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pdfNOTICE: This report is required by 49 CFR Part 195. Failure to report can result in a civil penalty not to exceed
$100,000 for each violation for each day that such violation persists except that the maximum civil penalty shall not
exceed $1,000,000 as provided in 49 USC 60122.
OMB NO: XXXX-XXXX
EXPIRATION DATE: mm/dd/yyyy
Report Date
ACCIDENT REPORT – HAZARDOUS LIQUID
PIPELINE SYSTEMS
U.S. Department of Transportation
Pipeline and Hazardous Materials
Safety Administration
No.
(DOT Use Only)
A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure
to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information
displays a current valid OMB Control Number. The OMB Control Number for this information collection is XXXX-XXXX. Public reporting for
this collection of information is estimated to be approximately (X) minutes 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.
Original
Report Type: (select all that apply)
PART A – KEY REPORT INFORMATION
1. Operator’s OPS-issued Operator Identification Number (OPID):
/
/
/
/
/
Supplemental
Final
/
2. Name of Operator: ______________________________________________________________________________________
3. Address of Operator:
3.a _______________________________________________________________________
(Street Address)
3.b ___________________________________________________
Moved physical address questions
for the incident to Part B, items 2-4.
(City)
3.c State: /
/
/
3.d Zip Code: /
/
/
/
/
/ - /
/
/
/
/
4. Local time (24-hr clock) and date of the Accident:
/
/
/
/
/
/
Hour
/
/
/
Month
5. Location of Accident:
Latitude:
/ / / . / /
Longitude: - / / / / . /
/
/
/
/
Day
/
/
/
/
/
/
6. National Response Center Report Number (if applicable):
/
/
/
Year
/
/
/
/
/
/
/
7. Local time (24-hr clock) and date of initial telephonic report to the
National Response Center (if applicable):
/
/
/
/
/
/
/
Hour
8. Commodity released: (select only one, based on predominant volume released)
/
/
/
Day
/
/
/
/
Year
Existing item but
expanded to
provide clarity.
Crude Oil
Refined and/or Petroleum Product (non-HVL) which is a Liquid at Ambient Conditions
Gasoline (non-Ethanol)
Diesel, Fuel Oil, Kerosene, Jet Fuel
Mixture of Refined Products (transmix or other mixture)
Other Name: __________________________________
/
Month
HVL or Other Flammable or Toxic Fluid which is a Gas at Ambient Conditions
Anhydrous Ammonia
LPG (Liquefied Petroleum Gas) / NGL (Natural Gas Liquid)
Other HVL Name: _______________________________
CO2 (Carbon Dioxide)
Biofuel / Alternative Fuel (including ethanol blends)
Ethanol Blend % Ethanol: /___/___/
Other Name: _______________________
Fuel Grade Ethanol
Biodiesel Blend (e.g. B2, B20, B100): B/___/___/___/
9.
Estimated volume of commodity released unintentionally:
/
/
/
/,/
/
/___/ . /___/___/ Barrels
10. Estimated volume of intentional and/or controlled release/blowdown:
/
/
/
/,/
/
/___/ . /___/___/ Barrels
11. Estimated volume of commodity recovered:
/
/
/
/,/
/
/___/ . /___/___/ Barrels
Form PHMSA F 7000-1 (Rev. xx-2009 )
Page 1 of 20
Reproduction of this form is permitted
12. Were there fatalities? Yes No
If Yes, specify the number in each category:
Yes No
13. Were there injuries requiring inpatient hospitalization?
If Yes, specify the number in each category:
12.a Operator employees
/
/
/
/
/
13.a Operator employees
/
/
/
/
/
12.b Contractor employees
working for the Operator
/
/
/
/
/
13.b Contractor employees
working for the Operator
/
/
/
/
/
12.c Non-Operator
emergency responders
/
/
/
/
/
13.c Non-Operator
emergency responders
/
/
/
/
/
/
/
/
/
/
12.d Workers working on the
right-of-way, but NOT
associated with this Operator
/
/
/
/
/
13.d Workers working on the
right-of-way, but NOT
associated with this Operator
12.e General public
/
/
/
/
/
13.e General public
/
/
/
/
/
12.f Total fatalities (sum of above)
/
/
/
/
/
13.f Total injuries (sum of above)
/
/
/
/
/
14. Was the pipeline/facility shut down due to the Accident?
Yes No Explain: ______________________________________________________________________________
If Yes, complete Questions 14.a and 14.b: (use local time, 24-hr clock)
