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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:
Damage and Injuries: Human Life, Minor Injury, Property Damage
Incident Date:
Severity: Incident
Leak: Yes
Ignition: Yes
Ignition Source:
Setting: Refinery
When Incident Discovered: During Operations
Lessons Learned:

1. Management must ensure that operating decisions are not based primarily on cost and production. Performance goals and operating risks must be effectively communicated to all employees. Facility management must set safe, achievable operating limits and not tolerate deviations from these limits. Risks of deviation from operating limits must be fully understood by operators. Also, management must provide an operating environment conducive for operators to follow emergency shutdown procedures when required.

2. Process instrumentation and controls should be designed to consider human factors consistent with good industry practice. Hydroprocessing reactor temperature controls should be consolidated with all necessary data available in the control room. Some backup system of temperature indicators should be used so that the reactors can be operated safely in case of instrument malfunction. Each alarm system should be designed to allow critical emergency alarms to be distinguished from other operating alarms.

3. Adequate supervision is needed for operators, especially to address critical or abnormal situations. Supervisors need to ensure that all required procedures are followed. Supervisors should identify and address all operating hazards and conduct thorough investigation of deviations to determine root causes and take corrective action. Equipment and job performance issues related to operating incidents should be corrected by management.

4. Facilities should maintain equipment integrity and discontinue operation if integrity is compromised. Hydroprocessing operations especially need to have reliable temperature monitoring systems and emergency shutdown equipment. Equipment should be tested regularly and practice emergency drills should be held on a regular basis. Maintenance and instrumentation support should be available during start up after equipment installation or major maintenance.

5. Management must ensure that operators receive regular training on the unit process operations and chemistry. For hydrocrackers, this should include training on reaction kinetics and the causes and control of temperature excursions. Operators need to be trained on the limitations of process instruments and how to handle instrument malfunctions. Facilities need to ensure that operators receive regular training on the use of the emergency shutdown systems and the need to activate these systems.

6. Management must develop written operating procedures for all phases of hydrocracker operations. The procedures should include operating limits and consequences of deviation from the limits. The procedures should be reviewed regularly and updated to reflect changes in equipment, process chemistry, and operation. As appropriate, the procedures should be updated to include recommendations from process hazard analysis and incident investigations.

7. Process hazard analysis must be based on actual equipment and operating conditions that exist at the time of the analysis. The analysis should include the failure of critical operating systems, such as temperature monitors or emergency operating systems. A Management of Change review should be conducted for all changes to equipment or processes, as necessary, and should include a safety hazard review of the changes.

More information on management of change can be found in the Lessons Learned Corner and also in the Hydrogen Safety Best Practices Manual.

Email (Primary):
Description
Characteristics:
Contributing Factors: Operation Induced Damage
Damage and Injuries: Plant shutdown for maintenance
Incident Date:
Severity: Incident
Leak: Yes
Ignition: No
Ignition Source:
Setting: Power Plant
When Incident Discovered: During Operations
Lessons Learned:
  1. Incorporate external operating experience lessons learned into site program controls. Other nuclear plants had similar strand failures and back-of-core issues that were not evaluated for impact on procedures or system/component health plans.
  2. Be more sensitive to precursor indications of declining system/component health; in this case the main generator. Insensitivity resulted in material condition deficiencies and elevated risks to generation that are undesirable given the economic importance of this high-value asset.
  3. Follow OEM and industry recommendations for component (stator) preparation for testing and lay-up.
  4. Have a detailed component (generator) Life-Cycle Management Plan.

Additional details regarding probable causes and lessons learned can be found in Attachment 2.

