Lessons Learned

When incidents or near misses occur, an institution should share any lessons learned so that future incidents or near misses can be prevented.

Incident investigation should include determination of the root cause(s) and the development of lessons learned. Subject matter experts, safety professionals, peers, and managers should be involved in this "no-blame" process.

A mitigation plan should be developed to address the root cause(s) in order to prevent future accidents. For example, maintenance frequencies may need to be increased to identify potential incidents before they occur.

Every organization should have a documented process for investigating any incident or near miss. That process should designate who will investigate an incident or near miss, what root cause analysis process will be used, when outside assistance is needed, how findings will be reported, and levels of approvals required to restart an operation or process.

Incident reports should be widely disseminated within the organization to maximize organizational learning. A library of safety reports that is readily accessible to employees will help keep lessons learned visible to the organization.

Hydrogen safety incidents and near misses should be reported in the H2 Lessons Learned Reporting Database. Please share your incidents and near misses with others who are working with hydrogen so they can benefit from your experiences. All incident reports will be "sanitized" to ensure that individuals and organizations are not identified.