14.a Local time and date of shutdown
/
/
/
/
/
/
Hour
14.b Local time pipeline/facility restarted
/
/
/
/
/
/
Hour
15. Did the commodity ignite?
Yes
No
16. Did the commodity explode?
Yes
No
17. Number of general public evacuated: /
/
/
/
/
Month
/,/
/
/
/
Month
/
/
Day
/
/
/
/
Year
/
/
/
Day
/
Still shut down*
/
Year
(*Supplemental Report required)
/___/___/
18. Time sequence: (use local time, 24-hour clock)
18.a Local time Operator identified Accident
/
/
/
/
/
/
Hour
18.b Local time Operator resources arrived on site
/
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/
Hour
/
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/
Month
/
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/
/
/
Day
/
Month
Form PHMSA F 7000-1 (Rev. xx-2009 )
/
/
Day
/
/
Year
/
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/
/
Year
Page 2 of 20
Reproduction of this form is permitted
PART B – ADDITIONAL LOCATION INFORMATION
1. Was the origin of the Accident onshore?
Yes (Complete Questions 2-12)
No
(Complete Questions 13-15)
If Onshore:
2. State: /
If Offshore:
/
/
13. Approximate water depth (ft.) at the point of the Accident:
3. Zip Code: /___/___/___/___/___/ - / _ / _ / _
4. _______________________
/_
/
5.________________________
City
County or Parish
6. Operator-designated location: (select only one)
Milepost/Valve Station (specify in shaded area below)
Survey Station No.
/ _ /___/,/ _
(specify in shaded area below)
8. Segment name/ID: __________________________________
9. Was Accident on Federal land, other than the Outer Continental
Shelf (OCS)?
Yes No
10. Location of Accident: (select only one)
Totally contained on Operator-controlled property
Originated on Operator-controlled property, but then flowed
or migrated off the property
Pipeline right-of-way
11. Area of Accident (as found): (select only one)
/_
/
In State waters
Specify: State: / / /
Area: ___________________
Block/Tract #: /___/___/___/___/
Nearest County/Parish: ________________
/___/___/___/___/___/___/___/___/___/___/___/___/___/
7. Pipeline/Facility name: _______________________________
/_
14. Origin of Accident:
On the Outer Continental Shelf (OCS)
Specify: Area: ___________________
Block #: /___/___/___/___/
15. Area of Accident: (select only one)
Shoreline/Bank crossing or shore approach
Below water, pipe buried or jetted below seabed
Below water, pipe on or above seabed
Splash Zone of riser
Portion of riser outside of Splash Zone, including riser bend
Platform
Tank, including attached appurtenances
Underground Specify:
Under soil
Under a building
Under pavement
Exposed due to excavation
In underground enclosed space (e.g., vault)
Other ____________________________
Depth-of-Cover (in): / _ /,/ _ _/ _ /_
Aboveground Specify:
/
Typical aboveground facility piping or appurtenance
Overhead crossing
In or spanning an open ditch
Inside a building
Inside other enclosed space
Other ____________________________
Transition Area Specify: Soil/air interface Wall
sleeve Pipe support or other close contact area
Other _________________________
12. Did Accident occur in a crossing?: Yes No
If Yes, specify type below:
Bridge crossing Specify: Cased Uncased
Railroad crossing
Cased
Road crossing
Cased
Water crossing
(select all that apply)
Uncased
Bored/drilled
(select all that apply)
Uncased
Bored/drilled
Specify: Cased
Uncased
Name of body of water, if commonly known:
_____________________________________
Approx. water depth (ft) at the point of the Accident:
/ _ /,/_
/_
/_
/
(select only one of the following)
Shoreline/Bank crossing
Below water, pipe in bored/drilled crossing
Below water, pipe buried below bottom (NOT in
bored/drilled crossing)
Below water, pipe on or above bottom
Form PHMSA F 7000-1 (Rev. xx-2009 )
Page 3 of 20
Reproduction of this form is permitted
PART C – ADDITIONAL FACILITY INFORMATION
1. Is the pipeline or facility:
Interstate
Intrastate
2. Part of system involved in Accident: (select only one)
Onshore Breakout Tank or Storage Vessel, Including Attached Appurtenances
Atmospheric or Low Pressure
Pressurized
Onshore Terminal/Tank Farm Equipment and Piping
Onshore Equipment and Piping Associated with Belowground Storage
Onshore Pump/Meter Station Equipment and Piping
Onshore Pipeline, Including Valve Sites
Offshore Platform/Deepwater Port, Including Platform-mounted Equipment and Piping
Offshore Pipeline, Including Riser and Riser Bend
3. Item involved in Accident: (select only one)
Pipe
Specify:
Pipe Body
3.a Nominal diameter of pipe (in):
/
3.b Wall thickness (in):
/___/___/
/
Pipe Seam
/./
/
/./___/___/___/
3.c SMYS (Specified Minimum Yield Strength) of pipe (psi):
/
/
/
/,/
/___/___/
3.d Pipe specification: _____________________________
3.e Pipe Seam
Specify: Longitudinal ERW - High Frequency
Longitudinal ERW - Low Frequency
Longitudinal ERW – Unknown Frequency
Spiral Welded ERW
Spiral Welded SAW
Lap Welded
Seamless
Single SAW
DSAW
Flash Welded
Continuous Welded
Furnace Butt Welded
Spiral Welded DSAW
Other ________________________
3.f Pipe manufacturer: _______________________________
3.g Year of manufacture: /
/
/
/
/
3.h Pipeline coating type at point of Accident
Fusion Bonded Epoxy
Specify:
Coal Tar
Asphalt
Polyolefin
Extruded Polyethylene Field Applied Epoxy Cold Applied Tape Paint