Email (Primary):
Description
Characteristics: High Pressure (> 100 bar)
Contributing Factors:
Damage and Injuries: None
Incident Date:
Severity: Incident
Leak: Yes
Ignition: Yes
Ignition Source:
Probable Cause: Equipment Failure
When Incident Discovered: During Operations
Lessons Learned:

The following corrective actions have been taken:

  • The non-return valve was dismantled, cleaned, and tested. Following positive testing, the system was restarted and pressurized without any further malfunctioning.
  • The hydrogen discharge pipe was extended from the low roof of the compressor building (2.5 m) to the higher roof of a neighboring building (6 m). With this modification, any potential hydrogen ignition would occur at approximately 6 meters from ground, farther from personnel than the 2.5 meters of the previous situation.
  • The compressor was sent to the manufacturer for preventive maintenance in order to lower the frequency of component malfunctioning.
  • Plans for regular maintenance of the non-return valve will be recorded in the next revision of the Design and Safety Report.
  • A flame arrestor was purchased and mounted at the end of the exhaust pipe on top of the building.
Email (Primary):
Description
Characteristics: High Pressure (> 100 bar)
Contributing Factors: Inadequate Inspection
Damage and Injuries: Minor Injury
Incident Date:
Severity: Incident
Leak: Yes
Ignition: Yes
Ignition Source:
Probable Cause: Equipment Failure
When Incident Discovered: During Operations
Lessons Learned:
  1. Specific response drills/exercises need to be conducted yearly. In this case, all safety systems worked as they should and outside emergency responders were not needed.
  2. Performing other tasks while filling hydrogen tube trailers, such as mechanic work, should be avoided. Most premature failures of hydrogen tube trailer PRD burst discs occur during the fill process.
  3. Grounding, as was done in the incident, should always be done during hydrogen filling. However, even when the fill vessel is grounded, it is not unusual for a hydrogen release to immediately ignite.
  4. The facility safety deluge water system should be checked periodically for coverage. In this case, a water cannon was a little off target from the last time it was operated and has now be repositioned and stabilized to ensure that it does not move in the future.
  5. Emergency responders assumed that adjacent tube trailers were heating up from single-cylinder vent flare as a 300°F (149°C) reading was obtained with a thermal device. This slightly delayed the closing of the cylinder isolation valves on the tube trailer. After-incident investigation found no paint discolored or burnt, so the temperature taken by the emergency responders was likely near the flaming vent discharge point.
  6. Securing hydrogen fill valve(s) at the back of the tube trailer was not dependent on the temperature at the vent stack, as this area was covered by deluge nozzles and located 40 feet (12.2 meters) away from the vent stack.
  7. Media involvement and resulting speculation can portray a situation as being much worse than it actually is.
Email (Primary):
Description
Characteristics:
Damage and Injuries: Property Damage
Incident Date:
Severity: Near-Miss
Leak: No
Ignition: No
Ignition Source:
Setting: Laboratory
Equipment: Glassware
When Incident Discovered: During Inspection
Lessons Learned:

1. Evaluate any change in normal procedures or conditions for storage of aluminum hydride products. In this case, the aluminum hydride material was typically stored at -35°C in the glove box freezer. However, due to a change in glove boxes, this was no longer an option. Since commercially available aluminum hydride compound is shipped in glass bottles at room temperature, it was assumed that this was considered safe handling. The vial was stable for 6 weeks before the near miss occurred.

2. Limit aluminum hydride materials to small quantities as needed for immediate use. Larger samples have the potential to caused more damage.

3. Do not store aluminum hydride materials for extended periods of time and promptly dispose of any remaining material after use.

4. In-process aluminum hydride material should be stored at lower temperatures (i.e., in a freezer) and in an air-free contained environment (i.e., inside an air-free glove box) to reduce or slow decomposition into volatile materials (e.g., hydrogen, aluminum metal, and similar). In this case, if the aluminum hydride material had been stored in air, it is likely that a fire may have started.

5. Store aluminum hydride material in plastic containers instead of sealed glass containers to avoid catastrophic failure of containment. In this case, it is likely that the decomposition process of the aluminum hydride compound slowly built up pressure sufficient to destroy the glass vial.

Additional discussion about working with reactive metal-hydride materials in the laboratory can be found in the Lessons Learned Corner on this website and in the Hydrogen Safety Best Practices Manual.

