

A5f. Latitude:
Longitude: -

/ . /

Form PHMSA F 7100.1 (rev

/ - /

/ . /

??-2019)

Reproduction of this form is permitted

Page 1 of 18

A6. Gas released : (select only one, based on predominant volume released)








Natural Gas
Propane Gas
Synthetic Gas
Hydrogen Gas
Landfill Gas



Other Gas

*Name: ___________________________

A7. Estimated volume of gas released unintentionally:

/,/

A8. Estimated volume of intentional and controlled release/blowdown: /

A9. Were there fatalities?  Yes  No
If Yes, specify the number in each category:

/,/

/ thousand standard cubic feet (mcf )
/

/ thousand standard cubic feet (mcf)

A10. Were there injuries requiring inpatient hospitalization?
If Yes, specify the number in each category:

 Yes  No

A9a. Operator employees

A10a. Operator employees

A9b. Contractor employees
working for the Operator

A10b. Contractor employees
working for the Operator

A9c. Non-Operator
emergency responders

A10c. Non-Operator
emergency responders

A9d. Workers working on the
right-of-way, but NOT
associated with this Operator

A10d. Workers working on the
right-of-way, but NOT
associated with this Operator

A9e. General public

A10e. General public

A9f. Total fatalities (sum of above)

calculated

A10f. Total injuries (sum of above)

calculated

A11. What was the Operator’s initial indication of the Failure? (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 _________________________________________________
A11a. If “Controller”, “Local Operating Personnel, including contractors”, “Air Patrol”, or “Ground Patrol by Operator or its contractor” is selected in
Question A11, specify the following: (select only one)

 Operator employee

 Contractor working for the Operator

A12. Local time operator identified failure

Hour

Month

Day

Year

If A11 = Notification from Emergency Responder, skip questions A13 through A15.
 Yes  No
A13. Did the operator communicate with Local, State, or Federal Emergency Responders about the incident?
If No, skip A14 and A15
A14. Which party initiated communication about the incident?  Operator  Local/State/Federal Emergency Responder
A15. Local time of initial Operator and Local/State/Federal Emergency Responder communication
/ / / / /
/
Hour

A16. Local time operator resources arrived on site

Hour

Month

Day

Year

A17. reserved
A18. Local time (24-hr clock) and date of initial operator report to the National Response Center:
/

Hour

Month

Day

Year

A19. Initial Operator National Response Center Report Number OR
 NRC Notification Required But Not Made
A19a. Additional NRC Report numbers submitted by the operator:_____________________

Form PHMSA F 7100.1 (rev

??-2019)

Reproduction of this form is permitted

Page 2 of 18

A20. Method of Flow Control (select all that apply)
 “Key/Critical” Valve – inspected in accordance with Part 192.747
 Main Valve other than “Key/Critical”
 Service (curb) Valve
 Meter/Regulator shut-off Valve
 Excess flow valve
 Squeeze-Off
 Stopple fitting
 Other – mandatory text field
A21. Did the gas ignite?

 Yes

 No

If A21 = Yes, answer A21a through A21d.
A21a. Local time of ignition

Hour

Month

Day

A21b. How was the fire extinguished?
 Operator/Contractor  Local/State/Federal Emergency Responder
A21c. Estimated volume of gas consumed by fire (MCF):
A21d. Did the gas explode?

 Yes

??-2019)

 Allowed to burn out  Other, specify:_________

(must be less than or equal to A7.)

 No

A22. Number of general public evacuated: /

Form PHMSA F 7100.1 (rev

Year

/,/

Reproduction of this form is permitted

Page 3 of 18

PART B – ADDITIONAL LOCATION INFORMATION

 Yes

B1. Was the Incident on Federal land?

 No

B2. Location of Incident: (select only one)



Operator-controlled property



Public property



Private property



Utility Right-of-Way / Easement

B3. 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)
 Exposed due to loss cover
 Other ____________________________

B3a. Depth-of-Cover (in): /

/,/

B3b. Were other underground facilities found within 12 inches of the failure location?  Yes

 No



Aboveground



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

Specify:

 Typical aboveground facility piping or appurtenance (e.g. valve or regulator station, outdoor meter set)
 Overhead crossing
 In or spanning an open ditch
 Inside a building
 In other enclosed space
 Other __________________

B4. Did Incident occur in a crossing?
If Yes, specify type below:








Road crossing 
Water crossing 

 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 at time and location of Incident (ft): /

/,/

/ or  Unknown

(select only one of the following)






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

Form PHMSA F 7100.1 (rev

??-2019)

Reproduction of this form is permitted

Page 4 of 18

PART C – ADDITIONAL FACILITY INFORMATION
C1. Indicate the type of pipeline system:







privately owned
municipally owned
investor owned
cooperative
Other  Specify: ____________________________________ __

C2. Part of system involved in Incident: (select only one)

 Main  Main Valve  Service  Service Valve  Service Riser  Outside Meter/Regulator set  Inside Meter/Regulator set
 Farm Tap Meter/Regulator set  District Regulator/Metering Station  Other mandatory text field _________
C2a. Year item involved in the incident was installed: /

