PHMSA Form 7100.2

NOTICE: This report is required by 49 CFR Part 191. Failure to report can result in a civil penalty not to exceed $25,000 for each violation Form Approved
for each day that such violation persists except that the maximum civil penalty shall not exceed $500,000 as provided in 49 USC 1678. OMB No. 2137-0522

U.S. Department of Transportation Pipeline and Hazardous Materials Safety Administration		INCIDENT REPORT - GAS TRANSMISSION AND GATHERING SYSTEMS					Report Date No. (DOT Use Only)
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 Office Of Pipeline Safety Web Page at http://ops.dot.gov.
PART A – GENERAL REPORT INFORMATION			Check one: ¨ Original Report ¨ Supplemental Report ¨ Final Report
Operator Name and Address a. Operator's 5-digit Identification Number (when known) / / / / / / If Operator does not own the pipeline, enter Owner’s 5-digit Identification Number (when known) / / / / / / Name of Operator ______________________________ _______________________________________________________ Operator street address ________________________________________________________________________________________ Operator address _______________________ City, County or Parrish, State and Zip Code
2. Time and date of the incident / / / / / / / / / / / / / / hr. month day year 3. Location of incident a. Nearest street or road b. City and County or Parrish c. State and Zip Code d. Mile Post/Valve Station e. Survey Station No. f. Latitude: Longitude: (if not available, see instructions for how to provide specific location) g. Class location description Onshore: ¡ Class 1 ¡ Class 2 ¡ Class 3 ¡ Class 4 Offshore: ¡ Class 1 (complete rest of this item) Area ___________________ Block # ___________ State / / / or Outer Continental Shelf ¨ h. Incident on Federal Land other than Outer Continental Shelf ¡ Yes ¡ No i. Is pipeline Interstate ¡ Yes ¡ No 4. Type of leak or rupture ¡ Leak: ¡Pinhole ¡Connection Failure (complete sec. F5) ¡ Puncture, diameter (inches) ¡ Rupture: ¡ Circumferential – Separation ¡ Longitudinal – Tear/Crack, length (inches) - Propagation Length, total, both sides (feet) ¡ N/A ¡ Other:				5. Consequences (check and complete all that apply) a. ¨ Fatality Total number of people: / / / / Employees: / / / / General Public: / / / / Non-employee Contractors: / / / / b. ¨ Injury requiring inpatient hospitalization Total number of people: / / / / Employees: / / / / General Public: / / / / Non-employee Contractors: / / / / c. ¨ Property damage/loss (estimated) Total $ Gas loss $ Operator damage $ Public/private property damage $ d. ¨ Release Occurred in a ‘High Consequence Area’ e. ¨ Gas ignited – No explosion f. ¨ Explosion g. ¨ Evacuation (general public only) / / / / / people Reason for Evacuation: ¡ Emergency worker or public official ordered, precautionary ¡ Threat to the public ¡ Company policy 6. Elapsed time until area was made safe: / / / hr. / / / min. 7. Telephone Report / / / / / / / / / / / / / / / / NRC Report Number month day year 8. a. Estimated pressure at point and time of incident: PSIG b. Max. allowable operating pressure (MAOP): PSIG c. MAOP established by 49 CFR section: ¨ 192.619 (a)(1) ¨ 192. 619 (a)(2) ¨ 192. 619 (a)(3) ¨ 192.619 (a)(4) ¨ 192. 619 (c) d. Did an overpressurization occur relating to the incident? ¡Yes ¡ No
PART B – PREPARER AND AUTHORIZED SIGNATURE
(type or print) Preparer's Name and Title						Area Code and Telephone Number
Preparer's E-mail Address						Area Code and Facsimile Number
Authorized Signature (type or print) Name and Title					Date	Area Code and Telephone Number

Form PHMSA F 7100.2 ( 01-2002 ) Reproduction of this form is permitted Page 1 of 3

PART C - ORIGIN OF THE INCIDENT

1. Incident occurred on ¡ Transmission System ¡ Gathering System ¡ Transmission Line of Distribution System 2. Failure occurred on ¡ Body of pipe ¡ Pipe Seam ¡ Joint ¡ Component ¡ Other:

3. Material involved (pipe, fitting, or other component) ¡ Steel ¡ Plastic (If plastic, complete all items that apply in a-c) Plastic failure was: ¨ a.ductile ¨ b.brittle ¨ c.joint failure ¡ Material other than plastic or steel: _________ 4. Part of system involved in incident ¡ Pipeline ¡ Regulator/Metering System ¡ Compressor Station ¡ Other: 5. Year the pipe or component which failed was installed: / / / / /

PART D – MATERIAL SPECIFICATION (if applicable)

PART E – ENVIRONMENT

1. Nominal pipe size (NPS) / / / / / in. 2. Wall thickness / / / / / in. 3. Specification SMYS / / / / / / / 4. Seam type

1. Area of incident ¡ In open ditch ¡ Under pavement ¡ Above ground ¡ Under ground ¡ Under water ¡ Inside/under building ¡ Other: 2. Depth of cover: inches

5. Valve type 6. Pipe or valve manufactured by in year / / / / /

PART F – APPARENT CAUSE

Important: There are 25 numbered causes in this section. Check the box to the left of the primary cause of the incident. Check one circle in each of the supplemental items to the right of or below the cause you indicate. See the instructions for this form for guidance.