Email (Primary):
Description
Characteristics: High Pressure (> 100 bar)
Contributing Factors: Incomplete O&M procedures
Damage and Injuries: None
Incident Date:
Severity: Near-Miss
Leak: Yes
Ignition: No
Ignition Source:
Equipment: Valve
Probable Cause: Inadequate Maintenance
When Incident Discovered:
Lessons Learned:

The packing in the flow control valve should be replaced periodically. A planned investigation will determine the optimum time period for packing replacement.

Email (Primary):
Description
Characteristics:
Damage and Injuries: Lost Time Injury, Property Damage
Incident Date:
Severity: Incident
Leak: No
Ignition: No
Ignition Source:
Setting: Refinery
Equipment: Furnace, Piping
When Incident Discovered: During Operations
Lessons Learned:
  1. Inadequate Safeguards - The system was designed with low-point drains to facilitate water removal, however, these were found to be inadequate in both location and size. The fact that the mixed feed pre-heat coil was not self-draining was unknown prior to the incident. After a thorough review of the entire reformer furnace feed system was completed, existing drains were increased in size and others added to ensure that the entire feed system could be drained.
  2. Inadequate Procedure - The startup procedure did not account for a startup of a cold furnace with no hold points for catalyst reduction or refractory dry out. As a result, the time to reach the critical "steam in" temperature of 350°C (662°F) was short as compared to previous startups. Also, the procedure provides little direction for confirming that the reformer furnace feed system is dry. Modifications to the procedure were completed that included a longer heat-up period, the addition of more detailed guidance for verifying that the feed system is dry, and a formal sign-off by both operations and engineering personnel. Also, a separate cold-eyes review by external experts was completed as part of the pre-startup safety review.
  3. Lack of Change Management - a. The startup procedure had two hold points for refractory dry out and new catalyst reduction during the heat-up phase prior to introducing the 4.1 mPa (600 psig) startup steam. These hold points were not utilized, since it appeared that neither was required. Consequently, the heat-up cycle was artificially shortened. It became apparent that this alteration to the startup sequence was not viewed as a change by operations. Several sections of the procedure were not performed, since they did not apply to this startup. b. Shutdown and startup procedures are designed to take a unit from safe operation to a zero energy state and then return it to safe operation. Changing these sequences by an intentional omission is a change and must be properly assessed for risk. The decision to leave some steam flow in the steam-generating system for this winter shutdown was made to keep the system warm and prevent freezing. However, no formal risk assessment was performed and no management of change (MOC) was generated. A risk assessment was performed prior to the startup, but the change in status of the steam system was not evaluated. In fact, the decision to leave steam in was seen as a safeguard from the risk of freezing. This provided an opportunity for water to accumulate upstream of the reformer furnace.
  4. Non-essential Personnel - At the time of the incident, there were seven people on the furnace structure. Only the operations personnel were essential. Changes have been made to ensure that non-essential personnel are cleared from the area during startup activities.

More information on management of change can be found in the Lessons Learned Corner and also in the Hydrogen Safety Best Practices Manual.

Email (Primary):
Description
Characteristics:
Contributing Factors: Improper Purging Procedure
Damage and Injuries: None
Incident Date:
Severity: Incident
Leak: Uncertain
Ignition: Yes
Ignition Source:
Setting: Laboratory
Equipment: Reactor
When Incident Discovered: During Operations
Lessons Learned:

The following recommended actions were identified:

  1. Reemphasize the current lab management policies and practices on how process changes are evaluated for direct/indirect impacts on the process.
  2. Reinforce with lab workers the expectations for bringing issues and concerns to management's immediate attention for evaluation of reporting needs.
  3. Increase the purge gas flow rate to ensure complete purging of the system.
  4. Extend the inert gas purging time of the reactor system before the run and use oxygen chemical indicator strips to indicate the quality of inert atmosphere in the enclosed system.
  5. After the run, extend the inert gas purging time of the installed glove bag above the chamber lid and use a high purge gas flow rate.
  6. Use oxygen chemical indicator strips to indicate the quality of inert atmosphere in the glove bag before opening the collection chamber.

The importance of purging hydrogen piping and equipment is discussed in the Lessons Learned Corner on this website.

Additional discussion about working with reactive metal-hydride materials in the laboratory can be found in the Lessons Learned Corner on this website and in the Hydrogen Safety Best Practices Manual.

