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pdfNOTICE: This report is required by 49 CFR Part 191. Failure to report can result in a civil penalty as provided in 49
USC 60122.
INCIDENT REPORT –
GAS TRANSMISSION AND GATHERING
SYSTEMS
U.S. Department of Transportation
Pipeline and Hazardous Materials
Safety Administration
OMB NO: 2137-0635
Expires: 5/31/2024
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 2137-0635. 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):
/
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/
Original
/
/
Supplemental
Final
/
A2. Name of Operator: auto-populated based on OPID
A3. Address of Operator:
A3a. Street Address:
A3b. City:
A3c. State:
A3d. Zip Code:
auto-populated based on OPID
auto-populated based on OPID
auto-populated based on OPID
auto-populated based on OPID
A4. Earliest local time (24-hr clock) and date an incident reporting criteria was met:
/
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Hour
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Month
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Day
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Year
A4a. Time Zone for local time (select only one) Alaska
A4b. Daylight Saving in effect?
A5. Location of Incident:
Latitude:
/ / / . / /
Longitude: - / / / / . /
/
Eastern Central Hawaii-Aleutian
Mountain Pacific.
Yes No
/
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/
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. Estimated volume of accompanying liquid released:
Form PHMSA F 7100.2 (rev 1-2020)
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/,/
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Reproduction of this form is permitted
/ thousand standard cubic feet (mcf)
/ thousand standard cubic feet (mcf)
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/ Barrels
Page 1 of 22
A10. Were there fatalities? Yes No
If Yes, specify the number in each category:
A10a. Operator employees
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/
A10b. Contractor employees
working for the Operator
/
/
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/
A10c. Non-Operator
emergency responders
/
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/
A10d. Workers working on the
right-of-way, but NOT
associated with this Operator
/
/
A10e. General public
/
/
A10f. Total fatalities (sum of above)
calculated
A11. Were there injuries requiring inpatient hospitalization?
No
If Yes, specify the number in each category:
Yes
A11a. Operator employees
/
/
/
/
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/
A11b. Contractor employees
working for the Operator
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A11c. Non-Operator
emergency responders
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A11d. Workers working on the
right-of-way, but NOT
associated with this Operator
/
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/
A11e. General public
/
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/
/
A11f. Total injuries (sum of above)
calculated
A12. 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 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 _________________________________________________
A12a. If “Controller”, “Local Operating Personnel, including contractors”, “Air Patrol”, or “Ground Patrol by Operator or its contractor” is selected in
Question 12, specify the following: (select only one)
Operator employee
Contractor working for the Operator
A13. Local time Operator identified failure
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Hour
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Month
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Day
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Year
A14. Part of system involved in Incident: (select only one)
Belowground Storage, Including Associated Equipment and Piping
Aboveground Storage, Including Associated Equipment and Piping
Onshore Compressor Station Equipment and Piping
Onshore Regulator/Metering Station Equipment and Piping
Onshore Pipeline, Including Valve Sites
Offshore Platform, Including Platform-mounted Equipment and Piping
Offshore Pipeline, Including Riser and Riser Bend
A15. Operational Status at time Operator identified failure (select only one)
Post-Construction Commissioning
Post-Maintenance/Repair
Routine Start-Up
Routine Shutdown
Normal Operation, includes pauses during maintenance
Idle
A16. If A15 = Routine Start-Up or Normal Operation, was the pipeline/facility shut down due to the incident?
Yes No Explain: ______________________________________________________________________________
If Yes, complete Questions A16.a and A16.b: (use local time, 24-hr clock)
A16a. Local time and date of shutdown
/
A16b. Local time pipeline/facility restarted
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Hour
Hour
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Month
Month
Day
Day
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/
Year
Year
Still shut down*
*Supplemental Report required
If A12. = Notification from Emergency Responder, skip A17.
A17a. Did the operator communicate with Local, State, or Federal Emergency Responders about the incident?
Yes
No
If No, skip A17b and c.
A17b. Which party initiated communication about the incident?
Operator
Local/State/Federal Emergency Responder
A17c. Local time of initial Operator and Local/State/Federal Emergency Responder communication
/ / / / /
/
Hour
A18. Local time operator resources arrived on site
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Hour
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Month
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Month
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Day
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Day
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Year
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Year
A19. reserved
Form PHMSA F 7100.2 (rev 1-2020)
Reproduction of this form is permitted
Page 2 of 22
A20a. Local time (24-hr clock) and date of initial operator report to the National Response Center :
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Hour
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Month
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Day
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Year
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A20b. Initial Operator National Response Center Report Number _____________________OR
NRC Notification Required But Not Made
A20c. Additional NRC Report numbers submitted by the operator:_____________________
A21. Did the gas ignite?
Yes
No
If A21 = Yes, then answer A21a through d:
A21a.
Local time of ignition
/
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Hour
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/
Month
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/
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
/
/
/
Year
/
Allowed to burn out Other, specify:_________
(must be less than or equal to A7.)