C2b. Year item involved in the incident was manufactured: __/



Unknown



Unknown

When C2.is any value other than “Main”, “Main Valve”, “District Regulator/Metering Station”, or “Other”:
C2c. Indicate the customer type: (select only one)  Single Family Residential  Multi-Family Residential
 Non-Residential with Meter capacity less than 1,000 scfh  Non-Residential with Meter Capacity 1,000 scfh of higher
C2d. Was an EFV installed on the service line before the time of the incident?  Yes  No
 Unable to determine
If C2d = Yes, then C2e. Did the EFV activate?  Yes  No
C2f. Was a curb valve installed on the service line before the time of the incident?  Yes  No
C3. When C2. is “Main” or “Service” answer C3a through c and C4:
C3a. Nominal Pipe Size: /
/
/./
/
/
/
C3b. Pipe specification (e.g., API 5L, ASTM D2513): ___________________



C3c. Pipe manufacturer: ______________________ or
C4. Material involved in Incident:

 Steel
 Cast/Wrought Iron
 Reconditioned Cast Iron


 Unknown

Unknown

 Ductile Iron
 Copper
 Plastic
Unknown
 Other  Specify: _________________________

C4a. If Steel  Specify seam type:

 Longitudinal ERW - High Frequency  Single SAW  Flash Welded  DSAW  Longitudinal ERW - Low Frequency
 Continuous Welded  Furnace Butt Welded  Longitudinal ERW – Unknown Frequency
 Spiral Welded  Lap Welded
 Seamless  Other  Specify: ________________
C4b. If Steel  Specify wall thickness (inches): /
C4c. If Plastic  Specify type:

/./

or  Unknown

 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: _______________________________________________
 Unknown

C4d. If Plastic  Specify Standard Dimension Ratio (SDR): /

or wall thickness: /

C4e. 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

C5. Type of release involved: (select only one)





Mechanical Puncture



Other

Leak



Approx. size: /__/__/__/__/./__/in. (axial) by /__/__/__/__/./__/in. (circumferential)

 Crack
 Select Type:  Pinhole
Select
Orientation:

Circumferential


Rupture

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

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



*Describe: ___________________________________________________________________

Form PHMSA F 7100.1 (rev

??-2019)

Reproduction of this form is permitted

Page 5 of 18

PART D – ADDITIONAL CONSEQUENCE INFORMATION
D1. Class Location of Incident: (select only one)






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

D2. Estimated Property Damage :
D2a. Estimated cost of public and non-Operator private property damage

/,/

D2b. Estimated cost of Operator’s property damage & repairs

/,/

D2c. Estimated cost of emergency response

D2d. Estimated other costs

/
$/

/,/
/

/
/

/,/

/
/

/,/

Describe: ___________________________________________________
D2e. Total estimated property damage (sum of above)

$ calculated

Cost of Gas Released
Cost of Gas in $ per thousand standard cubic feet (mcf):______________
D2f. Estimated cost of gas released unintentionally

$ calculated

D2g. Estimated cost of gas released intentionally during controlled release/blowdown

$ calculated

D2h. Total estimated cost of gas released (sum of D2f and g)

$ calculated

D2i. Estimated Total Cost (sum of D2e and D2h)

$ calculated

D3. Estimated number of customers out of service:
D3a. Commercial entities /

/,/

D3b. Industrial entities

/,/

D3c. Residences

/,/

Injured Persons not included in A10 The number of persons injured, admitted to a hospital, and remaining in the hospital for at least one
overnight are reported in A10. If a person is included in A10, do not include them in D4.
D4. Estimated number of persons with injuries requiring treatment in a medical facility but not requiring overnight in-patient hospitalization:
If a person is included in D4, do not include them in D5.
D5. Estimated number of persons with injuries requiring treatment by EMTs at the site of incident:
Buildings Affected
D6. Number of residential buildings affected (evacuated or required repair or had gas service interrupted):
D7. Number of business buildings affected (evacuated or required repair or had gas service interrupted):

Form PHMSA F 7100.1 (rev

??-2019)

Reproduction of this form is permitted

Page 6 of 18

PART E – ADDITIONAL OPERATING INFORMATION
E1. Estimated pressure at the point and time of the Incident (psig):

E2. Normal operating pressure at the point and time of the Incident (psig):

E3. Maximum Allowable Operating Pressure (MAOP) at the point and time of the Incident (psig):

E3a. MAOP established by 49 CFR section:
� 192.619 (a)(1) � 192. 619 (a)(2)
� 192.621m
� 192.623

� 192. 619 (a)(3)

E3b. Date MAOP established:

Month

Day

� 192.619 (a)(4)
/

Year

� 192. 619 (c)

E4. 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 the applicable allowance in §192.201
 Pressure exceeded the applicable allowance in §192.201
E5. Type of odorization system for gas at the point of failure:
� none � d r i p � i n j e c t i o n p u m p � b y - p a s s � wick
� combination of odorization types � o d o r i z e d b y o t h e r s
E6. Odorant level near the point of failure measured after the failure:

� Other, specify:

%LEL OR

 Not Measured

E7. Was a Supervisory Control and Data Acquisition (SCADA)-based system in place on the pipeline or facility involved in the Incident?
 No
 Yes  E7a. Was it operating at the time of the Incident?
 Yes
 No
E7b. Was it fully functional at the time of the Incident?
 Yes
 No
E7c. Did SCADA-based information (such as alarm(s), alert(s), event(s), and/or volume or pack calculations) assist with the
 Yes
 No
initial indication of the Incident?
E7d. Did SCADA-based information (such as alarm(s), alert(s), event(s), and/or volume calculations) assist with the
confirmed discovery of the Incident?
 Yes
 No
E8. 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

??-2019)

Reproduction of this form is permitted

Page 7 of 18

PART F – DRUG & ALCOHOL TESTING INFORMATION
F1. 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 

F1a. Specify how many were tested:

F1b. Specify how many failed:

F2. 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 

F2a. Specify how many were tested:
F2b. Specify how many failed:

Form PHMSA F 7100.1 (rev

??-2019)

/
/

Reproduction of this form is permitted

Page 8 of 18

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. Enter secondary, contributing, or
root causes of the Incident in Part J – Contributing Factors.

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 _____________________________________________________________
2a. If 2. is Stray Current, specify  Alternating Current  Direct Current

AND

2b. Describe the stray current source: _______________________
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 or submerged?
 Yes  4a. Was failed item considered to be under cathodic protection at the time of
the incident?
 Yes  Year protection started: / / / / /

 No

4b. Was shielding, tenting, or disbonding of coating evident at the point of
the incident?
 Yes  No
4c. Has one or more Cathodic Protection Survey been conducted at
the point of the incident? (select all that apply)
 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 

Describe Other CP Survey:

4d. 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  N/A Bare/Ineffectively Coated Pipe
6. Pipeline coating type, if steel pipe is involved: (select only one)
 Epoxy
 Coal Tar  Asphalt
 Polyolefin  Extruded Polyethylene
 Cold Applied Tape
 Paint
 Composite
 Other ___________________________________
 Unknown
6a. Field Applied? Y, N, or Unknown

Form PHMSA F 7100.1 (rev

??-2019)

Reproduction of this form is permitted

 None

Page 9 of 18

 Internal Corrosion

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

 Yes  No

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

Month

Day

Year

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

 No

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

Earth Movement, NOT due to Heavy
Rains/Floods

1. Specify:  Earthquake  Subsidence
 Other ___________________

 Landslide



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



Tree/Vegetation Roots

 Washouts/Scouring  Flotation  Mudslide  Other ________________

 Frost Heave
 Other ________________________________



Damage from Snow/Ice Impact or
Accumulation



Other Natural Force Damage

5. Describe: _________________________________________________

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

Form PHMSA F 7100.1 (rev

??-2019)

 Yes

 No

 Hurricane  Tropical Storm
 Tornado
 Other ______________________________

Reproduction of this form is permitted

Page 10 of 18

G3 – Excavation Damage – only one sub-cause can be picked from shaded left-hand column


Excavation Damage by Operator
(First Party)



Excavation Damage by Operator’s
Contractor (Second Party)



Excavation Damage by Third Party



Previous Damage due to Excavation
Activity

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

Month

Day

Year

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

 Yes  No

3a. If Yes, Notification received from: (select all that apply)  One-Call System  Excavator  Contractor  Landowner
3b. Per the primary Incident Investigator report, did State law exempt the excavator from notifying the one-call center?  Yes  No 
Unknown
If yes, answer 3c through 3e.
3c. (select only one)
 Excavator is exempt
 Activity is exempt and did not exceed the limits of the exemption
 Activity is exempt and exceeded the limits of the exemption
 Other mandatory text field:
3d. Exempting Authority: ________________
3e. Exempting Criteria: _______________________
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
Form PHMSA F 7100.1 (rev

 Cable TV
 Driveway
 Irrigation

??-2019)

 Curb/Sidewalk
 Electric
 Landscaping

 Building Construction
 Engineering/Surveying
 Liquid Pipeline

Reproduction of this form is permitted

 Building Demolition
 Fencing
 Milling
Page 11 of 18

 Natural Gas
 Pole
 Public Transit Authority
 Sewer (Sanitary/Storm)  Site Development
 Steam
 Telecommunications
Traffic Signal
 Traffic Sign
 Data not collected
 Unknown/Other
 Yes

9. Was the One-Call Center notified?

9a. If Yes, specify ticket number: /

 No
/

 Railroad Maintenance
 Storm Drain/Culvert
 Water

 Road Work
Street Light
 Waterway Improvement

If No, skip to question 13
/

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

 Utility Owner

10. Type of Locator:

 Contractor

Locator

 Data not collected

 Unknown/Other

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

 No

 Yes

 Data not collected

 Unknown/Other

12. Were facilities marked correctly?

 No

 Yes

 Data not collected

 Unknown/Other

 No

 Yes

 Data not collected

 Unknown/Other

13. Did the damage cause an interruption in service?
13a. 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

??-2019)

Reproduction of this form is permitted

Page 12 of 18

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
If this sub-cause is picked, complete questions 7-13 below.