Email (Primary):
Description
Characteristics:
Damage and Injuries: None
Incident Date:
Severity: Incident
Leak: Yes
Ignition: No
Ignition Source:
Setting: Laboratory
Equipment: Glassware
When Incident Discovered: During Inspection
Lessons Learned:

1. All samples with potential for hydrogen buildup should be limited to ground shipment only. (This shipment was by ground and air. If this incident were to have happened in an airplane, the consequences may have been worse.)

2. All samples must be properly labeled before shipping. Hazard label warnings need to be located on the outside of the shipment package.

3. The following safety information should be included with the shipment: the material safety data sheet (MSDS), applicable standard operating procedures (SOPs), and detailed information for the safe handling of the materials.

4. Improper labeling can result in improper handling and storage. Lack of proper labels allowed the sample to be delivered to an office rather than a laboratory, where the material can be properly handled and stored in an approved location.

5. For hazardous material shipments, do not ship material in quantities beyond what is needed by the receiver. Lesser material quantities lead to reduced risks in the event of a failure. In this incident, the analysis only required 0.1-0.2 gram of material, but 5 grams of the material were shipped. The receiver suggests that future sample sizes for this analysis be limited to a maximum of 0.5 gram (10% of what was shipped in this incident).

6. Samples that have the potential for hydrogen generation should use a pressure-rated container with the following features:

    a.  Head space to contain the maximum possible gas release from the sample below the container's maximum safety pressure limit.

    b.  Pressure relief mechanism (such as a release valve) that can be slowly opened within a glove box to safely equalize any pressure build-up.

    c.  Outer shell capable of containing any flying debris. A secondary metal container outside the pressure-rated container is suggested as a possible solution for containing potential flying debris.

7. Sealed glass containers should not be used to store samples that could generate pressure over time. These types of glass containers are not rated for pressure. Capped glass vials, bottles, or metal cans are alternate options to consider.

8. Safe transport and handling procedures for these types of materials need to be followed. The receiver requested that all shipments from the shipper of this sample be stopped until safety concerns from this incident are addressed.

9. Store these types of materials in proper approved storage. MSDSs should be available either locally or at a central location.

10. If a sample shipment lacks proper documentation, treat it as potentially hazardous until proper documentation is obtained.

11. DO NOT become comfortable with handling these types of aluminum hydride materials. Routine handling of these samples without problems can lull users into shortcuts that could result in more damaging results than this incident. If this incident had happened with personnel present, there was a potential for personnel injury.

Additional discussion about working with reactive metal-hydride materials in the laboratory can be found in the Lessons Learned Corner on this website and in the Hydrogen Safety Best Practices Manual.

