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Lessons Learned

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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: Lost Time Injury, Property Damage
Incident Date:
Severity: Incident
Leak: Yes
Ignition: Yes
Ignition Source: spark from a faulty lamp
Equipment: Process Vessels
When Incident Discovered: During Operations
Lessons Learned:

The company investigation revealed that the incident arose because insufficient water was added to the batch. This resulted in a rapid increase in temperature and evolution of hydrogen gas following the addition of aluminum powder in the last seconds of the mix. Despite the presence of a functioning level-control valve on the mixer, the hydrogen gas was ignited when the operator opened the hatch. The most likely source of ignition was the faulty lamp. The operator was acting in accordance with his training and following the company's written safety procedures.

The company took a number of measures to prevent a reoccurrence of this incident, including:

  •  provision of intrinsically safe lamps
  •  introduction of daily checks of the vent valve
  •  minor modification to LEV and increased venting throughout the mixing process
  •  lab testing by the aluminum supplier to evaluate system safety with regard to hydrogen generation for all reaction conditions and quantities of aluminum added
  •  reprogramming/development of the software to improve both the safety of the operation and operator understanding of warning alarms.
Email (Primary):
Description
Characteristics: High Pressure (> 100 bar)
Contributing Factors: Deficiency in Procedures
Incident Date:
Severity: Incident
Leak: Yes
Ignition: Yes
Ignition Source: self-ignition
Equipment: Flange, Bolts
When Incident Discovered: During Operations
Lessons Learned:

The incident was the result of a combination of factors leading to exceptional temperature conditions that were not taken into account in the mechanical design of the reactor. Corrective actions that were implemented by the plant management included:

  • redefinition of the appropriate tightening torque on flanges
  • improved design of the leak collector on the flange (which failed during the accident)
  • creation of a nitrogen injection system in the leak collector
  • installation of a steam-injection system to protect the bottom part of the synthesis reactor.
Email (Primary):
Description
Characteristics: High Pressure (> 100 bar)
Incident Date:
Severity: Incident
Leak: Yes
Ignition: Yes
Ignition Source: self-ignition
Probable Cause: Equipment Failure
When Incident Discovered: During Operations
Lessons Learned:

The following actions were proposed as a result of this incident:

  •  The company in charge of valve calibration and maintenance will be subject to approval of the plant service inspection team.
  •  Plant operating procedures will be improved.
  •  The specifications concerning the mounting and revision of valves will be strengthened.
  •  An additional pressure sensor will be installed.
Email (Primary):
Description
Characteristics:
Contributing Factors:
Damage and Injuries: None
Incident Date:
Severity: Incident
Leak: Yes
Ignition: Yes
Ignition Source: reactive hydride exposed to air
Setting: Laboratory
Equipment: Glassware
When Incident Discovered: During Operations
Lessons Learned:

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 any organic vapor that might be present nearby. Thus, the project team adopted a procedure that all hydrides must be submerged in mineral oil before they are removed from the glove box to prevent exposure to air before isopropanol treatment. Since this procedure was adopted for pacification/disposal of hydrides, there have been no more incidents or near-misses of this type in the laboratory.