Damage by Boats, Barges, Drilling
Rigs, or Other Maritime Equipment or
Vessels Set Adrift or Which Have
Otherwise Lost Their Mooring
Routine or Normal Fishing or Other
Maritime Activity NOT Engaged in
Excavation

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



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
5. Specify:
 Vandalism
 Terrorism
 Theft of transported commodity  Theft of equipment
 Other ________________________________________



Intentional Damage



Erosion of Support Due to Other
Utilities



Other Outside Force Damage

6. Describe: ________________

Complete the following if Damage by Car, Truck, or Other Motorized Vehicle/Equipment NOT Engaged in Excavation sub-cause is
selected.
7. Was the driver of the vehicle or equipment issued one or more citations related to the incident?

 Yes

 No  Unknown

If 7. is Yes, what was the nature of the citations (select all that apply)





7a. Excessive Speed
7b. Reckless Driving
7c. Driving Under the Influence
7d. Other, describe: _______________________

8. Was the driver under control of the vehicle at the time of the collision?

 Yes

 No  Unknown

9. Estimated speed of the vehicle at the time of impact (miles per hour)?_______________or  Unknown
10. Type of vehicle? (select only one)

 Motorcycle/ATV

 Passenger Car  Small Truck  Bus  Large Truck

11. Where did the vehicle travel from to hit the pipeline facility? (select only one)
 Roadway
 Driveway
 Parking Lot

 Loading Dock

 Off-Road

12. Shortest distance from answer in 11. to the damaged pipeline facility (in feet): .________________________
13. At the time of the incident, were protections installed to protect the damaged pipeline facility from vehicular damage?

 Yes

 No

If 13. is Yes, specify type of protection (select all that apply):







13a. Bollards/Guard Posts
13b. Barricades, including “jersey” barriers and fences
13c. Guard Rails
13d. Meter Box
13e. Ingress or Regress at a Residence
13f. Other, describe: _________________________________

Form PHMSA F 7100.1 (rev

??-2019)

Reproduction of this form is permitted

Page 13 of 18

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 Joint Failure - required to
submit PHMSA F 7100.1-2

5. Report ID for PHMSA F 7100.1-2

 Fusion Joint

6. Specify:

___ or  Report Pending

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

7. Year installed:

8. Other attributes:_________________________________________________________
9. Specify the two materials being joined:
9a. 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: __________________________________
9b. 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: __________________________________



10. Describe:______________________________________________________________

Other Pipe, Weld, or Joint Failure

Complete the following if any Pipe, Weld, or Joint Failure sub-cause is selected.
11. Additional Factors: (select all that apply)  Dent  Gouge  Pipe Bend
 Lamination
 Buckle
 Wrinkle
 Misalignment
 Other __________________________________
12. 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
13. Has one or more pressure test been conducted since original construction at the point of the Incident?

 Yes
 No

 Most recent year tested: /

Form PHMSA F 7100.1 (rev

??-2019)

Test pressure (psig): /

Reproduction of this form is permitted

Page 14 of 18

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

________________________________

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



Other Equipment Failure

Form PHMSA F 7100.1 (rev

??-2019)

/ or  Unknown

 Steel  Plastic  Cast/Wrought Iron  Ductile Iron
 Other, specify: mandatory text field______________________

5. Describe: __________________________________________________________________
______________________________________________________________________________

Reproduction of this form is permitted

Page 15 of 18

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

4a. 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
1. Describe: ___ ________________________________________

 Miscellaneous

2. Specify:

Mandatory comment field: ______________________________

 Still under investigation, cause of Incident to be determined*

 Unknown

Form PHMSA F 7100.1 (rev

 Investigation complete, cause of Incident unknown
(*Supplemental Report required)

??-2019)

Reproduction of this form is permitted

Page 16 of 18

PART J – CONTRIBUTING FACTORS
The Apparent Cause of the accident is contained in Part G. Do not report the Apparent Cause again in this Part J. If Contributing Factors were
identified, select all that apply below and explain each in the Narrative:
External Corrosion
 External Corrosion, Galvanic

Pipe/Weld Failure
 Design-related

 External Corrosion, Atmospheric
 External Corrosion, Stray Current Induced
 External Corrosion, Microbiologically Induced
 External Corrosion, Selective Seam
Internal Corrosion
 Internal Corrosion, Corrosive Commodity
 Internal Corrosion, Water drop-out/Acid
 Internal Corrosion, Microbiological

 Construction-related
 Installation-related
 Fabrication-related
 Original Manufacturing-related
Equipment Failure
 Malfunction of Control/Relief Equipment
 Threaded Connection/Coupling Failure
 Non-threaded Connection Failure

 Internal Corrosion, Erosion
Natural Forces
 Earth Movement, NOT due to Heavy Rains/Floods
 Heavy Rains/Floods
 Lightning

 Valve Failure
Incorrect Operation
 Damage by Operator or Operator’s Contractor NOT Excavation
and NOT Vehicle/Equipment Damage
 Valve Left or Placed in Wrong Position, but NOT Resulting in
Overpressure

