1. There should have been greater awareness during the design and installation of the burn box regarding the static pressure limitations of the exhaust fan in relation to the anticipated static pressure buildup across the HEPA filter.
…

This event illustrates the importance of adequately planning and communicating work. Procedures should cover all types of equipment that will be utilized. Work packages should clearly describe the equipment that will be used and the surrounding…

This occurrence underscores the importance of completing a hazard analysis for each different process. Non-safety-related systems or equipment may be used for purposes other than their primary purpose so long as potential hazards are identified…

The risk of a serious fire occurring inside the chemistry laboratory hood from use of hydrogen gas and/or presence of a small quantity of hydrazine-hydrate was underestimated. Additional control measures were required to reduce the risk of fire…

• Equipment that is designed to provide a safety barrier must be stringently tested upon installation.
• A procedure requiring annual testing of both excess flow valves, which includes proper seating for closure and proper flow, has…

All safety devices worked as designed thereby protecting the environment and laboratory personnel. Researchers involved in the experiment acted properly and with the parameters set forth in operational procedures.

Follow up: Stops have…

Whenever a new program or organization is created, management should ensure that program interfaces and new responsibilities are clearly defined. Effective program integration is necessary to ensure that all responsibilities and requirements are…

Procedures will be revised to include specific information about hydrogen sensors and alarm controls. Caution will be added about sparks and flames in the fuel cell operation area. Workers will be cautioned that shunt resistors may reach high…

Management should ensure that a complete and thorough review of the previous work activities identified in the work package is performed at the pre-job briefing for the planned work. Work activities should be discontinued if any confusion exists…

Utilize a Six Sigma Black Belt to statistically evaluate LFL monitor reliability and determine the failure rate based on the existing technology.

Revise the tank uncertainty calculation and surveillance to include a wider "Required…

In the future, the laboratory will issue a memorandum about this incident to illustrate the need to wear safety glasses with side shields, store chemicals compatibly, take care when placing chemicals in the refrigerators for storage, and keep the…

Implementing and enforcing the laboratory's stop work and restart policy and procedures in conjunction with peer reviews for new processes and experiments should help prevent future accidents due to a lack of recognition of potential reactions…

Frequently inspect and maintain all elements of hydrogen-related systems.

A flammable gas explosion is an analyzed hazard and gas detection/shut off is a safety significant control system that requires a limiting condition for operation (LCO). The rigor of the evaluation of flammable gas systems was inadequate. There…

1. Test safety system components even if they are new.
2. Do not rely on listening for valve movement as confirmation that a valve is closing; measure downstream pressure to determine if the valve is really sealing properly.
3. …

Recommended Actions:

• The recommended safe storage time for AHF is two years. Contact the vendor for pick up and disposal for cylinders more than two years old. (Unused gas should also be returned, even if it has been less than two…

In any event, the lesson that should be derived from this incident is the fact that the explosion could have been avoided either by using an inert gas instead of air across the diaphragm, or by monitoring the hydrogen concentration in the upper…

As demonstrated by the fire discussed above, lack of adequate maintenance, system monitoring and oversight of maintenance of these facilities can contribute to the ignition of a fire that is difficult to extinguish and poses an extreme danger to…

This incident illustrates how a hydrogen fire which appears to be 'quite small' can actually be only the visible portion of a much larger fire. Observation alone is not a reliable technique for detecting pure hydrogen fires and/or assessing their…

An important lesson to be derived from this incident is the need to carefully engineer and test all repairs and modifications to high-pressure process equipment.