Email (Primary):
Description
Contributing Factors:
Damage and Injuries: Property Damage
Incident Date:
Severity: Incident
Leak: Yes
Ignition: Yes
Ignition Source:
Equipment: Process Vessels
When Incident Discovered: During Operations
Lessons Learned:
  1. The presence of other flammable impurities (e.g., oil carryover from compressors, hydrocarbon contamination of the gas) is an additional hazard and should be eliminated before cryogenic purification.
  2. Potential sources of oxygen in the system include:
    1. Oxygen or air impurity entrainment in the main gas to be purified in conjunction with failure of the upstream processes to remove these impurities.
    2. Regeneration of previously desorbed oxygen in the activated carbon bed.
    3. Accidental ingress of oxygen or air in the upstream processes (e.g., during vacuum or low-pressure processes).
  3. Risk mitigation methods for processes involving cryogenic activated carbon adsorbers include:
    1. Identify and eliminate by design the following:
      1. Potential formation of liquid oxygen and its contact with the activated carbon bed. Sources of liquid oxygen could be air ingress or oxygen impurity being entrained in the main gas to be purified/liquefied.
      2. Potential ignition mechanisms/sources (e.g., electric heaters used for regeneration).
      3. Use of alternative/substitute adsorbent that is noncombustible with liquid oxygen (e.g., silica gel, molecular sieve).
      4. Add an oxygen trap (e.g., silica gel, liquid nitrogen trap/knockout pot system) upstream of the activated carbon adsorbent bed.
      5. Avoid having sudden flow or pressure changes through the activated carbon adsorber, since these would increase the likelihood of ignition.
    2. Use sensors to identify the presence of oxygen or air ingress upstream and actuate alarms or system emergency stop when concentrations exceed predetermined set points.
    3. Purge the adsorber bed with an inert gas to reduce the risk of ignition if high oxygen concentrations are present.
    4. Alternatively, pull a vacuum on the adsorber to remove any adsorbed oxygen before the adsorber is put back online.
    5. Look for alternatives to or add-on features for pressure-reducing devices.
  4. Years of satisfactory service without incident should not be taken as proof of safe operation of cryogenic activated carbon adsorbers.
Email (Primary):
Description
Characteristics: High Pressure (> 100 bar)
Incident Date:
Severity: Incident
Leak: Yes
Ignition: Yes
Ignition Source: Either static electricity or spark from escaping particle
When Incident Discovered: During Operations
Lessons Learned:

Three root-causes were noted during the investigation: (1) the use of incompatible materials in the manufacturing of the PRD valve, (2) improper assembly resulting in over-torquing of the inner assembly, and (3) over-hardening of the inner assembly materials by the valve manufacturer. These problems could have been avoided by adequate quality assurance/quality control procedures during the design and safety reviews.

The canopy was added to the station as an afterthought, sometime following the HazOps review. The prestart-up safety review by all parties and the local authority having jurisdiction did not recognize the setback distance of the canopy. Had an engineering management of change, follow-up HazOp or other form of risk assessment been conducted, it is likely that the vent stacks adjacent to the canopy would have been raised in order to avoid any damage in the event of a fire.

Prior to reopening the station, physical changes were made using the correct PRD valves and higher vent stacks, and new and modified procedures were instituted to improve the timely communication of station status during emergency events. Additional training of personnel focused on improving the response time and effective communication between employees, first responders, and the hydrogen equipment supplier.

Email (Primary):
Description
Characteristics: High Pressure (> 100 bar)
Contributing Factors:
Damage and Injuries: None
Incident Date:
Severity: Incident
Leak: Yes
Ignition: No
Ignition Source:
Equipment: Gas cylinder
Probable Cause: Equipment Failure
When Incident Discovered: During Operations
Lessons Learned:
  1. The hydrogen supplier installed a fire-resistant material board adjacent to the high-pressure hydrogen storage banks to prevent any potential jet flames from affecting adjacent high-pressure cylinders for several minutes. The 0.25 mm sandwich board of fiberglass-reinforced, lightweight concrete is easy to maintain and does not rot under outside conditions. This safety measure was implemented just three days after the incident occurred, although it had been planned for a long time.
  2. The hydrogen supplier installed a semi-automated sprinkler system to cool the high-pressure hydrogen storage banks to prevent any potential escaping hydrogen gas that might ignite in jet flames from affecting other hydrogen cylinders. In addition, the dry piping system above the high-pressure hydrogen storage banks can be flooded with water by the fire department in case of fire or leakages in the high-pressure banks.
  3. The alarm system was refined to send automated messages to relevant personnel informing them of gas/fire alarms.
  4. The remote control room where service personnel are monitoring the fueling station is now equipped with an additional audio system to draw faster attention to alarms.
  5. All plans and emergency procedures have been reviewed, adjusted and edited to document changes and fully capture the lessons learned.
  6. Other learnings: Training for worst-case scenarios is recommended in order to be prepared for those siutations.
Email (Primary):
Description
Characteristics: High Pressure (> 100 bar)
Contributing Factors:
Damage and Injuries: None
Incident Date:
Severity: Incident
Leak: Yes
Ignition: No
Ignition Source:
When Incident Discovered: During Maintenance
Lessons Learned:

Personnel were focused on the AGES system test and results, not the compatibility of the test equipment. The manual valve was needed to successfully test the system, however the fact that this particular valve could not accommodate the full cylinder pressure was overlooked.