 Temperature
 High Winds

 Pipeline or Equipment Overpressured

 Snow/Ice

 Equipment Not Installed Properly

 Tree/Vegetation Root
Excavation Damage
 Excavation Damage by Operator (First Party)
 Excavation Damage by Operator’s Contractor (Second Party)
 Excavation Damage by Third Party

 Wrong Equipment Specified or Installed
 Inadequate Procedure
 No procedure established
 Failure to follow procedures

 Previous Damage due to Excavation Activity
Other Outside Force
 Nearby Industrial, Man-made, or Other Fire/Explosion
 Damage by Car, Truck, or Other Motorized Vehicle/Equipment
NOT Engaged in Excavation
 Damage by Boats, Barges, Drilling Rigs, or Other Adrift Maritime
Equipment
 Routine or Normal Fishing or Other Maritime Activity NOT
Engaged in Excavation
 Electrical Arcing from Other Equipment or Facility
 Previous Mechanical Damage NOT Related to Excavation
 Intentional Damage
 Other underground facilities buried within 12 inches of the failure
location

Form PHMSA F 7100.1 (rev

??-2019)

Reproduction of this form is permitted

Page 17 of 18

PART H – NARRATIVE DESCRIPTION OF THE INCIDENT

(Attach additional sheets as necessary)

__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
PART I – PREPARER AND AUTHORIZED PERSON

Preparer's Name (type or print)

Preparer’s Telephone Number

Preparer's Title (type or print)
Preparer's E-mail Address

Preparer’s Facsimile Number

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

Authorized Signer

Authorized Signer Telephone Number

Authorized Signer’s Title

Authorized Signer’s E-mail Address

Form PHMSA F 7100.1 (rev

??-2019)

Reproduction of this form is permitted

Page 18 of 18

Instructions (rev ??-2019) for Form PHMSA F 7100.1 (rev ??-2019)
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 that
involves secondary ignition of the gas system. 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 event 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. . 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 27

Instructions (rev ??-2019) for Form PHMSA F 7100.1 (rev ??-2019)
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”
5. Under “Create Reports” on the left side of the screen, select “Gas Distribution” and
proceed with entering your data.
6. 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.
7. 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 27

Instructions (rev ??-2019) for Form PHMSA F 7100.1 (rev ??-2019)
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”).

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.

Page 3 of 27

Instructions (rev ??-2019) for Form PHMSA F 7100.1 (rev ??-2019)
INCIDENT REPORT – GAS DISTRIBUTION SYSTEMS

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/

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.

Page 4 of 27

Instructions (rev ??-2019) for Form PHMSA F 7100.1 (rev ??-2019)
INCIDENT REPORT – GAS DISTRIBUTION SYSTEMS

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
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 as provided in 49 USC 60122.
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.

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Instructions (rev ??-2019) for Form PHMSA F 7100.1 (rev ??-2019)
INCIDENT REPORT – GAS DISTRIBUTION SYSTEMS

 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”.)
A1. 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.

A2. 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.

A3. 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.

A4. Earliest local time (24-hour clock) and date an incident reporting criteria was met
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.

A4a. Select the local time zone where the Incident occurred (select only one).
A4b. Select “Yes” if Daylight Saving was in effect at the time of the Incident, or “No” if
it was not.
A5. 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.

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Instructions (rev ??-2019) for Form PHMSA F 7100.1 (rev ??-2019)
INCIDENT REPORT – GAS DISTRIBUTION SYSTEMS

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]).
A6. Gas released:
Select the type of gas released. An example of Synthetic Gas is manufactured gas based on
naphtha. Landfill Gas includes biogas.
A7. Estimated volume of gas released unintentionally
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.
A8. Estimated volume of intentional and controlled release/blowdown
Estimate the amount of gas that was released (in thousands of standard cubic feet, mcf) during
any intentional release or controlled blowdown conducted as part of responding to or recovering
from the Incident. Intentional and controlled blowdown implies a level of control of the site and
situation by the operator such that the area and the public are protected during the controlled
release. Important Note: Volumes consumed by fire and/or explosion are to be included in the
estimated volume reported.
A9. Were there fatalities?
Select “Yes” or “No” and if “Yes” is selected, enter the number of fatalities resulting from the
Incident for A9a through e as applicable.
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
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Instructions (rev ??-2019) for Form PHMSA F 7100.1 (rev ??-2019)
INCIDENT REPORT – GAS DISTRIBUTION SYSTEMS

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. Workers performing
work near, but not on, the right-of-way and who are affected are to be reported as “General
public”.
A10. Were there injuries requiring inpatient hospitalization?
Select “Yes” or “No” and if “Yes” is selected, enter the number of injured persons resulting from
the Incident for A10a through e as applicable.
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 A9 for additional definitions that apply.
A11. What was the Operator’s initial indication of the Failure? (select only one)
Select the best option to describe the manner in which the operator first became aware of a
failure resulting in this reported Incident.
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.