Email (Primary):
Description
Characteristics: High Pressure (> 100 bar)
Contributing Factors: Operation Induced Damage
Damage and Injuries: Property Damage
Incident Date:
Severity: Incident
Leak: Yes
Ignition: Yes
Ignition Source:
Probable Cause: Equipment Failure
When Incident Discovered: During Operations
Lessons Learned:
  1. A hydrogen tube pressure indication system needs to be developed that is robust enough to withstand an accident, indicates hydrogen pressure regardless of valve position, and would be visible from a safe distance during an accident situation. Hydrogen system pressure is very important in determining incident response actions. Centralizing the system pressure indicators on a highly visible information panel located in a protected area of the hydrogen cylinder package is a possible solution to increase visibility.
  2. Hydrogen valves should have a visible means to show that they are in the closed position. A highly visible lock or pin that can only be used when the valves are closed may help guarantee valve closure prior to transport. If the valve positions are visible, an operating procedure could be added that requires a final valve line-up check just prior to transport trailer departure.
  3. Hydrogen cylinders grouped together and secured for transport as packaged assemblies should be designed for potential accident conditions. The package tie-down system should be designed with adequate safety margins to assure that hydrogen cylinder packages remain secured to the transport trailer under adverse conditions. However, the package design should assume that the package might fall from a moving transport vehicle and impact the ground, but the hydrogen cylinders should still be contained within the package. A program to test hydrogen cylinder packages under hypothetical accident conditions would be useful for developing designs that could be certified to survive potential accident conditions.
Email (Primary):
Description
Characteristics: High Pressure (> 100 bar)
Contributing Factors: Operation Induced Damage
Damage and Injuries: Property Damage
Incident Date:
Severity: Incident
Leak: Yes
Ignition: Uncertain
Ignition Source:
Probable Cause: Vehicle Collision
When Incident Discovered: During Operations
Lessons Learned:
  1. Increased structural protection is needed at the back of a hydrogen tube trailer to protect the vulnerable hydrogen systems components in this location (valves, pressure-indicating devices, manifolds, piping) in case of an accident. Side protection is especially important.
  2. A system of designated lifting features is needed on hydrogen tube trailers to aid in accident recovery operations if the trailer is overturned or requires lifting. Typically, these types of accidents require the use of a crane for moving and lifting hydrogen tube trailers using lifting devices like slings. These lifting features should be designed to lift the hydrogen tube trailer with a full load of hydrogen cylinders and located at protected points. The current method for tube trailer lifting using slings around the hydrogen tube trailer at undefined locations and assumed centers of gravity is more hazardous and less safe.
Email (Primary):
Description
Characteristics:
Contributing Factors: Human Error
Damage and Injuries: Property Damage
Incident Date:
Severity: Incident
Leak: Yes
Ignition: Yes
Ignition Source:
Probable Cause: Vehicle Collision
When Incident Discovered: During Operations
Lessons Learned:
  1. A hydrogen tube pressure indication system needs to be developed that is robust enough to withstand an accident, indicates hydrogen pressure regardless of valve position, and would be visible from a safe distance during an accident situation. Hydrogen system pressure is very important in determining incident response actions. Centralizing the system pressure indicators on a highly visible information panel located in a protected area of the tube trailer is a possible solution to increase visibility. Fragile manometers should be replaced with more robust instruments and associated piping/components that can survive accident situations. Finally, pressure indications in all areas of the hydrogen system are desired, but especially the internal hydrogen tube pressure. System pressure components should be designed so that hydrogen pressure in the tubes is measured even when valves are closed and tubes are isolated.
  2. Increased structural protection is needed at the back of the hydrogen tube trailer to protect the vulnerable hydrogen systems components in this location (e.g., valves, pressure-indicating devices, manifolds, piping) in case of an accident. More robust components (especially the pressure-indicating manometers) and better support/tie-down to the tube trailer of the hydrogen pressure components may be beneficial.
  3. Hydrogen valves should have a visible means to show that they are in the closed position. A highly visible lock or pin that can only be used when the valves are closed may help guarantee valve closure prior to transport. If the valve positions are visible, an operating procedure could be added that requires a final valve line-up check just prior to hydrogen tube trailer departure.
  4. The hydrogen tubes need more fire protection/heat shielding at their location on the tube trailer, especially as related to the key fire load sources (combustible material) at the tire and fuel/oil locations. Local shielding, both at the fire source and at the protected destination, should be considered to provide the best method for reducing flame impingement and thermal loading/impact on the hydrogen tubes and associated components during a fire. Consideration should also be given to hydrogen tubes and components designed for higher pressures and greater fire resistance.
Email (Primary):
Description
Characteristics:
Contributing Factors: Inadequate Inspection
Damage and Injuries: Property Damage
Incident Date:
Severity: Incident
Leak: Yes
Ignition: Yes
Ignition Source:
Equipment: Piping
Probable Cause: Equipment Failure
When Incident Discovered: During Operations
Lessons Learned:
  • Replace the existing copper and carbon steel hydrogen pipeline with ¾-inch schedule 40 stainless steel.
  • Reroute the new hydrogen line in the preferred location.
  • Locate new hydrogen shut-off valves in a more convenient location.
  • Remove all abandoned underground hydrogen lines.
  • Continue to confer with the local fire department on the new piping system design until the project is completed.
Email (Primary):
Description
Characteristics: High Pressure (> 100 bar)
Damage and Injuries: Property Damage
Incident Date:
Severity: Incident
Leak: Yes
Ignition: Yes
Ignition Source:
Setting: Power Plant
Probable Cause: Inadequate Maintenance
When Incident Discovered: During Operations
Lessons Learned:

The uncontrolled release of hydrogen occurred as a result of the rupture of the No. 6 hydrogen storage tube’s burst disc. This disc failed in response to being overloaded by mechanical stresses developed as water expanded and formed ice while in direct contact with the burst disc. It was the degraded condition of the vent cap (defective equipment) that enabled water to access the burst disc.