Composite
None
Other _______________________________
Weld, including heat-affected zone Specify: Pipe Girth Weld Other Butt Weld Fillet Weld Other_____________
Valve
Mainline Specify: Butterfly Check Gate Plug Ball Globe
Other __________________________
3.i Mainline valve manufacturer: ______________________________
3.j Year of manufacture: /
/
/
/
/
Relief Valve
Auxiliary or Other Valve
Pump
Meter/Prover
Scraper/Pig Trap
Sump/Separator
Repair Sleeve or Clamp
Hot Tap Equipment
Stopple Fitting
Flange
Relief Line
Auxiliary Piping (e.g. drain lines)
Tubing
Instrumentation
Tank/Vessel Specify: Single Bottom System
Double Bottom System
Tank Shell
Chime
Roof Drain System
Mixer
Pressure Vessel Head or Wall
Other ________________________________
Roof/Roof Seal
Appurtenance
Other ___________________________________
4. Year item involved in Accident was installed:
/
/
/
/
/
Form PHMSA F 7000-1 (Rev. xx-2009 )
Page 4 of 20
Reproduction of this form is permitted
5. Material involved in Accident: (select only one)
Carbon Steel
Material other than Carbon Steel Specify: ____________________________________________
6. Type of Accident involved: (select only one)
Mechanical Puncture Approx. size: /__/__/__/__/./__/in. (axial) by /__/__/__/__/./__/in. (circumferential)
Crack
Connection Failure
Seal or Packing
Other
Select Type: Pinhole
Select
Orientation:
Circumferential
Longitudinal
Other
________________________________
Approx. size: /__/__/__/__/./__/ in. (widest opening) by /__/__/__/__/__/./__/in. (length circumferentially or axially)
Leak
Overfill or Overflow
Other Describe: _______________________________________________________________________________________
Rupture
Form PHMSA F 7000-1 (Rev. xx-2009 )
Page 5 of 20
Reproduction of this form is permitted
PART D – ADDITIONAL CONSEQUENCE INFORMATION
1. Wildlife impact:
Yes No
1.a If Yes, specify all that apply:
Deleted - If yes, estimated
number of cubic yards.
Fish/aquatic
Birds
Terrestrial
2. Soil contamination:
Yes No
3. Long term impact assessment performed or planned:
Yes No
4. Anticipated remediation: Yes No (not needed)
4.a If Yes, specify all that apply:
Surface water
5. Water contamination:
Groundwater Soil Vegetation Wildlife
Yes (Complete 5.a – 5.c below)
No
5.a Specify all that apply:
Ocean/Seawater
Surface
Groundwater
Drinking water
(Select one or both)
Private Well Public Water Intake
5.b Estimated amount released in or reaching water:
/
/
/
/,/
/
/___/./___/___/ Barrels
5.c Name of body of water, if commonly known: __________________________________________
6. At the location of this Accident, had the pipeline segment or facility been identified as one that “could affect” a High Consequence Area
(HCA) as determined in the Operator’s Integrity Management Program?
Yes No
7. Did the released commodity reach or occur in one or more High Consequence Area (HCA)?
Yes
No
7.a If Yes, specify HCA type(s): (select all that apply)
Commercially Navigable Waterway
Was this HCA identified in the “could affect” determination for this Accident site in the Operator’s Integrity Management Program?
Yes No
High Population Area
Was this HCA identified in the “could affect” determination for this Accident site in the Operator’s Integrity Management Program?
Yes No
Other Populated Area
Was this HCA identified in the “could affect” determination for this Accident site in the Operator’s Integrity Management Program?
Yes No
Unusually Sensitive Area (USA) – Drinking Water
Was this HCA identified in the “could affect” determination for this Accident site in the Operator’s Integrity Management Program?
Yes No
Unusually Sensitive Area (USA) – Ecological
Was this HCA identified in the “could affect” determination for this Accident site in the Operator’s Integrity Management Program?
Yes No
8. Estimated cost to Operator:
8.a Estimated cost of public and non-Operator private property damage
paid/reimbursed by the Operator
$/
/
/
/,/
/
/
/,/
/
/
8.b Estimated cost of commodity lost
$/
/
/
/,/
/
/
/,/
/
/
/
8.c Estimated cost of Operator’s property damage & repairs
$/
/
/
/,/
/
/
/,/
/
/
/
/
8.d Estimated cost of Operator’s emergency response
$/
/
/
/,/
/
/
/,/
/
/
/
8.e Estimated cost of Operator’s environmental remediation
$/
/
/
/,/
/
/
/,/
/
/
/
8.f Estimated other costs
$/
/
/
/,/
/
/
/,/
/
/
/
/,/
/
/
/,/
/
/
/
Describe ___________________________________________________
8.g Estimated total costs (sum of above)
$/
/
/
Form PHMSA F 7000-1 (Rev. xx-2009 )
Page 6 of 20
Reproduction of this form is permitted
PART E – ADDITIONAL OPERATING INFORMATION
1. Estimated pressure at the point and time of the Accident (psig):
/
/
/,/
/
/
/
2. Maximum Operating Pressure (MOP) at the point and time of the Accident (psig) :
/
/
/,/
/
/
/
3. Describe the pressure on the system or facility relating to the Accident: (select only one)
Pressure did not exceed MOP
Pressure exceeded MOP, but did not exceed 110% of MOP
Pressure exceeded 110% of MOP
4. Not including pressure reductions required by PHMSA regulations (such as for repairs and pipe movement), was the system or facility
relating to the Accident operating under an established pressure restriction with pressure limits below those normally allowed by the MOP?
