Lack of Protocol/SOP

During a facility walk-through, it was noted that a combustible gas (hydrogen) monitoring system installed in a furnace room was inoperable (the system had been unplugged). This system is used to detect and warn facility employees of an explosive or flammable environment. An explosive or flammable environment can only occur if there is a leak in the system, which would not be expected to occur during normal operations. When the system was reactivated, no leaks were indicated.

The incident had the following three causes:

A battery that was left on a charger over a given weekend was used to start a gasoline power generator. This battery was connected in series with another battery and the connection on the negative post was hand tightened. When an attempt was made to start the generator, the battery exploded on approximately the fifth click of the starter solenoid. No damage was done to any equipment or facilities and no one was injured.

On a given day personnel were removing a blind hub that had been used to temporarily isolate a portion of a gaseous hydrogen system. As a result of a sudden release of 2,800 psig gaseous nitrogen, sand and debris kicked up from the concrete pad and caused minor injury to two technicians.

During the investigation, it was found that:

An instrument engineer at a hydrogen production facility was arresting the hydrogen leakage in tapping a pressure transmitter containing 131-bar hydrogen gas. The isolation valve was closed and the fittings near the pressure transmitter were loosened. The pressure dropped from 131 bar to 51 bar. The fitting was further loosened (though very little); the instrument tube slipped out of the ferrule and got pulled out of the fitting. With the sudden release of the 51-bar hydrogen, there was a loud pop (like a fire cracker) and the spark-proof tool was observed to have black spot on it.

A metal hydride storage system was refilled using compressed hydrogen in a closed lab environment. The tank system is an in-house development and is optimized for high hydrogen storage density and use with an air-cooled fuel cell. The system is equipped with a pressure relief valve that opens gradually at 35 bar to protect the tank from overpressure conditions. The tank itself is designed to adsorb 400 g of hydrogen at a pressure less than 15 bar.

Operators in a powdered metals production facility heard a hissing noise near one of the plant furnaces and determined that it was a gas leak in the trench below the furnaces. The trench carried hydrogen, nitrogen, and cooling water runoff pipes as well as a vent pipe for the furnaces.

A university researcher reported that a fire resulted when he scraped lithium aluminum hydride (LiAlH4) out of the glass jar in which it was contained (see attached photo). The jar had been in the laboratory since 2005 (about 6 years), so the LiAlH4 was old. The researcher was using a dry metal spatula to scrape the LiAlH4 out of the jar. A quick review of the manufacturer's Material Safety Data Sheet (MSDS) for LiAlH4 informed the researcher of its moisture sensitivity, but there was no indication of friction causing a fire.

As part of preparing for material disposal, a small fire occurred within a fume hood as a researcher was combining several spent ammonia borane (AB) samples that had previously been stored uncovered in the back of the hood for 6+ months. These AB samples consisted primarily of two 40-gram products of a 50wt% AB in silicone oil that had been thermally dehydrogenated. A small amount of unreacted AB slurry is believed to also have been present.