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Instructions (rev ??-2019) for Form PHMSA F 7100.1 (rev ??-2019)
INCIDENT REPORT – GAS DISTRIBUTION SYSTEMS

A11a. If the Incident was identified by Operator’s personnel or a contractor working for the
Operator (including controller, air and ground patrols) in A11, identify if it was by an Operator
employee, or a contractor working for the Operator.
A12. When did the operator identify the failure?
Enter the date/time the operator’s initial indication 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.
A13 -15 Operator Communication with Local, State, or Federal Emergency Responders
In an Advisory Bulletin dated October 11, 2012, PHMSA reminded Operators of the need to
communicate with Emergency Responders in the early stages of a potential Incident. This is
typically accomplished by contacting Public Safety Access Points (PSAPs) along the pipeline
route. The purpose of the communication is to assist in the identification, location, and planning
for response to pipeline Incidents through coordination and information sharing.
Indicate in 13 if the Operator communicated with Local, State, or Federal Emergency
Responders about the Incident, identify who initiated the communication about the Incident in
14, and enter the Local date and time of the initial communication in 15.
A16. What time did Operator resources arrive on site?
Enter the date/time operator responders, company or contract, arrived on site. This time is 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.
A17. reserved
A18. Local time (24-hr clock) and date of initial operator report to the National Response
Center
Enter the time and date of the initial Immediate Notice of incident to the NRC submitted by the
operator. 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.)
A19. 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. The NRC assigns numbers to each call. The number assigned to Initial Immediate
Notice (sometimes referred to as the “Telephonic Report”) is to be entered in Question 19.
When there is more than one NRC report for the incident, enter the Initial report in this field and
remaining NRC report numbers in A19a. If a NRC report was not made, select NRC
Notification Required But Not Made.

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Instructions (rev ??-2019) for Form PHMSA F 7100.1 (rev ??-2019)
INCIDENT REPORT – GAS DISTRIBUTION SYSTEMS

A19a. Additional NRC Report Numbers
If the operator made more than one call to the NRC, enter each additional NRC report number.
A20. Method of Flow Control (select all that apply)
The response to gas distribution pipeline emergencies may involve several methods of
controlling flow to the failure location. Select all methods of flow control used during response
to the incident.
A21. Did the Gas Ignite?
Ignite means the released gas caught fire or a conflagration, detonation or explosion occurred,
even if there was no residual fire after the initial ignition event.
If the answer is “Yes,” complete questions A21a through d.
A21a. Enter the time and date of the ignition. The time is to be shown by 24-hour clock
notation in the time zone where the Incident occurred.
A21b. Indicate how the fire was extinguished.
A21c. Estimate volume of gas consumed by fire in thousands of standard cubic feet, MCF
A21d. Did the Gas Explode?
Explode means the ignition of the released gas occurred with a sudden and violent release of
energy.
A22. 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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Instructions (rev ??-2019) for Form PHMSA F 7100.1 (rev ??-2019)
INCIDENT REPORT – GAS DISTRIBUTION SYSTEMS

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
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.
Exposed due to Loss of Cover means that a normally buried facility had been exposed due to a
cause other excavation activities. For example, natural forces might cause a facility that had
been installed underground to become exposed.
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.

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Instructions (rev ??-2019) for Form PHMSA F 7100.1 (rev ??-2019)
INCIDENT REPORT – GAS DISTRIBUTION SYSTEMS

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.
If B3. is Underground, enter the depth of cover as found in B3a. and indicate whether other
underground facilities were found within 12 inches of the failure location in B3b.
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. Finally, specify the part of the water crossing where the failure occurred.

PART C – ADDITIONAL FACILITY INFORMATION
C1. Indicate the type of pipeline system:
Designate the type of gas distribution system on which the incident occurred.
C2. 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.
C2a. Year Installed Enter the year the item involved in the incident was installed.
C2b. Year Manufactured Enter the year the item involved in the incident was manufactured.

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Instructions (rev ??-2019) for Form PHMSA F 7100.1 (rev ??-2019)
INCIDENT REPORT – GAS DISTRIBUTION SYSTEMS

When C2. is any value other than “Main”, “Main Valve”, “District Regulator/Metering
Station”, or “Other”, answer 2c through 2f.
C2c. Customer Type Select only one. Customer Types are:
Single Family - residential building designed for a single family
Multi-Family - residential dwellings such as apartments, town homes, and duplexes
Industrial – customers manufacturing products
Commercial – retail and wholesale sales customers, including hospitals, schools, and
other government affiliated customers
C2d. EFV Installed
Had an Excess Flow Valve (EFV) been installed on the service line
before the time of the failure? If Yes:
C2e. EFV Activation
Did the EFV activate in response to the failure? If you are
unable to determine if the EFV activated, select “unable to determine.”
C2f. Curb Valve Installed Had a curb valve been installed on the service line before the time
of the failure? Curb valves are manually operated valves located near the main.
C3. When “Main” or “Service” is selected in C2., answer C3a. through c:
C3a. Nominal Pipe Size (NPS) For pipe greater than 5 inches in diameter, enter only the
integer portion of the diameter value; for example, 8-5/8 pipe has a nominal pipe size of 8. For
pipe less than 5 inches in diameter, the NPS may include decimals to three places. For more
details, see http://en.wikipedia.org/wiki/Nominal_Pipe_Size
C3b. Pipe Specification is the specification to which the pipe or component was manufactured,
such as API 5L or ASTM A106.
C3c. Pipe Manufacturer

Enter the name of the company that manufactured the pipe.