  • As a corrective action, eliminate burst discs from hydrogen storage assembly. Redesign venting system for the pressure relief valves to prevent or inhibit moisture build up and allow moisture drainage.

The investigation uncovered two instances where the supplier was in possession of information ("safety data") that, if successfully conveyed to plant management and subsequently acted upon, would have prevented or reduced the chance of occurrence of the subject incident. Specifically, the hydrogen supplier found ice in a vent pipe, and was aware that the vent caps were cracked (recall the cracks were painted). Had a requirement existed for this information to be communicated to the plant, then plant management would have had the opportunity to evaluate and potentially influence the supplier's maintenance and operations program.As a corrective action, contract documents for the hydrogen and nitrogen supplies will be modified to stipulate the following:

  • Suppliers of potentially hazardous equipment will provide plant management, for acceptance purposes, with written documentation describing the supplier’s preventive maintenance program.
  • The supplier shall provide the plant representative with a copy of a preventive maintenance report upon the completion of each PM check performed by the supplier. The supplier shall expeditiously rectify any identified deficiency.
  • Plant management will recommend to the Manager of Corporate Safety and Health that the above contract document modifications are implemented corporate wide.
Email (Primary):
Description
Characteristics:
Contributing Factors: Design Flaw, Inadequate Maintenance
Damage and Injuries: Property Damage
Incident Date:
Severity: Incident
Leak: Yes
Ignition: Yes
Ignition Source: self ignition
Equipment: Vessel, Piping
When Incident Discovered: During Operations
Lessons Learned:

Recommendation 1 - Overhaul and replace the diaphragms on all cells showing low-purity results. Check on a routine basis the individual cell purity levels to monitor the deterioration of performance of individual cells. Certain contaminants are produced as a result of the process that settle to the bottom of the cells. These contaminants, particularly magnetite, can block the water makeup ports and the drain valves. This was found to be the case on 6 makeup ports and on most drain valves. The blocked drain valves made it very difficult to clean the cells and to unblock the makeup ports.

Recommendation 2 - Replace the existing low-purity (LP) purity analyzer with a fail-safe model that ensures the vent valve is opened under the conditions described above. Carry out a risk assessment of the current LP purity analyzers to determine the level of risk associated with a loss of sample flow.

Recommendation 3 - Fit hydrogen purity analyzers that fail safe either between the stages of the compressor or immediately after the compressor. Carry out a risk assessment of the current LP and HP purity analyzers to determine the level of risk associated with a loss of sample flow failure.

Recommendation 4 - Fit pot-type water seals with open trough water makeup as a replacement for the existing U-tube and pot-type seals The original design drawings for the gasholder show the inlet and outlet pipes extend 50 mm above the water line. The actual measured extension was less than 20 mm. Small variations in the level control could allow water to enter the lines.

Recommendation 5 - The building is fitted with partially closed-in ends that can trap the gas under the roof. The current construction standard for this type of facility is to have the storage banks in an open area rather than inside a building of any kind. Any leakage will then quickly disperse into the atmosphere and not form an explosive mixture. This is not practicable at the current plant, but improvements are possible.

Recommendation 6 - Remove the end sheeting from the building to increase ventilation.

Recommendation 7 - Conduct an investigation into the feasibility of establishing a gas-up station away from the hydrogen generation plant, possibly near the CO2 plant, to allow the units to be gassed from transportable pallets in an emergency.

