Form Phmsa F 7100.1-2 - Mechanical Fitting Failure Report Form For Distribution Operators Page 2
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2PART C – MECHANICAL FITTING FAILURE DATA – (If the data about the “Manufacturer”, “Part or Model Number”, or” Lot Number” cannot be
located with reasonable effort or if the data is unknown, enter “Unavailable”; do not leave data fields blank.)
1)
State in Which Fitting Failed: _____________________
2)
Date of Failure:___________________
Specify the Mechanical Fitting Involved: Stab
Nut Follower
Bolted
Other Compression Type Fitting______________
3)
Specify the Type of Mechanical Fitting: Service or Main Tee Tapping Tee Transition Fitting Coupling Riser
4)
Adapter
Valve
Sleeve End Cap Other _____________________
Leak Location: Aboveground
Belowground;
5)
or
Inside
Outside;
or
Main-to-Main
Main-to-Service
Service-to-Service
Meter Set
or
or
or
6)
Year Installed: ___________
7)
Year Manufactured: ___________
8)
If Neither Year Installed or Year Manufactured is Known, Provide Decade Installed: ___________
9)
Manufacturer: _____________________________
10) Part or Model Number:______________________
11) Lot Number:_______________________________
12) Other Attributes:____________________________
Steel Plastic Combination Plastic and Steel
Brass Unknown Other_____________
13) Fitting Material:
14) Specify the Two Materials Being Joined:
a)
First Pipe
Nominal Size: 1/4”
1/2”
3/4”
1”
1-1/4”
1-1/2”
1-3/4”
2”
3”
4”
6”
8” or larger
Unit: IPS
CTS
NPS
or
or
Material: Steel
Cast/Wrought Iron
Ductile Iron
Copper
Plastic
Unknown
Other______________
If Plastic Specify: Polyethylene (PE)
Polyvinyl Chloride (PVC)
Cross-linked Polyethylene (PEX)
Polybutylene (PB) Polypropylene (PP) Acrylonitrile Butadiene Styrene (ABS) Polyamide (PA)
Cellulose Acetate Butyrate (CAB) Other Specify: __________________________________
b)
Second Pipe
Nominal Size: 1/4”
1/2”
3/4”
1”
1-1/4”
1-1/2”
1-3/4”
2”
3”
4”
6”
8” or larger
Unit: IPS
CTS
NPS
or
or
Material: Steel
Cast/Wrought Iron
Ductile Iron
Copper
Plastic
Unknown
Other______________
If Plastic Specify: Polyethylene (PE)
Polyvinyl Chloride (PVC)
Cross-linked Polyethylene (PEX)
Polybutylene (PB) Polypropylene (PP) Acrylonitrile Butadiene Styrene (ABS) Polyamide (PA)
Cellulose Acetate Butyrate (CAB) Other Specify: __________________________________
15) Apparent Cause of Leak:
Corrosion
Natural Forces
Was there thermal expansion/contraction? Yes
or
No
Excavation Damage
Time excavation damage occurred? At time of leak discovery or Previous to leak discovery
Other Outside Force Damage
Material or Welds/Fusions
Was the leak due to Construction/Installation Defect or Material Defect or Design Defect
Equipment
Incorrect Operation
Other
Explain:_______________________________________
16) How did the leak occur? Leaked Through Seal
Leaked Through Body
Pulled Out
or
or
Operator’s Internal Mechanical Fitting Failure Tracking Number (optional):
17)
_______________________________
Record Identification Number <<This number will be auto-generated by PHMSA for each submitted mechanical fitting failure
report.>>
Form PHMSA F 7100.1-2 Mechanical Fitting Failures (01/2011)
Reproduction of this form is permitted.
Page 2 of 2
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