The following corrective actions will be implemented:

  1. Evaluate the interfaces between engineering and operations systems and procedures to manage temporary modification work.
  2. Develop and implement a procedure for engineering design of instrument systems.
  3. Evaluate alarms/emergency response procedures for a relevant set of facility systems and revise, if necessary.
  4. Evaluate the relevant facility building access training for appropriateness of the alarm response section and revise, if necessary.

This safety event suggests that temporary modifications, particularly those required for system testing, should be given the same level of attention and review as permanent modifications.

Email (Primary):
Description
Characteristics: High Pressure (> 100 bar)
Damage and Injuries: Property Damage
Incident Date:
Severity: Incident
Leak: Yes
Ignition: Yes
Ignition Source: unknown
When Incident Discovered: During Operations
Lessons Learned:

An important aspect of the reliability of a valve is the condition of the stem seal which tends to deteriorate with time and wear. Valves used in hydrogen service should be packed with the correct valve packing material and periodically checked for leaks as part of a regular maintenance program.

Email (Primary):
Description
Characteristics:
Damage and Injuries: Human Life, Property Damage
Incident Date:
Severity: Incident
Leak: Yes
Ignition: Yes
Ignition Source:
Setting: Refinery
When Incident Discovered: During Operations
Lessons Learned:
  1. Carbon steel Nelson curve methodology cannot be depended on to prevent HTHA equipment failures and cannot be reliably used to predict the occurrence of HTHA equipment damage. Revisions to recommended practices should be considered regarding the use of carbon steel in HTHA-susceptible service and the verification of actual operating conditions.
  2. Given the difficulty of inspecting for HTHA because the damage might not be detected, inherently safer design is a better approach to prevent HTHA.
  3. Process hazards analysis (PHA) and damage mechanism hazard reviews (DMHRs) need to carefully consider all assumptions, periodically if necessary, to ensure that hazard identification, safeguards and control of hazards to prevent equipment failure are effective.
  4. Effective programs need to be in place to manage and provide oversight for hazardous nonroutine work.
Email (Primary):
Description
Characteristics:
Incident Date:
Severity: Incident
Leak: Yes
Ignition: Yes
Ignition Source:
Setting: Refinery
When Incident Discovered: During Operations
Lessons Learned:

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 safety incidents." Regarding the similarity of this accident to others, it is also noted that "while sulfidation is a well-known damage mechanism at refineries that requires regular inspection and monitoring, the segment that failed has no record of ever being inspected."

NOTE: This record is based upon an investigative report and related communications and will be updated, as appropriate, when additional investigative reports are completed, released and reviewed. Additional details regarding mechanical integrity programs and procedures in place at the time of the accident are expected.

Email (Primary):
Description
Characteristics:
Damage and Injuries: Laboratory equipment damage
Incident Date:
Severity: Incident
Leak: Yes
Ignition: Yes
Ignition Source: (Spontaneous combustion)
Setting: Laboratory
When Incident Discovered: During Operations
Lessons Learned:

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 borane produces hydrogen as well as other pyrophoric impurities. Reactions should be carried out in inert atmospheres or purged with inert gases. Furthermore, efforts should be made to prevent oxygen from coming in contact with the material while hot.

As a consequence of this incident, an updated procedure was put in place to check critical fittings before each subsequent test and to purge the apparatus with argon in the area surrounding the reactor/fittings.

Email (Primary):
Description
Damage and Injuries: Project Delay
Incident Date:
Severity: Incident
Leak: Yes
Ignition: Yes
Ignition Source: (Spontaneous combustion)
Setting: Laboratory
When Incident Discovered: During Operations
Lessons Learned:

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 similar inert materials. It is then disposed of as a slurry.

