Hazard assessment is critical during the design, fabrication, and installation of system modifications to ensure hazards and potential hazards are addressed prior to system start-up and operation.

Personnel should be aware that items requiring special receiving inspections should still be verified/examined by the end user prior to use.

Given that the anaerobic chamber and associated nearby electrical equipment were not designed or…

All chemicals, including gases, should be clearly labeled and expiration dates (if applicable) identified. Incidents are more common when incompatible chemicals are mixed or when chemicals are stored/transferred using incompatible equipment.…

The manufacturer will be notified of the failed parts identified as a result of the follow-up testing plan. These results may be useful to them for their information and forwarding to others with the same equipment.

Designs for high-tech systems/components evolve based on operating experience. The design changes should resolve identified deficiencies and are part of a continuous improvement process to increase reliability and productivity.

Laboratory accidents can happen despite the best preparation and careful attention to procedures. However, the lesson to be learned here is that employees must always be sure they understand the hazards of the activities, and that they know how…

Diligence needs to be practiced when performing assigned work tasks. To guard against complacency, it is necessary to emphasize adherence to established procedures, including appropriate reviews of preventive maintenance instructions (PMI) and…

The lessons learned in this situation center around basic conduct of operations principles. Policies and procedures related to operations performance, safety performance, and management oversight were in place. They were not employed…

On-site personnel performing treatment of reactive metals/chemicals must continue to exercise caution. Although there is an inherent risk in treating reactive metals/chemicals, personnel must adhere to conduct of operations principles to include…

Thoroughly plan and schedule work such that the correct tools are at the job site. If activities take place that take the job supervisor away from the job location while critical steps are to be performed, the work should be temporarily stopped.…

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…