No
Yes (Complete 4.a and 4.b below)
4.a Did the pressure exceed this established pressure restriction?
Yes
No
4.b Was this pressure restriction mandated by PHMSA or the State?
PHMSA
State
Not mandated
5. Was “Onshore Pipeline, Including Valve Sites” OR “Offshore Pipeline, Including Riser and Riser Bend” selected in PART C, Question 2?
No
Yes
(Complete 5.a – 5.f below)
5.a Type of upstream valve used to initially isolate release source:
Manual
Automatic
Remotely Controlled
5.b Type of downstream valve used to initially isolate release source:
Manual Automatic
Check Valve
Remotely Controlled
5.c Length of segment initially isolated between valves (ft):
/
/
/
/,/___/___/___/
5.d Is the pipeline configured to accommodate internal inspection tools?
Yes
No Which physical features limit tool accommodation? (select all that apply)
Changes in line pipe diameter
Presence of unsuitable mainline valves
Tight or mitered pipe bends
Other passage restrictions (i.e. unbarred tee’s, projecting instrumentation, etc.)
Extra thick pipe wall (applicable only for magnetic flux leakage internal inspection tools)
Other Describe:__________________________________________________________________
5.e For this pipeline, are there operational factors which significantly complicate the execution of an internal inspection tool run?
No
Yes
Which operational factors complicate execution?
(select all that apply)
Excessive debris or scale, wax, or other wall build-up
Low operating pressure(s)
Low flow or absence of flow
Incompatible commodity
Other Describe:__________________________________________________________________
5.f Function of pipeline system: (select only one)
> 20% SMYS Regulated Trunkline/Transmission
≤ 20% SMYS Regulated Trunkline/Transmission
≤ 20% SMYS “Unregulated” Trunkline/Transmission
> 20% SMYS Regulated Gathering
≤ 20% SMYS Regulated Gathering
≤ 20% SMYS “Unregulated” Gathering
Form PHMSA F 7000-1 (Rev. xx-2009 )
Page 7 of 20
Reproduction of this form is permitted
6. Was a Supervisory Control and Data Acquisition (SCADA)-based system in place on the pipeline or facility involved in the Accident?
No
Yes 6.a Was it operating at the time of the Accident?
Yes
No
6.b Was it fully functional at the time of the Accident?
Yes
No
6.c Did SCADA-based information (such as alarm(s), alert(s), event(s), and/or volume calculations) assist with the
Yes
No
detection of the Accident?
6.d Did SCADA-based information (such as alarm(s), alert(s), event(s), and/or volume calculations) assist with the
Yes
No
confirmation of the Accident?
7. Was a CPM leak detection system in place on the pipeline or facility involved in the Accident?
No
Yes
7.a Was it operating at the time of the Accident?
Yes
No
7.b Was it fully functional at the time of the Accident?
Yes
No
7.c Did CPM leak detection system information (such as alarm(s), alert(s), event(s), and/or volume calculations) assist
with the detection of the Accident?
Yes
No
7.d Did CPM leak detection system information (such as alarm(s), alert(s), event(s), and/or volume calculations) assist
Yes
No
with the confirmation of the Accident?
8. How was the Accident initially identified for the Operator? (select only one)
CPM leak detection system or 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 Accident
Other _________________________________________________
8.a If “Controller”, “Local Operating Personnel, including contractors”, “Air Patrol”, or “Ground Patrol by Operator or its contractor” is
selected in Question 8, specify the following: (select only one)
Operator employee
Contractor working for the Operator
9. 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
Accident? (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 Accident
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 7000-1 (Rev. xx-2009 )
Page 8 of 20
Reproduction of this form is permitted
PART F – DRUG & ALCOHOL TESTING INFORMATION
1. As a result of this Accident, were any Operator employees tested under the post-accident drug and alcohol testing requirements of DOT’s
Drug & Alcohol Testing regulations?
No
Yes
1.a Specify how many were tested:
/
/
/
1.b Specify how many failed:
/
/
/
2. As a result of this Accident, were any Operator contractor employees tested under the post-accident drug and alcohol testing requirements
of DOT’s Drug & Alcohol Testing regulations?