Email (Primary):
Description
Characteristics: High Pressure (> 100 bar)
Contributing Factors: Design Flaw
Incident Date:
Severity: Near-Miss
Leak: Yes
Ignition: No
Ignition Source:
When Incident Discovered: During Operations
Lessons Learned:

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, pressures, temperatures, and other conditions experienced during operation of the system in which they are a part. Don’t rely solely on a manufacturer to provide appropriately rated materials and components. Verify components and their specifications as early in the design or procurement process as possible. Manufacturer-provided literature (brochures, instruction manuals, bills of materials, etc.) may not always identify the specific materials for each component, so verification may require Internet research or contacting the manufacturer to obtain the necessary information or certification. (Reference https://h2tools.org/tech-ref/technical-reference-for-hydrogen-compatibi…)

Email (Primary):
Description
Characteristics: High Pressure (> 100 bar)
Contributing Factors: Deficiency in Procedures, Human Error
Incident Date:
Severity: Incident
Leak: Yes
Ignition: Yes
Ignition Source: Undetermined, possible loose gravel
When Incident Discovered: During Operations
Lessons Learned:

Implement rigorous assembly, verification, and documentation procedures for equipment.

Increase automated leak detection frequency.

Email (Primary): enupo@nelhydrogen.com
Description
Characteristics:
Damage and Injuries: Lost Time Injury
Incident Date:
Severity: Incident
Leak: Yes
Ignition: Yes
Ignition Source: Electrical switch
When Incident Discovered: During Operations
Lessons Learned:

Do not interconnect hydrogen drain trap lines with other drain lines

Thoroughly inspect equipment installation to manufacturer’s installation instructions

Warn against unauthorized field modifications

Consult the manufacturer and listing agency before any field modifications are undertaken

Email (Primary): Aaron.Corvin@oregon.gov
Description
Characteristics: High Pressure (> 100 bar)
Contributing Factors: Fatigue
Incident Date:
Severity: Incident
Leak: Yes
Ignition: No
Ignition Source:
When Incident Discovered: During Operations
Lessons Learned:

Maintain an internal process for verifying component wetted material compatibility for intended use as part of the procurement process for hydrogen system equipment. 

Don’t rely solely on a manufacturer to provide appropriately rated materials and components. Verify H2 compatibility of components and their specifications as early in the design or procurement process as possible.

Manufacturer-provided literature (brochures, instruction manuals, bills of materials, etc.) may not always identify the specific materials for each component, so verification may require Internet research or contacting the manufacturer to obtain the necessary information or certification. 

Email (Primary): Danny.Terlip@nrel.gov
Description
Characteristics: High Pressure (> 100 bar)
Contributing Factors:
Incident Date:
Severity: Incident
Leak: No
Ignition: No
Ignition Source:
Probable Cause: Equipment Failure
When Incident Discovered: During Operations
Lessons Learned: Proactive pre-operational training of host site personnel and first responders helped assure a measured response to this incident. First responders were familiar with location of local alarm panels, emergency stop actuation, and hydrogen storage. First responders will use site orientation presentation materials in post-incident training. Keep spare alarm equipment in stock to minimize repair time. Check hydrogen sensor readings monthly. Calibrate hydrogen sensors every 3 months.
Email (Primary):
Description
Characteristics:
Contributing Factors: Human Error
Damage and Injuries: Property Damage
Incident Date:
Severity: Incident
Leak: Yes
Ignition: No
Ignition Source:
Setting: Power Plant
When Incident Discovered: During Operations
Lessons Learned:
  1. Train personnel on delivery procedures and emphasize the safety aspects of hydrogen connections and disconnections, and verification of clearance for trailer movement prior to departure.
  2. Provide site-specific delivery procedures and possibly include a checklist as a reminder of key safety items prior to departure.
Email (Primary):
Description
Characteristics: High Pressure (> 100 bar)
Contributing Factors:
Damage and Injuries: None
Incident Date:
Severity: Incident
Leak: Yes
Ignition: No
Ignition Source:
Setting: Power Plant
Probable Cause: Fault in original weld
When Incident Discovered: During Operations
Lessons Learned:
  1. Defects in equipment, such as welds, may not be evident during initial proof testing and operation.
  2. When an equipment defect is found, check equipment for possible similar defects in other areas of the equipment.
Email (Primary):
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