Gas Cylinder Inadvertently Replaced with Hydrogen Gas Cylinder for Use in AL Proportional Counter

Severity

Incident

Was Hydrogen Released?

Yes

Was There Ignition?

Incident Date

Dec 15, 2003

Setting

Laboratory

Equipment

Hydrogen Storage Equipment
Gas cylinder

Damage and Injuries

None

Probable Cause

Improper/Inadequate Equipment Labeling

Contributing Factors

Human Error

When Incident Was Discovered

During Operations

Lessons Learned

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. Personnel should ensure that labels are read and understood prior to mixing, dispensing, or transferring chemicals.

Key:

= No Ignition
= Explosion
= Fire

Hydrogen Incident Summaries by Equipment and Primary Cause/Issue
Equipment / Cause	Equipment Design or Selection	Component Failure	Operational Error	Installation or Maintenance	Inadequate Gas or Flame Detection	Emergency Shutdown Response	Other or Unknown
Hydrogen Gas Metal Cylinder or Regulator		3/31/2012 4/30/1995 2/6/2013	4/26/2010	12/31/1969			3/17/1999 11/1/2001 12/23/2003
Piping/Valves	4/4/2002 2/2/2008 5/11/1999	4/20/1987 11/4/1997 12/31/1969 8/19/1986 7/27/1991 12/19/2004 2/6/2008 10/3/2008 4/5/2006 5/1/2007 9/19/2007 10/31/1980	2/7/2009	1/24/1999 2/24/2006 6/8/1998 12/31/1969 2/7/2009	9/1/1992 10/31/1980	10/3/2008
Tubing/Fittings/Hose		9/23/1999 8/2/2004 8/6/2008 9/19/2007	1/1/1982	9/30/2004 10/7/2005		10/7/2005
Compressor		10/5/2009 6/10/2007 8/21/2008 1/15/2019			10/5/2009	8/21/2008
Liquid Hydrogen Tank or Delivery Truck	4/27/1989	12/19/2004 1/19/2009	8/6/2004	12/31/1969		1/1/1974	12/17/2004
Pressure Relief Device	7/25/2013 5/4/2012	1/15/2002 1/08/2007	12/31/1969
Instrument	1/15/2019	3/17/1999 12/31/1969 2/6/2013			11/13/73
Hydrogen Generation Equipment	7/27/1999			10/23/2001
Vehicle or Lift Truck		7/21/2011					2/8/2011 12/9/2010
Fuel Dispenser		8/2/2004 5/1/2007 6/11/2007 9/19/2007		2/24/2006 1/22/2009
Fuel Cell Stack							5/3/2004 12/9/2010 2/8/2011
Hydrogen Cooled Generator				12/31/1969 2/7/2009
Other (floor drain, lab anaerobic chamber, heated glassware, test chamber, gaseous hydrogen composite cylinder, delivery truck)		11/14/1994 7/21/2011	7/27/1999 6/28/2010 8/21/2008	12/31/1969 3/22/2018			6/10/2019

= No Ignition
= Explosion
= Fire