C4. Material involved in incident:
Identify the type of material involved and provide additional information as indicated.
C5. 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.

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Instructions (rev ??-2019) for Form PHMSA F 7100.1 (rev ??-2019)
INCIDENT REPORT – GAS DISTRIBUTION SYSTEMS

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 one decimal.)

PART D – ADDITIONAL CONSEQUENCE INFORMATION
D2. 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.
D2a. 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.
D2b. Operator’s property damage & repairs 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, secure, excavate, and repair the facility using methods, materials, and
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Instructions (rev ??-2019) for Form PHMSA F 7100.1 (rev ??-2019)
INCIDENT REPORT – GAS DISTRIBUTION SYSTEMS

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.
D2c. Emergency response includes emergency response operations necessary to return the
incident site to a safe state, actions to minimize the volume of gas released, conduct
reconnaissance, and to identify the extent of incident impacts. They include materials, supplies,
labor, and benefits. If you reimbursed local, state, or federal emergency responders, include
these amounts. Costs related to stakeholder outreach, media response, etc. are not to be included.
D2d. 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 – enter your gas cost, excluding taxes, in dollars per thousand standard
cubic feet (mcf). The cost of gas released will be calculated based on the volumes reported in
A7 and A8.
D3. Estimated number of customers out of service:
Count number of individual services in each category that were affected, not number of persons
served.
Injured persons not included in A10. The number of persons injured, admitted to a hospital,
and remaining in the hospital for at least one overnight are reported in A10. If a person is
included in A10, do not include them in D4.
D4. Estimated number of persons with injuries requiring treatment in a medical facility but not
requiring overnight in-patient hospitalization.
If a person is included in D4, do not include them in D5.
D5. Estimated number of persons with injuries requiring treatment by EMTs at the site of
incident.
Buildings Affected The term ‘affected’ means the building was either damaged and required
repair, or evacuated, or had gas service interrupted.
D6. Enter the number of residential buildings affected.

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Instructions (rev ??-2019) for Form PHMSA F 7100.1 (rev ??-2019)
INCIDENT REPORT – GAS DISTRIBUTION SYSTEMS

D7. Enter the number of commercial and industrial buildings affected.

PART E – ADDITIONAL OPERATING INFORMATION
E2. 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.
E3a. MAOP Established By Select the response serving as the limiting factor for establishing
MAOP at the incident site. A short explanation of each option is:
§ 192.619
(paragraph)

(a)

(a)(1)
(a)(2)
(a)(3)

(a)(4)
(c)
§192.621
§192.623

Methodology Description
Introduction: Except as specified in (c), use the lowest MAOP determined by
(a)(1), (a)(2), (a)(3), (a)(4).
Design Pressure
Post-Construction Pressure Test
High Actual Operation Pressure during 5 years preceding July 1, 1970 – this is
NOT the Grandfather Clause
History of Pipe (primarily corrosion and actual operating pressure)
Grandfather Clause – Highest Actual Operating Pressure during five years
preceding 1970, even if this MAOP is higher than MAOPs determined by other
(a) methods
Maximum allowable operating pressure: High-pressure distribution systems
Maximum and minimum allowable operating pressure; Low-pressure
distribution systems

E3b. MAOP Date

Enter the date the MAOP in E3a. was established.

E4. Operating Pressure and MAOP Select the option that describes the relationship among
the operating pressure at the point and time of the incident, the MAOP, and the allowances in
§192.201.
E5. Odorization Type
Select the one option that best describes the odorization system(s)
affecting gas at the point of failure.
E6. Odorant Level Enter the odorant level in, % LEL, as measured near the failure site or
indicate that no measurement was done.
E7. 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.
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Instructions (rev ??-2019) for Form PHMSA F 7100.1 (rev ??-2019)
INCIDENT REPORT – GAS DISTRIBUTION SYSTEMS

E7a. Was it operating at the time of the Incident?
Was the SCADA system in operation at the time of the incident?
E7b. 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.
E7c 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.
E8. 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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Instructions (rev ??-2019) for Form PHMSA F 7100.1 (rev ??-2019)
INCIDENT REPORT – GAS DISTRIBUTION SYSTEMS

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 enter secondary, contributing, or root causes of
the Incident in PART J – Contributing Factors.
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 G7 Incorrect Operation for improper installation or G6 Equipment Failure if the gasket failed.)
External Corrosion
4a. 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.
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.

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Instructions (rev ??-2019) for Form PHMSA F 7100.1 (rev ??-2019)
INCIDENT REPORT – GAS DISTRIBUTION SYSTEMS

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.
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.