No
If A14. is “Onshore Pipeline, Including Valve Sites” OR “Offshore Pipeline, Including Riser and Riser Bend”, answer A22a through f
A22a. Initial action taken to control flow upstream of failure location
If Valve Closure, answer A22.b and c:
A22b. Local time of final upstream valve closure
/ / /
Hour
Valve Closure Operational Control - mandatory text field
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Month
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Day
/
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/
Year
/
A22c. Type of upstream valve used to complete upstream isolation of release source:
Manual Automatic
Remotely Controlled
A22d. Initial action taken to control flow downstream of failure location
If Valve Closure, answer A22e and f.:
Valve Closure Operational Control - mandatory text field
A22e. Local time of final downstream valve closure
/
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/
Hour
/
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/
Month
/
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Day
A22f. Type of downstream valve used to complete downstream isolation of release source:
Manual Automatic
Remotely Controlled
A23. Number of general public evacuated: /
Form PHMSA F 7100.2 (rev 1-2020)
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Year
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Check Valve
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Reproduction of this form is permitted
Page 3 of 22
PART B – ADDITIONAL LOCATION INFORMATION
B1. Was the origin of the Incident onshore? Auto-populated based on A14
Yes (Complete Questions B2-B11)
No (Complete Questions B12-B14)
B1a. Pipeline/Facility name: _______________________________
B1b. Segment name/ID: __________________________________
If Onshore:
B2. State: /
/
/
B3. Zip Code: /
B4 ______________________
City
/
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/
B5______________________
County or Parish
B6. Operator designated location: (select only one)
B7.
/ - /
Milepost (specify in shaded area below)
Survey Station No. (specify in shaded area below)
Not Applicable (B7 will not accept data)
/___/___/___/___/___/___/___/___/___/___/___/___/___/
Yes
B8. Was Incident on Federal land, other than the Outer Continental Shelf (OCS)?
Operator-controlled property
B9. Location of Incident: (select only one)
No
Pipeline right-of-way
B10. Area of Incident (as found): (select only one)
Belowground storage or aboveground storage vessel, including attached appurtenances
Underground Specify: Under soil Under a building
Under pavement Exposed due to excavation
Exposed due to loss of cover In underground enclosed space (e.g., vault) Other ________________
B10a. Depth-of-Cover (in): /
/,/
/
/
/
B10.b. Were other underground facilities found within 12 inches of the failure location? Yes
No
Aboveground Specify: Typical aboveground facility piping or appurtenance
Overhead crossing
In or spanning an open ditch Inside a building O Inside other enclosed space O Other _______________
Transition Area Specify: Soil/air interface Wall sleeve Pipe support or other close contact area
Other ____________________________
B11. Did Incident occur in a crossing?
Yes
No
If Yes, specify type:
Bridge crossing Specify: Cased Uncased
Railroad crossing (select all that apply) Cased
Road crossing
(select all that apply) Cased
Water crossing
Specify:
Cased
Uncased
Uncased
Bored/drilled
Bored/drilled
Uncased
Name of body of water, if commonly known: ______________________
Approx. water depth (ft) at the point of the Incident: / /,/ / / / 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
Yes No
Is this water crossing 100 feet or more in length from high water mark to high water mark?
If Offshore:
B12. Approximate water depth (ft.) at the point of the Incident:
B13. Origin of Incident:
In State waters Specify: State: /
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/
Area: _________
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/
Block/Tract #: /___/___/___/___/
Nearest County/Parish: ________________
On the Outer Continental Shelf (OCS) ) (select only one) OCS – Alaska
OCS-Gulf of Mexico
Area: ___________________
Block/Tract #: /___/___/___/___/
OCS- Atlantic
OCS – Pacific
B14. Area of Incident: (select only one)
Shoreline/Bank/Marsh crossing or shore approach
Below water, pipe buried or jetted below seabed
Below water, pipe on or above seabed
Splash Zone of riser
Portion of riser outside of Splash Zone, including riser bend
Platform
Form PHMSA F 7100.2 (rev 1-2020)
Reproduction of this form is permitted
Page 4 of 22
PART C – ADDITIONAL FACILITY INFORMATION
C1. Is the pipeline or facility:
Interstate
Intrastate
C2. Material involved in Incident: (select only one)
Carbon Steel
Plastic
Material other than Carbon Steel or Plastic
C3. Item involved in Incident: (select only one)
Pipe Specify:
*Specify: ____________________________________________
Pipe Body
Pipe Seam
If Pipe Body: Was this a Puddle/Spot Weld? Yes No
If C2. is Carbon Steel
C3b. Wall thickness (in):
/
/./
/
/
C3a. Nominal Pipe Size:
/
C3d. Pipe specification: _____________________________
OR
/
/
Longitudinal ERW – Unknown Frequency
Spiral Welded
Lap Welded
C3g. Pipeline coating type at point of Incident
Epoxy
Specify:
/,/
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/
Seamless
/
/
/
Other ________________
Unknown
Coal Tar
Cold Applied Tape
Other _______________________________
Yes No Unknown
If C2. is Plastic
C3i. If Plastic Specify type:
/
Single SAW Flash Welded
DSAW
Continuous Welded Furnace Butt Welded
C3f. Pipe manufacturer: _______________________________ OR
C3h. Coating field applied?
/./
Unknown
Specify: Longitudinal ERW - High Frequency
Longitudinal ERW - Low Frequency
Extruded Polyethylene
/
/
C3c. SMYS (Specified Minimum Yield Strength) of pipe (psi):
C3e. Pipe Seam
/
Asphalt
Paint
Polyolefin
Composite None
Polyvinyl Chloride (PVC)
Polyethylene (PE)
Cross-linked Polyethylene (PEX)
Polybutylene (PB)
Polypropylene (PP)
Acrylonitrile Butadiene Styrene (ABS)
Polyamide (PA)
Cellulose Acetate Butyrate (CAB)
Unknown
Other: mandatory text field_
C3j. If Plastic Specify Standard Dimension Ratio (SDR): /
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or wall thickness: /
/./
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/
or
Unknown
C3k. If Polyethylene (PE) is selected as the type of plastic in C3j, specify PE Pipe Material Designation Code (i.e., 2406, 3408, etc.)
