First Name
Andy
Last Name
Piatt
Severity
Incident
Was Hydrogen Released?
No
Was There Ignition?
No
Incident Date
Jan 30, 2005
Setting
Equipment
  • Piping/Fittings/Valves
  • Piping
  • Heating Equipment
  • Furnace
Damage and Injuries
When Incident Was Discovered
Lessons Learned

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.
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.
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.
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.

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