Disclaimer: The Lessons Learned Database includes the incidents that were voluntarily submitted. The database is not a comprehensive source for all incidents that have occurred.
An investigative communication notes that "mechanical integrity programs at refineries repeatedly emphasize inspection strategies rather then the use of inherently safer design to control the damage mechanisms that ultimately cause major process…
The researcher's failure to pull the fire alarm was an oversight of required facility practice. The alarm should have been triggered in consideration of the potential for greater harm to personnel and facilities.
Hot, reacting ammonia…
The procedure for disposal of spent or partially spent AB has been modified so that it does not include the use of water. Instead, the AB is removed from containers and transferred for disposal by rinsing with mineral oil, silicone oil or other…
Maintain an internal process for verifying component wetted material compatibility for intended use as part of the procurement process for hydrogen system equipment. It is critical that component parts be appropriately rated for the materials,…
The following actions were proposed as a result of this incident:
The project team concluded that the jar contained a sufficient vapor pressure of isopropanol to ignite when it came into contact with the decomposing hydride. The lesson learned was that hydrides react rapidly in air and can lead to combustion of…
As stated on the MSDS and also on the container labels, LiAlH4 should be handled under argon. LiAlH4 is advertised and sold as a powder. If the researcher had to scrape it out of the jar, then it was no longer a powder, which seems indicative of…
Because the bottle was located outside at the time of the event, and the hydrogen did not find a source of ignition while venting through the relief valve, nothing serious happened. The failed regulator was replaced and operations continued.…
The lessons learned from this incident are:
The investigation team concluded that hydrogen gas was released through a failed 19-inch diameter gasket and ignited under the roof of the compressor shed where it was partially confined. Some gas escaped from the shed prior to the explosion, but…
The investigation determined that hydrogen was formed by the reaction of hot aluminum and water, air was admitted via the inspection door, and the mixture was ignited by the hot clinker or sparks from the chisel. Aluminum should have been…
The ignition of the fireball could have been caused by any of the following mechanisms:
A tool is provided for removing the cylinder cap that cannot contact the valve.
Several best practices resulted from this incident and will be implemented if similar circumstances present themselves in the future.
A new best practice resulted resulted from this incident. It states that before any work is started, a third party should verify with a visual inspection that the actual equipment to be used matches the planned equipment list/protocol.
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