/ / / or Unknown
PE /
Weld/Fusion, including heat-affected zone
Specify: Pipe Girth Weld Pipe Plastic Fusion Other Butt Weld Fillet Weld
If Pipe Girth Weld is selected, complete items C3.a through h above.
Are any of the C3b through h values different on either side of the girth weld? Yes No
If Yes, enter the different value(s) below:
C3l. Wall thickness (in):
/
/./
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/
C3m. SMYS (Specified Minimum Yield Strength) of pipe (psi):
/
C3n. Pipe specification: _____________________________ OR
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Unknown
Specify: Longitudinal ERW - High Frequency Single SAW Flash Welded
Longitudinal ERW - Low Frequency DSAW Continuous Welded Longitudinal ERW – Unknown Frequency
Furnace Butt Welded Spiral Welded Lap Welded
Seamless Other, describe: ________________________
C3o. Pipe Seam
C3p. Pipe manufacturer: _______________________________
OR
Unknown
C3q. Pipeline coating type at point of Accident
Specify: Fusion Bonded Epoxy (FBE)
Coal Tar Asphalt Polyolefin Extruded Polyethylene
Epoxy other than FBE Cold Applied Tape Paint Composite None Other, describe: _______________
C3r. Coating field applied?
Yes
No
Unknown
If Plastic Pipe Fusion is selected, complete items C3.a and c3.i through k above.
Form PHMSA F 7100.2 (rev 1-2020)
Reproduction of this form is permitted
Page 5 of 22
/
Valve, excluding Regulator/Control Valves
Mainline Specify: Butterfly Check
tubing.
Relief Valve
Auxiliary or Other Valve
Gate
Plug
C3s. Mainline valve manufacturer:
Ball Globe Other _______________
OR Unknown
Compressor, including auxiliary piping, connections, valves, and equipment, but excluding product drain lines and tubing.
Meter, including auxiliary piping, connections, valves, and equipment, but excluding product drain lines and tubing.
Scraper/Pig Trap, including auxiliary piping, connections, valves, and equipment, but excluding product drain lines and tubing.
Odorization System, including auxiliary piping, connections, valves, and equipment, but excluding product drain lines and tubing.
Filter/Strainer/Separator, including auxiliary piping, connections, valves, and equipment, but excluding product drain lines and tubing.
Dehydrator/Drier/Treater/Scrubber, including auxiliary piping, connections, valves, and equipment, but excluding product drain lines and
Regulator/Control Valve, including auxiliary piping, connections, valves, and equipment, but excluding product drain lines and tubing.
Pulsation Bottle or Drip/Drip Collection Device
Cooler or Heater, including auxiliary piping, connections, valves, and equipment, but excluding product drain lines and tubing.
Repair Sleeve or Clamp
Hot Tap Equipment
Tap Fitting (stopple, thread-o-ring, weld-o-let, etc.)
Flange Assembly, including Gaskets
ESD System, including auxiliary piping, connections, valves, and equipment, but excluding product drain lines and tubing.
Drain Lines
Tubing, including Fittings
C3t. Tubing material (select only one):
Stainless steel
Carbon steel
Copper
Other
C3u. Type of tubing (select only one):
Rigid
Flexible
Instrumentation, including Programmable Logic Controllers and Controls
Underground Gas Storage or Cavern
Other ___________________________________
C4. Year item involved in Incident was installed:
/
C5. Year item involved in Incident was manufactured:
/
/
/
/
/
Unknown
/ OR
/
/
/
Unknown
OR
C6. Type of release involved: (select only one)
Mechanical Puncture Approx. size: /__/__/__/__/./__/in. (axial) by /__/__/__/__/./__/in. (circumferential)
Leak Select Type: Pinhole
Crack
Connection Failure
Seal or Packing
Other
Rupture Select Orientation: Circumferential
Longitudinal
Other ________________________________
Approx. size: /__/__/__/__/./__/ in. (widest opening) by /__/__/__/__/__/./__/in. (length circumferentially or axially)
Other *Describe: ___________________________________________________________________
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. Did this Incident occur in a High Consequence Area (HCA)?
No
Yes D2.a Specify the Method used to identify the HCA:
Method 1(Class Location)
Method 2 (PIR)
Not Flammable
Yes
D5. Were any structures outside the PIR impacted or otherwise damaged NOT by heat/fire resulting from the Incident? Yes
D6. Were any of the fatalities or injuries (A11 only) reported for persons located outside the PIR?
Yes
D3. What is the PIR (Potential Impact Radius) for the location of this Incident?
/
/,/
/
/
/ feet
or
D4. Were any structures outside the PIR impacted or otherwise damaged by heat/fire resulting from the Incident?
If Yes, Describe the cause of the fatalities or injuries: ______________________________________
D13. If D2. Is No, answer D13a.
D13a. Did this incident occur in a Moderate Consequence Area (MCA)?
Yes
No
If D13a. is Yes, answer D13b.
