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Lessons Learned

CHECK OUT OUR MOST RELEVANT INCIDENT LISTINGS!

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.

Description
Characteristics:
Contributing Factors: Deficiency in Procedures
Damage and Injuries: Property Damage
Incident Date:
Severity: Incident
Leak: Yes
Ignition: No
Ignition Source:
When Incident Discovered: During Inspection
Lessons Learned:

The direct cause of the over-pressurization of the two drums was the repackaging of the phosphoric acid into metal UN1A1 drums and the resultant hydrogen gas generation within the sealed drums. At the time of this incident (1997), 49 CFR and several MSDSs supported the selection of the UN1A1 drums. After the incident, laboratory studies conducted by facility staff indicated that the corrosion and subsequent hydrogen gas generation rates for the amount of phosphoric acid present would result in a pressure buildup and the drum failures observed. Facility staff then contacted DOT to request that changes be made to the packaging guidance listed for this material.

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Description
Characteristics:
Contributing Factors: Situational Awareness
Damage and Injuries: Property Damage
Incident Date:
Severity: Incident
Leak: Yes
Ignition: Yes
Ignition Source: spark from switching instrument on
Setting: Laboratory
When Incident Discovered: During Operations
Lessons Learned:

The lessons learned from this incident are:

  1. Verify the gas that you are using.
  2. Avoid using "quick-disconnect" fittings in this type of situation. If they are absolutely needed, there are sets available that ensure that every pair of matching fittings are different from all the others.
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Description
Characteristics:
Contributing Factors: Design Flaw
Damage and Injuries: None
Incident Date:
Severity: Near-Miss
Leak: No
Ignition: No
Ignition Source:
Setting: Laboratory
Equipment: Valve
Probable Cause: Material Incompatibility
When Incident Discovered: During Operations
Lessons Learned:

1. Ensure that equipment and materials exposed to hydrogen are compatible with a hydrogen environment (even hydrogen-service-rated equipment).

2. Equipment designs in a hydrogen environment that use the fracture toughness for 17-4 precipitation hardening stainless steel may want to consider a 90% derating in published values (see Attachment 1).

Additional discussion of materials selection for compressed gas storage vessels can be found in the Hydrogen Safety Best Practices Manual. Similar discussion of materials selection for cryogenic liquid storage vessels can be found in the Hydrogen Safety Best Practices Manual.

A web-based resource developed by Sandia National Laboratories to provide data on hydrogen embrittlement of various materials is available at Technical Reference for Hydrogen Compatibility of Materials.

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