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Instructions (rev ??-2019) for Form PHMSA F 7100.1 (rev ??-2019)
INCIDENT REPORT – GAS DISTRIBUTION SYSTEMS

Tree/Vegetation Root includes damages when tree and vegetation roots caused damage to the
gas distribution system asset which results in an incident.
Snow/Ice Impact or Accumulation includes damages when snow or ice accumulation or impact
caused damage to the gas distribution system asset which results in an incident.
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 6a if the incident occurred in conjunction with an extreme weather event. If the extreme
weather was something other than those listed, 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
instance, may indicate an earlier strike, as might marks from the bucket or tracks of an earth
moving machine or similar pieces of equipment.

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Instructions (rev ??-2019) for Form PHMSA F 7100.1 (rev ??-2019)
INCIDENT REPORT – GAS DISTRIBUTION SYSTEMS

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.
If Excavation Damage by Third Party is selected, answer question 3
3. and 3a. Prior Notification Indicate whether you received prior notification of the excavation
activity. If yes, indicate all of the notification sources.
3b. through 3e. One-Call State Law Exemptions Per the primary Incident Investigator
results, indicate whether State law exempted the excavator from notifying a one-call center. If
yes, select the type of exemption from the list. If “Other” is selected, enter text describing the
exemption. Describe the exempting authority and exempting criteria.
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.
NOTE: If you have or will be reporting the information in questions 4 thru 14 to CGADIRT, select “No” in question 4 to avoid duplication of data submitted to CGA.
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).
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
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Instructions (rev ??-2019) for Form PHMSA F 7100.1 (rev ??-2019)
INCIDENT REPORT – GAS DISTRIBUTION SYSTEMS

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
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,

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Instructions (rev ??-2019) for Form PHMSA F 7100.1 (rev ??-2019)
INCIDENT REPORT – GAS DISTRIBUTION SYSTEMS

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.
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.
Damage from Snow/Ice Impact or Accumulation includes damage caused by snow and/or ice.
Select this category if the damage is due to Snow/Ice, including encased regulator sets.
Erosion of Support Due to the Other Utilities Select this sub-cause when utilities near the gas
distribution system caused the removal of support from under the gas system. Do NOT report
this type of event as G5 – Pipe, Weld, or Joint Failure.
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.
7 - 13 Additional Data for Damage by Car, Truck, or Other Motorized Vehicle/Equipment
NOT Engaged in Excavation
When answering the questions, include information that can be substantiated from police reports
or other investigative reports.
The following definitions apply for reporting the type of motorized vehicle in Question 10:
Motorcycle/All-Terrain Vehicle (ATV) - All two or three-wheeled motorized vehicles, and some
four-wheeled vehicles are to be reported in this category. Typical vehicles in this category have
saddle type seats and are steered by handlebars rather than steering wheels. This category
includes motorcycles, motor scooters, mopeds, motor-powered bicycles, and three-wheel
motorcycles. Additionally, four-wheeled off-road and all-terrain vehicles (sometimes referred to
as “four-wheelers”) are to be reported under this category.
Passenger Car -- All sedans, coupes, and station wagons manufactured primarily for the purpose
of carrying passengers and including those passenger cars pulling recreational or other light
trailers.

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Instructions (rev ??-2019) for Form PHMSA F 7100.1 (rev ??-2019)
INCIDENT REPORT – GAS DISTRIBUTION SYSTEMS

Small Truck - All two-axle, four-tire, vehicles, other than passenger cars. Included in this
classification are pickups, panels, vans, and other vehicles such as campers, motor homes,
ambulances, hearses, carryalls, and minibuses.
Bus - All vehicles manufactured as traditional passenger-carrying buses with two axles and six
tires or three or more axles. This category includes only traditional buses (including school
buses) functioning as passenger-carrying vehicles. Modified buses should be considered to be a
truck and should be appropriately classified.
Large Truck - All vehicles on a single frame including trucks, camping and recreational
vehicles, motor homes, etc., with two or more axles and at least two rear wheels on each side
When specifying the type of protection in Question 13; select the category “Barricades” for
Jersey barriers, fencing, and other structures that are other than Guard Rails or Bollards/Guard
Posts. If “Other” is selected, enter text describing the protection.
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 material defect, design defect, , or in-service
stresses such as vibration, fatigue, and environmental cracking.
Mechanical Joint Failure: Indicate the Report ID for PHMSA F7100.1-2 or choose “Report
Pending.”
13. Has one or more pressure test been conducted since original construction at the point
of the Incident?
Information from the initial post-construction pressure 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.
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.
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INCIDENT REPORT – GAS DISTRIBUTION SYSTEMS

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.

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Instructions (rev ??-2019) for Form PHMSA F 7100.1 (rev ??-2019)
INCIDENT REPORT – GAS DISTRIBUTION SYSTEMS

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.
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 J – CONTRIBUTING FACTORS
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. The
Apparent Cause of the accident is contained in Part G. Do not select the Apparent Cause again
in Part J. If Contributing Factors were identified, select all that apply and explain each in the
Narrative.

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 and to explain any estimated data.
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Instructions (rev ??-2019) for Form PHMSA F 7100.1 (rev ??-2019)
INCIDENT REPORT – GAS DISTRIBUTION SYSTEMS

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 PERSON
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 Person 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 Person.

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File Type	application/pdf
Author	PHMSA
File Modified	2019-04-30
File Created	2019-04-30