Email (Primary):
Description
Characteristics: High Pressure (> 100 bar)
Damage and Injuries: Minor Injury, Property Damage
Incident Date:
Severity: Incident
Leak: Yes
Ignition: Yes
Ignition Source:
Setting: Refinery
Probable Cause: Human Error
When Incident Discovered: During Operations
Lessons Learned:

In the future, refining, petrochemical, and chemical industries need to review material verification programs to ensure that the maintenance procedures include sufficient controls and positive material identification (PMI) testing to prevent improper material substitutions in hazardous process systems.

Human Factors Based Design 
Designers should consider the entire process system life cycle, including planned maintenance, to avoid piping configurations that allow critical alloy piping components to be interchanged with non-compatible piping components.

Positive Material Verification Programs 
In-situ alloy steel material verification using x-ray fluorescence or non-destructive material testing is an accurate, inexpensive, and fast PMI test method. Facility owners, operators, and maintenance contractors should ensure that the verification program requires PMI testing, such as specified in API Recommended Practice 578, or other suitable verification process, for all critical-service alloy steel piping components that are removed and reinstalled during maintenance.

At a minimum, piping components and their respective locations should be tagged or marked before removal, and the correct installed location should be verified after reinstallation.

Email (Primary):
Description
Characteristics:
Damage and Injuries: Property Damage
Incident Date:
Severity: Incident
Leak: Yes
Ignition: Yes
Ignition Source:
Setting: Paper Mill
Probable Cause: Abnormal Operations
When Incident Discovered: During Operations
Lessons Learned:

The accident proves that under special circumstances, the potential hazard connected with unforeseen microbial gas formation and accumulation should not be neglected. Thus, to avoid new accidents at the paper mill described above, the tower has now been equipped with a high-capacity fan for dilution of possible gases with air. Precautions are also taken to reduce the microbial contamination.

Email (Primary):
Description
Characteristics:
Damage and Injuries: Property Damage
Incident Date:
Severity: Incident
Leak: Yes
Ignition: Yes
Ignition Source:
Probable Cause: Abnormal Operations
When Incident Discovered: During Operations
Lessons Learned:

The lesson to pass on is that ventilation is critical in UPS battery rooms. Great care should be taken to ensure that the ventilation system is operational and brings in enough outdoor air to properly ventilate the enclosure.

Electrical safety interlocks should also be considered, which would isolate the batteries from their power supply, not allowing the batteries to charge if the ventilation system isn't working properly.

It is imperative that the battery room designers pay close attention to the design of ventilation systems and electrical safety interlocks. There are lots of good (and bad) ways to design and install battery rooms and critical ventilation systems. If designers do not have experience designing UPS battery rooms, experienced consultants should be contacted to ensure a safe and effective design.

In addition, internal management procedures need to be developed which analyze operation of such systems. As in this case, the entire data center was removed and the UPS system was no longer needed. The UPS system should have been decommissioned when the data center was removed. A good management-of-change procedure would have uncovered this problem before it became an incident.

More information on management of change can be found in the Lessons Learned Corner and also in the Hydrogen Safety Best Practices Manual.

Email (Primary):
Description
Characteristics: High Pressure (> 100 bar)
Contributing Factors: Design Flaw
Damage and Injuries: None
Incident Date:
Severity: Incident
Leak: Yes
Ignition: No
Ignition Source:
Equipment: Compressor, Piping
Probable Cause: Equipment Failure
When Incident Discovered: During Operations
Lessons Learned:

Hydrogen distribution lines should be designed and carefully inspected to ensure process equipment in the area is correctly and safely installed. Equipment subject to vibration should not be placed in contact with hydrogen lines or with other equipment.

If equipment is moved or rearranged, the hydrogen system should be re-inspected as per the above.

Email (Primary):
Description
Characteristics:
Damage and Injuries: Lost Time Injury, Minor Injury
Incident Date:
Severity: Incident
Leak: No
Ignition: No
Ignition Source:
Equipment: Hydraulic Jacks
When Incident Discovered: During Operations
Lessons Learned:

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 environment. Workers should be aware of potential hazards and un­known configurations before they begin work. Job hazard analyses should identify all situations that could pose a hazard to workers.

Email (Primary):
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