D13b. Select each of the items below that were present within the potential impact circle:
5 or more buildings intended for human occupancy
Paved surface for a designated interstate, freeway, expressway, or other principal 4-lane arterial roadway
Form PHMSA F 7100.2 (rev 1-2020)
Reproduction of this form is permitted
Page 6 of 22
No
No
No
D7. Estimated Property Damage:
D7a. Estimated cost of public and non-Operator private property damage
$/
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/
D7b. Estimated cost of Operator’s property damage & repairs
$/
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/
D7c. Estimated cost of emergency response
$/
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/
D7d. Estimated other costs
$/
/
/
/,/
/
/
/,/
/
/
/
Describe: _______________________________
D7e. Total estimated property damage (sum of above)
$ calculated
Cost of Gas Released
Cost of Gas in $ per thousand standard cubic feet (mcf): ______________
D7f. Estimated cost of gas released unintentionally
$ calculated
D7g. Estimated cost of gas released during intentional and controlled blowdown
$ calculated
D7h. Total estimated cost of gas released (sum of 7.f & 7.g above)
$ calculated
D7i. Estimated Total Cost (sum of D7e and D7h)
$ calculated
Injured Persons not included in A11 The number of persons injured, admitted to a hospital, and remaining in the hospital for at least one overnight
are reported in A11. If a person is included in A11, do not include them in D8.
D8. 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 D8, do not include them in D9.
D9. Estimated number of persons with injuries requiring treatment by EMTs at the site of incident:
Buildings Affected
D10. Number of residential buildings affected (evacuated or required repair or gas service interrupted):
D11. Number of business buildings affected (evacuated or required repair or gas service interrupted):
D12. Wildlife impact:
Yes No
D12a. If Yes, specify all that apply:
Fish/aquatic
Birds
Terrestrial
Form PHMSA F 7100.2 (rev 1-2020)
Reproduction of this form is permitted
Page 7 of 22
PART E – ADDITIONAL OPERATING INFORMATION
E1. Estimated pressure at the point and time of the Incident (psig):
/
/
/,/
E1a. Estimated gas flow in pipe segment at the point and time of the incident (MSCF/D):
/
/
/
E2. Maximum Allowable Operating Pressure (MAOP) at the point and time of the Incident (psig) :
/
/
/,/
E2a.
MAOP established by 49 CFR section:
� 192.619 (a)(1) � 192. 619 (a)(2) � 192. 619 (a)(3) � 192.619 (a)(4)
� 192.624 (c)(1) � 192. 624(c)(2) � 192.624 (c)(3) � 192.624 (c)(4)
� Other
Specify Other:
E2b.
Date MAOP established:
/
/
Month
/
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/
Day
/
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/
Year
/
/
/
/
/
/
/
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/
� 192. 619 (c)
� 192.619 (d)
� 192.624(c)(5) � 192.624 (c)(6)
/
E2c. Was the MAOP in E2a and b established in conjunction with a reversal of flow direction?
Yes No
Bi-Directional
E3. Describe the pressure on the system or facility relating to the Incident: (select only one)
Pressure did not exceed MAOP
Pressure exceeded MAOP, but did not exceed the applicable allowance in §192.201
Pressure exceeded the applicable allowance in §192.201
E4. Was the system or facility relating to the Incident operating under an “established pressure restriction” with pressure limits below those normally
allowed by the MAOP ?
No Yes
(Complete E4.a and E4.b below)
E4a. Did the pressure exceed this “established pressure restriction?”
E4b. Was this pressure restriction mandated by PHMSA or the State?
Yes
No
PHMSA
State
E5. Was the gas at the point of failure required to be odorized in accordance with §192.625?
If yes, Was the gas at the point of failure odorized in accordance with §192.625?
Not mandated
Yes No
Yes No
If A14. is “Onshore Pipeline, Including Valve Sites” OR “Offshore Pipeline, Including Riser and Riser Bend”, answer E6 through E8.
E6. Length of segment between upstream and downstream shut-off valves closest to failure location (ft):
/
/
/
/,/
/
/
E7 Is the pipeline configured to accommodate internal inspection tools?
Yes
No Which physical features limit tool accommodation? (select all that apply)
Changes in line pipe diameter
Presence of unsuitable mainline valves
Tight or mitered pipe bends
Other passage restrictions (i.e. unbarred tee’s, projecting instrumentation, etc.)
Extra thick pipe wall (applicable only for magnetic flux leakage internal inspection tools)
Other Describe:______________________________
E8 For this pipeline, are there operational factors which significantly complicate the execution of an internal inspection tool run?
No
Yes
Which operational factors complicate execution?
(select all that apply)
Excessive debris or scale, wax, or other wall build-up
Low operating pressure(s)
Low flow or absence of flow
Incompatible commodity
Other Describe:_______________________________
E9 Function of pipeline system: (select only one)
Transmission System
Transmission Line of Distribution System
Type A Gathering
Type B Gathering
Transmission in Storage Field
Offshore Gathering
Form PHMSA F 7100.2 (rev 1-2020)
Reproduction of this form is permitted
Page 8 of 22
/
E10 Was a Supervisory Control and Data Acquisition (SCADA)-based system in place on the pipeline or facility involved in the Incident?
No
Yes E10.a Was it operating at the time of the Incident?
Yes
No
Yes
No
E10.b Was it fully functional at the time of the Incident?
