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Inadequate Maintenance at a Soap Manufacturing Plant Causes a Hydrogen Flash Fire

Severity
Incident
Was Hydrogen Released?
Yes
Was There Ignition?
Yes
Incident Date
Incident Attributes
Describe the incident, including corrective steps taken and their result.

An employee at a soap manufacturing plant died in a flash fire outside the facility's hydrogenation building. Responding personnel encountered a fire at the base of the plant's hydrogen storage towers, and they found the victim, who was burned over 90 percent of his body, some 50 feet away.

Officials determined that a pipe connection failed and that hydrogen, pressurized at 1,800 psi, ignited when it was released into the atmosphere, killing the plant operator.

According to reports, the pipe connection failure stemmed from pressures higher than design tolerance, which in turn were the result of over tightening that occurred during routine maintenance replacement. The new bolts were stronger than those they replaced, and the threads of the nuts had been partially corroded with age.

This combination of factors led to the failure and the flash fire. The facility's automatic detection system and wet pipe sprinkler system were not factors in the fire. When the plant's emergency response team arrived, it directed two monitor nozzles on the fire scene and the hydrogen towers. Responding fire companies added a third nozzle stream when they arrived at 11:50 am. The combined forces knocked down the fire in just over one-half hour.

Damage was estimated at $250,000.

Lessons Learned

Routine maintenance activities on pressurized hydrogen systems should be conducted per written design specifications. The procedures should provide detailed oversight regarding bolt, nut and fitting replacements or repairs. A formal review process should be required to ensure that the maintenance was performed according to the written specifications, and that the hydrogen system will continue to function as designed until the next scheduled maintenance activity.

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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