First Name
Andy
Last Name
Piatt
Severity
Incident
Was Hydrogen Released?
Yes
Was There Ignition?
Yes
Ignition Source
unknown
Incident Date
Apr 20, 1984
Setting
Equipment
  • Motive Power Systems
  • Compressor
  • Piping/Fittings/Valves
  • Gasket
  • Piping/Fittings/Valves
  • Flange
When Incident Was Discovered
Lessons Learned

The investigation team concluded that hydrogen gas was released through a failed 19-inch diameter gasket and ignited under the roof of the compressor shed where it was partially confined. Some gas escaped from the shed prior to the explosion, but it was confined beneath the deck of an adjacent structure and overhead piping. The compressor shed was originally just a roof over the compressors, but over time, walls were added to aid winter operation and maintenance. These walls resulted in confinement of the hydrogen and contributed to the violent explosion.

Unauthorized modifications played a major role in this incident. The team discovered that the original design specifications called for a spiral-wound gasket, but for the previous 7 or 8 years, only compressed asbestos fiber (CAF) gaskets had been used. It appears that the risk of the gasket disintegrating or blowing out during a high-pressure leak had not been identified.

Actions taken as a result of the incident included the following:

Checklists for startup and shutdown procedures, and design and engineering safety were updated and became mandatory.
Pressure testing at operating pressure became mandatory prior to process startup.
Process hazard analysis was introduced. - Gasket material specifications were revised.
Separation standards were developed and implemented for all site buildings and facilities.
Shatter-resistant windows and doors were installed.
Process enclosures were minimized in new designs and existing enclosures were opened up and/or forced ventilation was upgraded.
A formal modification procedure was instituted (i.e., management of change).
Additional combustible gas detectors were installed, with frequent calibration and maintenance required. - Emergency shutoff valves were installed on vessels with critical hydrocarbon inventories.
Awareness of chemical processing hazards was increased among all employees through better communication and training.

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