F1 – CORROSION

If either F1 (1) External Corrosion, or F1 (2) Internal Corrosion is checked, complete all subparts a – e.

1. o External Corrosion

a. Pipe Coating ¡ Bare ¡ Coated

b. Visual Examination ¡ Localized Pitting ¡ General Corrosion ¡ Other: ____________________

c. Cause of Corrosion ¡ Galvanic ¡ Stray Current ¡ Improper Cathodic Protection ¡ Microbiological ¡ Stress Corrosion Cracking ¡ Other: ____________________

2.o Internal Corrosion

d. Was corroded part of pipeline considered to be under cathodic protection prior to discovering incident? ¡ No ¡ Yes, Year Protection Started: / / / / / e. Was pipe previously damaged in the area of corrosion? ¡ No ¡ Yes, How long prior to incident: / / / / years / / / months

F2 – NATURAL FORCES 3. o Earth Movement  ¡ Earthquake ¡ Subsidence ¡ Landslide ¡ Other: 4. o Lightning 5. o Heavy Rains/Floods  ¡ Washouts ¡ Flotation ¡ Mudslide ¡ Scouring ¡ Other: 6. o Temperature  ¡ Thermal stress ¡ Frost heave ¡ Frozen components ¡ Other: 7. o High Winds F3 - EXCAVATION 8. o Operator Excavation Damage (including their contractors) / Not Third Party

9. o Third Party Excavation Damage (complete a-d) a. Excavator group ¡ General Public ¡ Government ¡ Excavator other than Operator/subcontractor b. Type: ¡ Road Work ¡ Pipeline ¡ Water ¡ Electric ¡ Sewer ¡ Phone/Cable ¡ Landowner ¡ Railroad ¡ Other: c. Did operator get prior notification of excavation activity? ¡ No ¡ Yes: Date received: / / / mo. / / / day / / / yr. Notification received from: ¡ One Call System ¡ Excavator ¡ Contractor ¡ Landowner d. Was pipeline marked? ¡ No ¡ Yes (If Yes, check applicable items i – iv) i. Temporary markings: ¡ Flags ¡ Stakes ¡ Paint ii. Permanent markings: ¡ Yes ¡ No iii. Marks were (check one) ¡ Accurate ¡ Not Accurate iv. Were marks made within required time? ¡ Yes ¡ No F4 – OTHER OUTSIDE FORCE DAMAGE 10. o Fire/Explosion as primary cause of failure  Fire/Explosion cause: ¡ Man made ¡ Natural 11. o Car, truck or other vehicle not relating to excavation activity damaging pipe 12. o Rupture of Previously Damaged Pipe 13. o Vandalism

Form PHMSA F 7100.2 ( 01-2002 ) Page 2 of 3

F5 – MATERIAL AND WELDS Material 14. o Body of Pipe  ¡ Dent ¡ Gouge ¡ Wrinkle Bend ¡ Arc Burn ¡ Other: 15. o Component  ¡ Valve ¡ Fitting ¡ Vessel ¡ Extruded Outlet ¡ Other: 16. o Joint  ¡ Gasket ¡ O-Ring ¡ Threads ¡ Other: Weld 17. o Butt  ¡ Pipe ¡ Fabrication ¡ Other: 18. o Fillet  ¡ Branch ¡ Hot Tap ¡ Fitting ¡ Repair Sleeve ¡ Other: 19. o Pipe Seam  ¡ LF ERW ¡ DSAW ¡ Seamless ¡ Flash Weld o ¡ HF ERW ¡ SAW ¡ Spiral ¡ Other:
Complete a-g if you indicate any cause in part F5. a. Type of failure: o Construction Defect  ¡ Poor Workmanship ¡ Procedure not followed ¡ Poor Construction Procedures o Material Defect b. Was failure due to pipe damage sustained in transportation to the construction or fabrication site? ¡ Yes ¡ No c. Was part which leaked pressure tested before incident occurred? ¡ Yes, complete d-g ¡ No d. Date of test: / / / mo. / / / day / / / yr. e. Test medium: ¡ Water ¡ Natural Gas ¡ Inert Gas ¡ Other: f. Time held at test pressure: / / / hr. g. Estimated test pressure at point of incident: PSIG
F6 – EQUIPMENT AND OPERATIONS 20. o Malfunction of Control/Relief Equipment  ¡ Valve ¡ Instrumentation ¡ Pressure Regulator ¡ Other: 21. o Threads Stripped, Broken Pipe Coupling  ¡ Nipples ¡ Valve Threads ¡ Mechanical Couplings ¡ Other: 22. o Ruptured or Leaking Seal/Pump Packing
23. o Incorrect Operation a. Type: ¡ Inadequate Procedures ¡ Inadequate Safety Practices ¡ Failure to Follow Procedures ¡ Other: b. Number of employees involved who failed post-incident drug test: / / / / Alcohol test: / / / / c. Were most senior employee(s) involved qualified? ¡ Yes ¡ No d. Hours on duty: / / /
F7 – OTHER 24. o Miscellaneous, describe: 25. o Unknown ¡ Investigation Complete ¡ Still Under Investigation (submit a supplemental report when investigation is complete)
PART G – NARRATIVE DESCRIPTION OF FACTORS CONTRIBUTING TO THE EVENT	(Attach additional sheets as necessary)

Form PHMSA F 7100.2 ( 01-2002 ) Page 3 of 3