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Hydrogen Leak due to Inappropriate Operator Action results in Fire

Severity
Incident
Was Hydrogen Released?
Yes
Was There Ignition?
Yes
Incident Date
Ignition Source
self ignition
Incident Attributes
Setting
Equipment
Probable Cause
When Incident Was Discovered
Describe the incident, including corrective steps taken and their result.

Unit 1 Plant power was stable at 90% following a plant startup. The Auxiliary Operator (AO) performed a pre-job brief with shift management before adding hydrogen to the main generator. While performing the addition, the AO attempted to verify open a half-inch hydrogen addition valve. The AO was unable to move the valve by hand and mistakenly assumed the valve was stuck on its closed seat. The valve is a normally open valve and the procedure step was to verify the valve was, in fact, open. The AO obtained a pipe wrench to assist in freeing the valve off of its "closed" seat. Using the pipe wrench, the valve handwheel was turned in the open direction. The AO attempted to open the valve by hand again. Unable to move the valve by hand, the pipe wrench was used to further open the valve approximately 6 turns (two turns of the handwheel for this particular valve results in full stem travel). The bonnet, handwheel, stem and valve internals were eventually ejected from the body of the valve by hydrogen system pressure. The AO promptly evacuated the area due to the hydrogen release and the hydrogen ignited within seconds. The AO informed the Control Room via radio of the leak and fire at the hydrogen add station. The AO and other operators proceeded immediately to the hydrogen bulk storage facility to isolate the hydrogen supply to the turbine building.

The control room supervisor directed a manual reactor trip. The plant Fire Plan and Abnormal Operating Procedure were entered and the fire brigade was dispatched. The hydrogen fire was extinguished following isolation of the hydrogen supply. However, there continued to be re-flash, arcing, and a small fire in the cable tray located in the overhead above the hydrogen add station. Fire extinguishers and eventually water were used to extinguish the fire in the cables.

A Notification of Unusual Event was declared for a fire not extinguished within 10 minutes. No injuries occurred as a result of this event. The damage in the cable tray required the replacement of 29 cables (480 volt). This and other damage to local components required the Unit to be shutdown for approximately five days to complete repairs.

Lessons Learned
  1. Follow the rules (e.g., using a torque-amplifying device requires supervisor approval).
  2. Some valves are susceptible to disassembly, with potentially significant consequences, if excessive torque is applied to the handwheel.

Key:

  • = No Ignition
  • = Explosion
  • = Fire
Hydrogen Incident Summaries by Equipment and Primary Cause/Issue
Equipment / CauseEquipment Design or SelectionComponent FailureOperational ErrorInstallation or MaintenanceInadequate Gas or Flame DetectionEmergency Shutdown ResponseOther or Unknown
Hydrogen Gas Metal Cylinder or Regulator 3/31/2012
4/30/1995
2/6/2013
4/26/201012/31/1969  3/17/1999
11/1/2001
12/23/2003
Piping/Valves4/4/2002
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
2/7/20091/24/1999
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
1/1/19829/30/2004
10/7/2005
 10/7/2005 
Compressor 10/5/2009
6/10/2007
8/21/2008
1/15/2019
  10/5/20098/21/2008 
Liquid Hydrogen Tank or Delivery Truck4/27/198912/19/2004
1/19/2009
8/6/200412/31/1969 1/1/197412/17/2004
Pressure Relief Device7/25/2013
5/4/2012
1/15/2002
1/08/2007
12/31/1969    
Instrument1/15/20193/17/1999
12/31/1969
2/6/2013
  11/13/73  
Hydrogen Generation Equipment7/27/1999  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
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