No
Yes
2.a Specify how many were tested:
2.b
Specify how many failed:
/
/
/
/
/
/
Form PHMSA F 7000-1 (Rev. xx-2009 )
Page 9 of 20
Reproduction of this form is permitted
PART G – APPARENT CAUSE
Select only one box from PART G in the shaded column on the left representing the
APPARENT Cause of the Accident, and answer the questions on the right. Describe
secondary, contributing, or root causes of the Accident in the narrative (PART H).
G1 - Corrosion Failure – only one sub-cause can be picked from shaded left-hand column
External Corrosion
1. Results of visual examination:
Listed as "cause of corrosion" on current
Localized Pitting General Corrosion
form. Deleted - Cathodic protection
Other _______________________________________________
disrupted & stress corrosion cracking
2. Type of corrosion: (select all that apply)
Galvanic Atmospheric Stray Current Microbiological Selective Seam
Other ________________________________________________
3. The type(s) of corrosion selected in Question 2 is based on the following: (select all that
apply)
Field examination
Determined by metallurgical analysis
Other _____________________________________________________________
4. Was the failed item buried under the ground?
Yes 4.a Was failed item considered to be under cathodic protection at the time of
the Accident?
Yes Year protection started: / / / / /
No
4.b Was shielding, tenting, or disbonding of coating evident at the point of
the Accident?
Yes No
4.c Has one or more Cathodic Protection Survey been conducted at
the point of the Accident?
Yes, CP Annual Survey Most recent year conducted:
/ / /
Yes, Close Interval Survey Most recent year conducted:
Yes, Other CP Survey Most recent year conducted:
No
No
4.d Was the failed item externally coated or painted?
/
/
/
/
/
/
/
/
/
/
/
/
Yes No
5. Was there observable damage to the coating or paint in the vicinity of the corrosion?
Yes No
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
Other ________________________________________________
Erosion
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
Other_____________________________________
10. Was the commodity treated with corrosion inhibitors or biocides?
11. Was the interior coated or lined with protective coating?
Yes No
Yes No
12. Were cleaning/dewatering pigs (or other operations) routinely utilized?
Not applicable - Not mainline pipe
Yes
No
13. Were corrosion coupons routinely utilized?
Not applicable - Not mainline pipe
Yes
No
Complete the following if any Corrosion Failure sub-cause is selected AND the “Item Involved in Accident” (from PART C, Question 3) is
Tank/Vessel.
14. List the year of the most recent inspections:
14.a API Std 653 Out-of-Service Inspection
14.b API Std 653 In-Service Inspection
/
/
/
/
/
/
/
/
/
/
No Out-of-Service Inspection completed
No In-Service Inspection completed
Form PHMSA F 7000-1 (Rev. xx-2009 )
Page 10 of 20
Reproduction of this form is permitted
Complete the following if any Corrosion Failure sub-cause is selected AND the “Item Involved in Accident” (from PART C, Question 3) is
Pipe or Weld.
15. Has one or more internal inspection tool collected data at the point of the Accident?
Yes No
15.a. If Yes, for each tool used, select type of internal inspection tool and indicate most recent year run:
Magnetic Flux Leakage Tool
Ultrasonic
Geometry
Caliper
Crack
Hard Spot
Combination Tool
Transverse Field/Triaxial
Other __________________________
/
/
/
/
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15 & 15a are similar to Part C
3f & g on the current form.
16. Has one or more hydrotest or other pressure test been conducted since original construction at the point of the Accident?
Yes Most recent year tested: / / / / /
Test pressure (psig): /
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No
17. Has one or more Direct Assessment been conducted on this 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
Most recent year conducted:
Most recent year conducted:
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18. Has one or more non-destructive examination been conducted at the point of the Accident since January 1, 2002?
Yes No
18.a If Yes, for each examination conducted since January 1, 2002, select type of non-destructive examination and indicate most recent
year the examination was conducted:
Radiography
Guided Wave Ultrasonic
Handheld Ultrasonic Tool
Wet Magnetic Particle Test
Dry Magnetic Particle Test
Other __________________________
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G2 - Natural Force Damage - only one sub-cause can be picked from shaded left-hand column
Earthquake Subsidence Landslide Other ____________________
Earth Movement, NOT due to
Heavy Rains/Floods
1. Specify:
Heavy Rains/Floods
2. Specify:
Washout/Scouring Flotation Mudslide Other _________________
Lightning
3. Specify:
Direct hit
Temperature
4. Specify:
Thermal Stress
Frozen Components
High Winds
Other Natural Force Damage
Separate item on current form.
Secondary impact such as resulting nearby fires
Frost Heave
Other ________________________________
5. Describe: _________________________________________________
Complete the following if any Natural Force Damage sub-cause is selected.
6. Were the natural forces causing the Accident generated in conjunction with an extreme weather event?
6.a If Yes, specify: (select all that apply)
Yes
No
Hurricane
Tropical Storm
Tornado
Other ______________________________
Form PHMSA F 7000-1 (Rev. xx-2009 )
Page 11 of 20
Reproduction of this form is permitted
G3 – Excavation Damage - only one sub-cause can be picked from shaded left-hand column
Excavation Damage by Operator
(First Party)
Excavation Damage by Operator’s
Contractor (Second Party)
Excavation Damage by Third Party
Previous Damage due to Excavation
Activity
Complete Questions 1-5 ONLY IF the “Item Involved in Accident” (from PART C,
Question 3) is Pipe or Weld.