E10.c Did SCADA-based information (such as alarm(s), alert(s), event(s), and/or volume or pack calculations) assist with
the initial indication of the Incident?
Yes
No
E10.d 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
E11 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: ____________________________________
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 7100.2 (rev 1-2020)
Reproduction of this form is permitted
Page 9 of 22
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 K – 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:
/ / / / /
Describe other CP survey
____________________________________
No
No 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
Internal Corrosion
6. Results of visual examination:
Localized Pitting
General Corrosion
Not cut open
Other
________________________________________________________
____
7. Cause of corrosion: (select all that apply)
Corrosive Commodity Water drop-out/Acid
Microbiological Erosion
Other ____________
________________________________________________
Form PHMSA F 7100.2 (rev 1-2020)
Reproduction of this form is permitted
Page 10 of 22
8. The cause(s) of corrosion selected in Question 7 is based on the
following: (select all that
apply)
Field examination
Determined by metallurgical analysis
Other
________________________________________________________
_____
9. Location of corrosion: (select all that apply)
Low point in pipe Elbow Drop-out Dead-Leg
Other
________________________________________________________
____
10. Was the gas/fluid treated with corrosion inhibitors or biocides?
Yes No
11. Was the interior coated or lined with protective coating?
No
Yes
12. Were cleaning/dewatering pigs (or other operations) routinely
utilized?
Not applicable - Not mainline pipe
Yes
No
13. Were corrosion coupons routinely utilized?
Not applicable - Not mainline pipe
Yes
Form PHMSA F 7100.2 (rev 1-2020)
Reproduction of this form is permitted
Page 11 of 22
No
G2 - Natural Force Damage - only one sub-cause can be picked from shaded left-hand column
Earth Movement, NOT due to Heavy Rains/Floods
1. Specify: Earthquake Subsidence
Other __________________
Landslide
Heavy Rains/Floods
2. Specify: Washout/Scouring
Other _______________
Flotation Mudslide
Lightning
3. Specify:
nearby fires
Direct hit Secondary impact such as resulting
Temperature
4. Specify:
Thermal Stress
Frozen Components
Frost Heave
Other
________________________________
High Winds
Trees/Vegetation Roots
Snow/Ice impact or Accumulation
5. Describe: __________________________
Other Natural Force Damage
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?
6a. If Yes, specify: (select all that apply)
Form PHMSA F 7100.2 (rev 1-2020)
Yes
No
Hurricane Tropical Storm
Tornado
Other ______________________________
Reproduction of this form is permitted
Page 12 of 22
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 if Excavation Damage by Third Party is selected as the sub-cause.
1. Did the operator get prior notification of the excavation activity?
Yes No
One-Call System
1a. If Yes, Notification received from: (select all that apply)
Excavator Contractor
1b. Per the primary Incident Investigator results, did State law exempt the excavator from notifying the one-call center?
Unknown
If yes, answer 1c. through 1e.
1c. select one of the following:
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: _______________________________________
1d. Exempting authority
_
1e. Exempting criteria
___
Landowner
Yes No
Complete the following mandatory CGA-DIRT Program questions if any Excavation Damage sub-cause is selected.
2. Do you want PHMSA to upload the following information to CGA-DIRT (www.cga-dirt.com)?
Yes
No
3. 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
4. Type of excavator: (select only one)
Contractor
Railroad
County
State
Developer
Utility
Farmer
Municipality
Data not collected
Occupant
Unknown/Other
5. 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
6. Type of work performed: (select only one)
Agriculture
Drainage
Grading
Natural Gas
Sewer (Sanitary/Storm)
Telecommunications
Data not collected
Cable TV
Curb/Sidewalk
Driveway
Electric
Irrigation
Landscaping
Pole
Public Transit Authority
Site Development
Steam
Traffic Signal
Traffic Sign
Unknown/Other
Form PHMSA F 7100.2 (rev 1-2020)
Building Construction
Engineering/Surveying
Liquid Pipeline
Railroad Maintenance
Storm Drain/Culvert
Water
Reproduction of this form is permitted
Building Demolition
Fencing
Milling
Road Work
Street Light
Waterway Improvement
Page 13 of 22
7. Was the One-Call Center notified?
Yes
*7a. If Yes, specify ticket number: /
/
No
/
/
/
/
If No, skip to question 11
/
/
/
/
/
/
/
/
/
/
/
/
/
*7b. If this is a State where more than a single One-Call Center exists, list the name of the One-Call Center notified:
