Form PHMSA F 7100.2 PHMSA F 7100.2 Incident Report—Natural and Other Gas Transmission and G

Incident Reports for Natural Gas Pipeline Operators

GT GG Incident Form - PHMSA F 7100 2 (rev 1-2020) Clean 2021-03-22

Incident Report - Gas Transmission and Gathering Systems

OMB: 2137-0635

⚠️ Notice: This form may be outdated.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

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

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):

 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:
/

Hour

Month

Day

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
/
/

/
/

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)

/
/

/,/
/,/

/,/

/
/

Reproduction of this form is permitted

/ thousand standard cubic feet (mcf)
/ thousand standard cubic feet (mcf)

/ Barrels

Page 1 of 22

A10. Were there fatalities?  Yes  No
If Yes, specify the number in each category:
A10a. Operator employees

A10b. Contractor employees
working for the Operator

A10c. Non-Operator
emergency responders

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

A11b. Contractor employees
working for the Operator

A11c. Non-Operator
emergency responders

A11d. Workers working on the
right-of-way, but NOT
associated with this Operator

A11e. General public

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

Hour

Month

Day

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

Hour

Month
Month

Day

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

Hour

Month

Day

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 :
/

Hour

Month

Day

Year

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

Hour

Month

Day

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

 Yes

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
/

Month

Day

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

Hour

Month

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)

/,/

Year

 Check Valve

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

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: /

/,/

Area: _________

/
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: _____________________________

Longitudinal ERW – Unknown Frequency

 Spiral Welded

 Lap Welded

C3g. Pipeline coating type at point of Incident
 Epoxy
 Specify:

/,/

 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): /

or wall thickness: /

/./

 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):

/./

C3m. SMYS (Specified Minimum Yield Strength) of pipe (psi):

C3n. Pipe specification: _____________________________ OR

/,/

 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: _______________________________

 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

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

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

/,/

D7b. Estimated cost of Operator’s property damage & repairs

/,/

D7c. Estimated cost of emergency response

/,/

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

Day

Year

/
/

� 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

 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)

 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:

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

 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

 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

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)

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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