1. Has one or more internal inspection tool collected data at the point of the Accident?
Yes No
New to "Excavation
Damage" cause category
but similar questions
appear on current liquid
accident form.
1.a If Yes, for each tool used, select type of internal inspection tool and indicate most
recent year run:
Magnetic Flux Leakage
Ultrasonic
Geometry
Caliper
Crack
Hard Spot
Combination Tool
Transverse Field/Triaxial
Other _____________________
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2. Do you have reason to believe that the internal inspection was completed BEFORE the
damage was sustained? Yes No
3. Has one or more hydrotest or other pressure test been conducted since original construction
at the point of the Accident?
Yes Most recent year tested:
Test pressure (psig):
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No
4. Has one or more Direct Assessment been conducted on the pipeline segment?
Yes, and an investigative dig was conducted at the point of the Accident
Most recent year conducted: / / / / /
Yes, but the point of the Accident was not identified as a dig site
Most recent year conducted: / / / / /
No
5. Has one or more non-destructive examination been conducted at the point of the Accident
since January 1, 2002?
Yes No
5.a If Yes, for each examination conducted since January 1, 2002, select type of nondestructive examination and indicate most recent year the examination was conducted:
Radiography
Guided Wave Ultrasonic
Handheld Ultrasonic Tool
Wet Magnetic Particle Test
Dry Magnetic Particle Test
Other __________________________
Complete the following if Excavation Damage by Third Party is selected as the sub-cause.
6. Did the Operator get prior notification of the excavation activity?
6.a If Yes, Notification received from: (select all that apply)
Yes No
One-Call System
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Date of notification was
removed.
Excavator
Form PHMSA F 7000-1 (Rev. xx-2009 )
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Contractor
Landowner
Page 12 of 20
Reproduction of this form is permitted
Complete the following mandatory CGA-DIRT Program questions if any Excavation Damage sub-cause is selected.
7. Do you want PHMSA to upload the following information to CGA-DIRT (www.cga-dirt.com)?
Yes
No
8. Right-of-Way where event occurred: (select all that apply)
Public Specify: City Street State Highway County Road Interstate Highway Other
Private Specify: Private Landowner Private Business Private Easement
Pipeline Property/Easement
The CGA-DIRT section (#s7-17) is new
Power/Transmission Line
to the form although some items similar
Railroad
to the CGA-DIRT questions appear on
Dedicated Public Utility Easement
Federal Land
the current form.
Data not collected
Unknown/Other
9. Type of excavator: (select only one)
Contractor
Railroad
County
State
Developer
Utility
Farmer
Municipality
Data not collected
Occupant
Unknown/Other
10. Type of excavation equipment: (select only one)
Auger
Explosives
Probing Device
Backhoe/Trackhoe
Farm Equipment
Trencher
Boring
Grader/Scraper
Vacuum Equipment
Drilling
Directional Drilling
Hand Tools
Milling Equipment
Data not collected Unknown/Other
11. Type of work performed: (select only one)
Agriculture
Drainage
Grading
Natural Gas
Sewer (Sanitary/Storm)
Telecommunications
Data not collected
Cable TV
Curb/Sidewalk
Driveway
Electric
Irrigation
Landscaping
Pole
Public Transit Authority
Site Development
Steam
Traffic Signal
Traffic Sign
Unknown/Other
12. Was the One-Call Center notified?
Yes
Building Construction
Engineering/Surveying
Liquid Pipeline
Railroad Maintenance
Storm Drain/Culvert
Water
Building Demolition
Fencing
Milling
Road Work
Street Light
Waterway Improvement
No
12.a If Yes, specify ticket number: /__/__/__/__/__/__/__/__/__/__/__/__/__/__/__/__/__/__/
12.b If this is a State where more than a single One-Call Center exists, list the name of the One-Call Center notified:
_____________________________________________________________
Contract Locator
Data not collected
Unknown/Other
14. Were facility locate marks visible in the area of excavation?
No
Yes
Data not collected
Unknown/Other
15. Were facilities marked correctly?
No
Yes
Data not collected
Unknown/Other
No
Yes
Data not collected
Unknown/Other
13. Type of Locator:
Utility Owner
16. Did the damage cause an interruption in service?
16.a If Yes, specify duration of the interruption:
/___/___/___/___/ hours
(This CGA-DIRT section continued on next page with Question 17.)