_____________________________________________________________
8. Type of Locator:
Utility Owner
Contract Locator
Data not collected
Unknown/Other
No
Data not collected
Unknown/Other
9. Were facility locate marks visible in the area of excavation?
No
10. Were facilities marked correctly?
No
11. Did the damage cause an interruption in service?
16a. If Yes, specify duration of the interruption:
Yes
Yes
Yes
Data not collected
Data not collected
Unknown/Other
Unknown/Other
/___/___/___/___/ hours
12. Description of the CGA-DIRT Root Cause (select only the one predominant first level CGA-DIRT Root Cause and then, where available as a
choice, the one predominant second level CGA-DIRT Root Cause as well):
One-Call Notification Practices Not Sufficient: (select only one)
No notification made to the One-Call Center
Notification to One-Call Center made, but not sufficient
Wrong information provided
Locating Practices Not Sufficient: (select only one)
Facility could not be found/located
Facility marking or location not sufficient
Facility was not located or marked
Incorrect facility records/maps
Excavation Practices Not Sufficient: (select only one)
Excavation practices not sufficient (other)
Failure to maintain clearance
Failure to maintain the marks
Failure to support exposed facilities
Failure to use hand tools where required
Failure to verify location by test-hole (pot-holing)
Improper backfilling
One-Call Notification Center Error
Abandoned Facility
Deteriorated Facility
Previous Damage
Data Not Collected
Other / None of the Above (explain)____________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Form PHMSA F 7100.2 (rev 1-2020)
Reproduction of this form is permitted
Page 14 of 22
G4 - Other Outside Force Damage - only one sub-cause can be picked from shaded left-hand column
Nearby Industrial, Man-made, or Other Fire/Explosion as
Primary Cause of Incident
Damage by Car, Truck, or Other Motorized
1. Vehicle/Equipment operated by: (select only one)
Operator
Operator’s Contractor
Third Party
If this sub-section is picked, please complete questions 5-11 below
Damage by Boats, Barges, Drilling Rigs, or Other Maritime
2. Select one or more of the following IF an extreme weather event
was a factor:
Hurricane
Tropical Storm
Tornado
Heavy Rains/Flood
Other
______________________________
Vehicle/Equipment NOT Engaged in Excavation
Equipment or Vessels Set Adrift or Which Have Otherwise
Lost Their Mooring
Routine or Normal Fishing or Other Maritime Activity NOT
Engaged in Excavation
Electrical Arcing from Other Equipment or Facility
Previous Mechanical Damage NOT Related to Excavation
Intentional Damage
3. Specify:
Other Outside Force Damage
4. Describe:
________________________________________________________
_
Vandalism
Terrorism
Theft of transported commodity Theft of equipment
Other ________________________________________
Complete the following if Damage by Car, Truck, or Other Motorized Vehicle/Equipment NOT Engaged in Excavation sub-cause is selected.
5. Was the driver of the vehicle or equipment issued one or more citations related to the incident?
If 5 is Yes, what was the nature of the citations (select all that apply)
5a. Excessive Speed
5b. Reckless Driving
5c. Driving Under the Influence
5e. Other, describe: _______________________
6. Was the driver under control of the vehicle at the time of the collision?
Yes
Yes
No Unknown
No Unknown
7. Estimated speed of the vehicle at the time of impact (miles per hour)?_______________or Unknown
8. Type of vehicle? (select only one)
Motorcycle/ATV
Passenger Car Small Truck Bus Large Truck
9. Where did the vehicle travel from to hit the pipeline facility? (select only one)
Roadway
Driveway
Parking Lot
Loading Dock
Off-Road
10. Shortest distance from answer in 9. to the damaged pipeline facility (in feet): .________________________
11. At the time of the Incident, were protections installed to protect the damaged pipeline facility from vehicular damage?
Yes
No
If 11. is Yes, specify type of protection (select all that apply):
11a. Bollards/Guard Posts
11b. Barricades – include Jersey barriers and fences in instructions
11c. Guard Rails
11d. Other, describe: _________________________________
Form PHMSA F 7100.2 (rev 1-2020)
Reproduction of this form is permitted
Page 15 of 22
Use this section to report material failures ONLY IF the “Item
Involved in Incident” (from PART C, Question 3) is “Pipe” or
“Weld.”
G5 - Material Failure of Pipe or Weld
Only one sub-cause can be picked from shaded left-hand column
1. The sub-cause selected below is based on the following: (select all that apply)
Field Examination
Determined by Metallurgical Analysis
Other Analysis__________________________
Sub-cause is Tentative or Suspected; Still Under Investigation (Supplemental Report required)
Design-, Construction-, Installation-, or Fabrication-related
Original Manufacturing-related
(NOT girth weld or other welds formed in the field)
2. List contributing factors: (select all that apply)
Fatigue- or Vibration-related:
Mechanically-induced prior to installation (such as during
transport of pipe)
Mechanical Vibration
Pressure-related
Thermal
Other __________________________________
Mechanical Stress
Other __________________________________
3. Specify:
Cracking
Environmental Cracking-related
Stress Corrosion Cracking
Sulfide Stress
Hydrogen Stress Cracking Hard Spot
Other ____________________________________
Complete the following if any Material Failure of Pipe or Weld sub-cause is selected.
4. Additional factors (select all that apply): Dent Gouge Pipe Bend
Lamination
Buckle
Wrinkle
Misalignment
Other __________________________________
5. Post-construction pressure test value (psig) /
Form PHMSA F 7100.2 (rev 1-2020)
/
/
/
/
OR
Arc Burn Crack
Burnt Steel
Lack of Fusion
Unknown
Reproduction of this form is permitted
Page 16 of 22
G6 - Equipment Failure - only one sub-cause can be picked from 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
ESD System Failure
Other
________________________________________________________
Compressor or Compressor-related Equipment
2. Specify: Seal/Packing Failure
Crack in Body
Appurtenance Failure
Vessel Failure
Body Failure
Pressure
Other
_______________________________________________________
Threaded Connection/Coupling Failure
3. Specify: Pipe Nipple
Valve Threads
Mechanical Coupling
Threaded Pipe Collar
Threaded Fitting
Other
_______________________________________________________
Non-threaded Connection Failure
4. Specify: O-Ring
Gasket
compressor seal) or Packing
Seal (NOT
Other____________________________________________________
___
Defective or Loose Tubing or Fitting
Failure of Equipment Body (except Compressor), Vessel
Plate, or other Material
5. Describe:
________________________________________________________
___
________________________________________________________
_______________
Other Equipment Failure
Complete the following if any Equipment Failure sub-cause is selected.