Form PHMSA F 7000-1 (Rev. xx-2009 )
Page 13 of 20
Reproduction of this form is permitted
17. Description of the CGA-DIRT Root Cause (select only the one predominant first level CGA-DIRT Root Cause and then, where available
as a choice, the one predominant second level CGA-DIRT Root Cause as well):
One-Call Notification Practices Not Sufficient: (select only one)
No notification made to the One-Call Center
Notification to One-Call Center made, but not sufficient
Wrong information provided
Locating Practices Not Sufficient: (select only one)
Facility could not be found/located
Facility marking or location not sufficient
Facility was not located or marked
Incorrect facility records/maps
Excavation Practices Not Sufficient: (select only one)
Excavation practices not sufficient (other)
Failure to maintain clearance
Failure to maintain the marks
Failure to support exposed facilities
Failure to use hand tools where required
Failure to verify location by test-hole (pot-holing)
Improper backfilling
One-Call Notification Center Error
Abandoned Facility
Deteriorated Facility
Previous Damage
Data Not Collected
Other / None of the Above (explain)_____________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
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Form PHMSA F 7000-1 (Rev. xx-2009 )
Page 14 of 20
Reproduction of this form is permitted
G4 - Other Outside Force Damage - only one sub-cause can be picked from shaded left-hand column
Nearby Industrial, Man-made, or
Other Fire/Explosion as Primary
Cause of Accident
Damage by Car, Truck, or Other
Motorized Vehicle/Equipment NOT
Engaged in Excavation
1. Vehicle/Equipment operated by: (select only one)
Operator
Operator’s Contractor
Damage by Boats, Barges, Drilling
Rigs, or Other Maritime Equipment or
Vessels Set Adrift or Which Have
Otherwise Lost Their Mooring
2. Select one or more of the following IF an extreme weather event was a factor:
Hurricane
Tropical Storm
Tornado
Heavy Rains/Flood
Other ______________________________
Routine or Normal Fishing or Other
Maritime Activity NOT Engaged in
Excavation
Electrical Arcing from Other
Equipment or Facility
Previous Mechanical Damage NOT
Related to Excavation
Third Party
Complete Questions 3-7 ONLY IF the “Item Involved in Accident” (from PART C,
Question 3) is Pipe or Weld.
3. Has one or more internal inspection tool collected data at the point of the Accident?
Yes No
3.a If Yes, for each tool used, select type of internal inspection tool and indicate most
recent year run:
New to "Other Outside Force
Damage" cause category but
similar questions appear on
current form.
Magnetic Flux Leakage
Ultrasonic
Geometry
Caliper
Crack
Hard Spot
Combination Tool
Transverse Field/Triaxial
Other _____________________
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4. Do you have reason to believe that the internal inspection was completed BEFORE the
damage was sustained? Yes No
5. Has one or more hydrotest or other pressure test been conducted since original construction
at the point of the Accident?
Yes Most recent year tested:
Test pressure (psig):
/
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/, /
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No
6. Has one or more Direct Assessment been conducted on the pipeline segment?
Yes, and an investigative dig was conducted at the point of the Accident
Most recent year conducted: / / / / /
Yes, but the point of the Accident was not identified as a dig site
Most recent year conducted: / / / / /
No
(This section continued on next page with Question 7.)
Form PHMSA F 7000-1 (Rev. xx-2009 )
Page 15 of 20
Reproduction of this form is permitted
7. Has one or more non-destructive examination been conducted at the point of the Accident
since January 1, 2002?
Yes No
7.a If Yes, for each examination conducted since January 1, 2002, select type of nondestructive examination and indicate most recent year the examination was conducted:
Radiography
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Guided Wave Ultrasonic
Handheld Ultrasonic Tool
Wet Magnetic Particle Test
Dry Magnetic Particle Test
Other __________________________
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Intentional Damage
8. Specify:
Other Outside Force Damage
9. Describe: _________________________________________________________
Vandalism
Terrorism
Theft of transported commodity Theft of equipment
Other ________________________________________
Form PHMSA F 7000-1 (Rev. xx-2009 )
Page 16 of 20
Reproduction of this form is permitted
Listed as "Material and Welds"
on current form.
Use this section to report material failures ONLY IF the “Item Involved in
Accident” (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
Construction-, Installation-, or
Fabrication-related
Original Manufacturing-related
(NOT girth weld or other welds
formed in the field)
Environmental Cracking-related
(Supplemental Report required)
2. List contributing factors: (select all that apply)
Fatigue- or Vibration-related:
Mechanically-induced prior to installation (such as during transport of pipe)
Mechanical Vibration
Pressure-related
Thermal
Other __________________________________
Mechanical Stress
Other __________________________________
3. Specify: Stress Corrosion Cracking
Sulfide Stress Cracking
Hydrogen Stress Cracking
Other ______________________________
Complete the following if any Material Failure of Pipe or Weld sub-cause is selected.
4. Additional factors: (select all that apply) Dent Gouge Pipe Bend
Lamination
Buckle
Wrinkle
Misalignment
Other __________________________________
Arc Burn Crack
Burnt Steel
5. Has one or more internal inspection tool collected data at the point of the Accident?
Lack of Fusion
Yes No
5.a If Yes, for each tool used, select type of internal inspection tool and indicate most recent year run:
Magnetic Flux Leakage Tool
Ultrasonic
Geometry
Caliper
Crack
Hard Spot
Combination Tool
Transverse Field/Triaxial
Other __________________________
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6. Has one or more hydrotest or other pressure test been conducted since original construction at the point of the Accident?