6. Additional factors that contributed to the equipment failure: (select all that apply)
Excessive vibration
Overpressurization
No support or loss of support
Manufacturing defect
Loss of electricity
Improper installation
Improper maintenance
Mismatched items (different manufacturer for tubing and tubing fittings)
Dissimilar metals
Breakdown of soft goods due to compatibility issues with transported gas/fluid
Valve vault or valve can contributed to the release
Alarm/status failure
Misalignment
Thermal stress
Erosion/abnormal wear
Other _______________________________________________________
Form PHMSA F 7100.2 (rev 1-2020)
Reproduction of this form is permitted
Page 17 of 22
G7 - Incorrect Operation - only one sub-cause can be picked from shaded left-hand column
Damage by Operator or Operator’s Contractor NOT Related
to Excavation and NOT due to Motorized Vehicle/Equipment
Damage
Underground Gas Storage, Pressure Vessel, or Cavern
Allowed or Caused to Overpressure
1. Specify: Valve Misalignment
Incorrect Reference
Data/Calculation
Miscommunication
Inadequate Monitoring
Other ____________________________________
Valve Left or Placed in Wrong Position, but NOT Resulting
in an Overpressure
Pipeline or Equipment Overpressured
Equipment Not Installed Properly
Wrong Equipment Specified or Installed
Other Incorrect Operation
2. Describe:
__________________________________________________
Complete the following if any Incorrect Operation sub-cause is selected.
3. Was this Incident related to: (select all that apply)
Inadequate procedure
No procedure established
Failure to follow procedure
Other: ______________________________________________________
4. What category type was the activity that caused the Incident:
Construction
Commissioning
Decommissioning
Right-of-Way activities
Routine maintenance
Other maintenance
Normal operating conditions
Non-routine operating conditions (abnormal operations or emergencies)
5. Was the task(s) that led to the Incident identified as a covered task in your Operator Qualification Program? Yes
No
5a. If Yes, were the individuals performing the task(s) qualified for the task(s)?
Yes, they were qualified for the task(s)
No, but they were performing the task(s) under the direction and observation of a qualified individual
No, they were not qualified for the task(s) nor were they performing the task(s) under the direction and observation of a qualified
individual
G8 – Other Incident Cause - only one sub-cause can be picked from shaded left-hand column
Miscellaneous
1. Describe: _____
_________________________________________
Unknown
2. Specify:
Form PHMSA F 7100.2 (rev 1-2020)
Investigation complete, cause of Incident unknown
Mandatory comment field:
________________________________________
Still under investigation, cause of Incident to be
determined*
(*Supplemental Report required)
Reproduction of this form is permitted
Page 18 of 22
PART J – INTEGRITY INSPECTIONS
Complete the following if the “Item Involved in Accident” (from PART C, Question 3) is Pipe or Weld and the “Cause” (from Part G) is:
Corrosion (any subCause in Part G1); or
Previous Damage due to Excavation Activity (subCause in Part G3); or
Previous Mechanical Damage NOT Related to Excavation (subCause in Part G4); or
Material Failure of Pipe or Weld (any subCause in Part G5)
J1. Have internal inspection tools collected data at the point of the Incident?
Yes No
J1a. If Yes, for each tool and technology used provide the information below for the most recent and previous tool runs:
Axial Magnetic Flux Leakage
Most recent run Year:
Free Swimming Tethered
Metal Loss Hard Spots Girth Weld Anomalies
Other Describe:
If Metal Loss, specify (select only one): High Resolution
Standard Resolution
Other Describe:
Most recent run Propulsion Method (select only one):
Most recent run Attuned to Detect (select only one):
Previous run Year:
Free Swimming Tethered
Metal Loss Hard Spots Girth Weld Anomalies
Other Describe:
If Metal Loss, specify (select only one): High Resolution
Standard Resolution
Other Describe:
Previous run Propulsion Method (select only one):
Previous run Attuned to Detect (select only one):
Circumferential/Transverse Wave Magnetic Flux Leakage
Most recent run Year:
Free Swimming Tethered
High Resolution Standard Resolution
Other Describe:
Most recent run Propulsion Method (select only one):
Most recent run Resolution (select only one):
Previous run Year:
Previous run Propulsion Method (select only one):
Previous run Resolution (select only one):
Free Swimming Tethered
High Resolution Standard Resolution
Other Describe:
Ultrasonic
Most recent run Year:
Free Swimming Tethered
Wall Measurement Crack
Other Describe:
Most recent run Propulsion Method (select only one):
Most recent run Attuned to (select only one)
If Attuned to Wall Measurement, most recent run Metal Loss Resolution (select only one):
Standard Resolution
Previous run Year:
Other Describe:
Previous run Propulsion Method (select only one):
Most recent run Attuned to (select only one)
Free Swimming Tethered
Wall Measurement Crack
Other Describe:
If Attuned to Wall Measurement, most recent run Metal Loss Resolution (select only one):
Standard Resolution
Form PHMSA F 7100.2 (rev 1-2020)
Other Describe:
Reproduction of this form is permitted
Page 19 of 22
Geometry/Deformation
Most recent run Year:
Free Swimming Tethered
High Resolution Standard Resolution
Most recent run Resolution (select only one):
Other Describe:
Most recent run Measurement Cups (select only one): Inside ILI Cups
No Cups
Most recent run Propulsion Method (select only one):
Previous run Year:
Free Swimming Tethered
High Resolution Standard Resolution
Other Describe:
Previous run Measurement Cups (select only one): Inside ILI Cups
No Cups
Previous run Propulsion Method (select only one):
Previous run Resolution (select only one):
Electromagnetic Acoustic Transducer (EMAT)
Most recent run Year:
Most recent run Propulsion Method (select only one):
Previous run Year:
Previous run Propulsion Method (select only one):
Free Swimming Tethered
Free Swimming Tethered
Cathodic Protection Current Measurement (CPCM)
Most recent run Year:
Most recent run Propulsion Method (select only one):
Previous run Year:
Previous run Propulsion Method (select only one):
Free Swimming Tethered
Free Swimming Tethered
Other, specify tool:
Most recent run Year:
Most recent run Propulsion Method (select only one):
Previous run Year:
Previous run Propulsion Method (select only one):
Free Swimming Tethered
Free Swimming Tethered
Answer J1b only when the cause is:
Previous Damage due to Excavation Activity (subCause in Part G3); or
Previous Mechanical Damage NOT Related to Excavation (subCause in Part G4)
J1b. Do you have reason to believe that the internal inspection was completed BEFORE the damage was sustained?