Yes Most recent year tested: / / / / /
Test pressure (psig): /
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No
7. Has one or more Direct Assessment been conducted on the pipeline segment?
Yes, and an investigative dig was conducted at the point of the Accident
Yes, but the point of the Accident was not identified as a dig site
No
Most recent year conducted:
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Most recent year conducted:
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8. Has one or more non-destructive examination(s) been conducted at the point of the Accident since January 1, 2002?
Yes No
8.a If Yes, for each examination conducted since January 1, 2002, select type of non-destructive examination and indicate most recent
year the examination was conducted:
Radiography
Guided Wave Ultrasonic
Handheld Ultrasonic Tool
Wet Magnetic Particle Test
Dry Magnetic Particle Test
Other ________________________________
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Form PHMSA F 7000-1 (Rev. xx-2009 )
Page 17 of 20
Reproduction of this form is permitted
G6 - Equipment Failure - only one sub-cause can be picked from shaded left-hand column
Malfunction of Control/Relief
Equipment
1. Specify: (select all that apply)
Control Valve
Instrumentation
SCADA
Communications Block Valve
Check Valve
Relief Valve
Power Failure
Stopple/Control Fitting
ESD System Failure
Other ________________________________________________________
Pump or Pump-related Equipment
2. Specify: Seal/Packing Failure Body Failure Crack in Body
Appurtenance Failure
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
Seal (NOT pump seal) or Packing
Other ________________________________________________________
Defective or Loose Tubing or Fitting
Failure of Equipment Body (except
Pump), Tank Plate, or other Material
Other Equipment Failure
Replaced "Seal Failure" on current liquid form.
5. Describe: ___________________________________________________________
______________________________________________________________________
Complete the following if any Equipment Failure sub-cause is selected.
6. Additional factors that contributed to the equipment failure: (select all that apply)
Excessive vibration
Overpressurization
No support or loss of support
Manufacturing defect
Loss of electricity
Improper installation
Mismatched items (different manufacturer for tubing and tubing fittings)
Dissimilar metals
Breakdown of soft goods due to compatibility issues with transported commodity
Valve vault or valve can contributed to the release
Alarm/status failure
Misalignment
Thermal stress
Other _______________________________________________________
Form PHMSA F 7000-1 (Rev. xx-2009 )
Page 18 of 20
Reproduction of this form is permitted
G7 - Incorrect Operation - only one sub-cause can be picked from shaded left-hand column
Damage by Operator or Operator’s
Contractor NOT Related to
Excavation and NOT due to
Motorized Vehicle/Equipment
Damage
Tank, Vessel, or Sump/Separator
Allowed or Caused to Overfill or
Overflow
Valve Left or Placed in Wrong
Position, but NOT Resulting in a
Tank, Vessel, or Sump/Separator
Overflow or Facility Overpressure
1. Specify:
Valve misalignment
Incorrect reference data/calculation
Miscommunication
Inadequate monitoring
Other ____________________________________
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.
Items 3-5.a are new; however, on the
3. Was this Accident related to: (select all that apply)
current form, "inadequate procedure" &
Inadequate procedure
"failure to follow procedure" appear as a
No procedure established
type of incorrect operation.
Failure to follow procedure
Other: ______________________________________________________
4. What category type was the activity that caused the Accident:
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 Accident identified as a covered task in your Operator Qualification Program? Yes
No
5.a If Yes, were the individuals performing the task(s) qualified for the task(s)?
Yes, they were qualified for the task(s)
No, but they were performing the task(s) under the direction and observation of a qualified individual
No, they were not qualified for the task(s) nor were they performing the task(s) under the direction and observation of a
qualified individual
G8 – Other Accident Cause - only one sub-cause can be picked from shaded left-hand column
Miscellaneous
Unknown
1. Describe:
___________________________________________________________________________
___________________________________________________________________________
2. Specify:
Investigation complete, cause of Accident unknown
Still under investigation, cause of Accident to be determined*
(*Supplemental Report required)
Form PHMSA F 7000-1 (Rev. xx-2009 )
Page 19 of 20
Reproduction of this form is permitted
PART H – NARRATIVE DESCRIPTION OF THE ACCIDENT
(Attach additional sheets as necessary)
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PART I – PREPARER AND AUTHORIZED SIGNATURE
Signature section appears on the first
page on the current form.
Preparer's Name (type or print)
Preparer’s Telephone Number
Preparer's Title (type or print)
Preparer's E-mail Address
Authorized Signature
Preparer’s Facsimile Number
Date
Authorized Signature Telephone Number
Authorized Signature’s Name (type or print)
Authorized Signature’s E-mail Address
Authorized Signature’s Title (type or print)
Form PHMSA F 7000-1 (Rev. xx-2009 )
Page 20 of 20
Reproduction of this form is permitted
| File Type | application/pdf |
| File Title | NOTICE: This report is required by 49 CFR Part 195 |
| Author | Debbie |
| File Modified | 2009-12-15 |
| File Created | 2009-12-11 |