Yes No
J2. Has one or more hydrotest or other pressure test been conducted since original construction at the point of the Incident?
(initial post construction pressure test is NOT reported here)
Yes Most recent year tested: /
No
/
/
/
/
Test pressure (psig): /
J3. Has Direct Assessment been conducted on the pipeline segment?
Yes, and an investigative dig was conducted at the point of the Accident
Yes, but the point of the Accident was not identified as a dig site
No
If Yes, J3a. For each type, indicate the year of the most recent assessment:
External Corrosion Direct Assessment (ECDA)
/
/
Internal Corrosion Direct Assessment (ICDA)
/
/
Stress Corrosion Cracking Direct Assessment (SCCDA)
/
/
Confirmatory Direct Assessment
/
/
Other, specify type:
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
Most recent year conducted:
Most recent year conducted:
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
J4. Has one or more non-destructive examination been conducted prior to the Incident at the point of the Incident since January 1, 2002?
Yes No
J4a. If Yes, for each examination conducted, select type of non-destructive examination and indicate most recent year the examination was
conducted:
Radiography
Guided Wave Ultrasonic
Handheld Ultrasonic Tool
Wet Magnetic Particle Test
Dry Magnetic Particle Test
Other, specify type _______________
Form PHMSA F 7100.2 (rev 1-2020)
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/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
Reproduction of this form is permitted
Page 20 of 22
PART K – CONTRIBUTING FACTORS
The Apparent Cause of the accident is contained in Part G. Do not report the Apparent Cause again in this Part K. If Contributing Factors were
identified, select all that apply below and explain each in the Narrative:
Pipe/Weld Failure
External Corrosion
External Corrosion, Galvanic
Design-related
External Corrosion, Atmospheric
Construction-related
External Corrosion, Stray Current Induced
Installation-related
External Corrosion, Microbiologically Induced
Fabrication-related
External Corrosion, Selective Seam
Original Manufacturing-related
Internal Corrosion
Internal Corrosion, Corrosive Commodity
Environmental Cracking-related, Stress Corrosion Cracking
Environmental Cracking-related, Sulfide Stress Cracking
Internal Corrosion, Water drop-out/Acid
Environmental Cracking-related, Hydrogen Stress Cracking
Internal Corrosion, Microbiological
Environmental Cracking-related, Hard Spot
Internal Corrosion, Erosion
Equipment Failure
Natural Forces
Earth Movement, NOT due to Heavy Rains/Floods
Malfunction of Control/Relief Equipment
Compressor or Compressor-related Equipment
Heavy Rains/Floods
Threaded Connection/Coupling Failure
Lightning
Non-threaded Connection Failure
Temperature
Defective or Loose Tubing or Fitting
High Winds
Failure of Equipment Body (except Compressor), Vessel Plate,
or other Material
Tree/Vegetation Root
Excavation Damage
Excavation Damage by Operator (First Party)
Incorrect Operation
Excavation Damage by Operator’s Contractor (Second Party)
Excavation Damage by Third Party
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
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
Pipeline or Equipment Overpressured
Equipment Not Installed Properly
Wrong Equipment Specified or Installed
Inadequate Procedure
No procedure established
Failure to follow procedures
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 7100.2 (rev 1-2020)
Reproduction of this form is permitted
Page 21 of 22
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 Title (type or print)
Preparer’s Telephone Number
Preparer's E-mail Address
Local Contact Name: optional
Local Contact Email: optional
Preparer’s Facsimile Number
Local Contact Phone: optional
Authorized Signer Telephone Number
Authorized Signer-Name
Authorized Signer’s Title
Authorized Signer’s E-mail Address
Form PHMSA F 7100.2 (rev 1-2020)
Reproduction of this form is permitted
Page 22 of 22
File Type | application/pdf |
File Title | NOTICE: This report is required by 49 CFR Part 191 |
Author | PHMSA |
File Modified | 2021-05-17 |
File Created | 2021-05-17 |