Severity
Incident
Was Hydrogen Released?
Was There Ignition?
Incident Date
Incident Attributes
Lessons Learned

1. Management must ensure that operating decisions are not based primarily on cost and production. Performance goals and operating risks must be effectively communicated to all employees. Facility management must set safe, achievable operating limits and not tolerate deviations from these limits. Risks of deviation from operating limits must be fully understood by operators. Also, management must provide an operating environment conducive for operators to follow emergency shutdown procedures when required.

2. Process instrumentation and controls should be designed to consider human factors consistent with good industry practice. Hydroprocessing reactor temperature controls should be consolidated with all necessary data available in the control room. Some backup system of temperature indicators should be used so that the reactors can be operated safely in case of instrument malfunction. Each alarm system should be designed to allow critical emergency alarms to be distinguished from other operating alarms.

3. Adequate supervision is needed for operators, especially to address critical or abnormal situations. Supervisors need to ensure that all required procedures are followed. Supervisors should identify and address all operating hazards and conduct thorough investigation of deviations to determine root causes and take corrective action. Equipment and job performance issues related to operating incidents should be corrected by management.

4. Facilities should maintain equipment integrity and discontinue operation if integrity is compromised. Hydroprocessing operations especially need to have reliable temperature monitoring systems and emergency shutdown equipment. Equipment should be tested regularly and practice emergency drills should be held on a regular basis. Maintenance and instrumentation support should be available during start up after equipment installation or major maintenance.

5. Management must ensure that operators receive regular training on the unit process operations and chemistry. For hydrocrackers, this should include training on reaction kinetics and the causes and control of temperature excursions. Operators need to be trained on the limitations of process instruments and how to handle instrument malfunctions. Facilities need to ensure that operators receive regular training on the use of the emergency shutdown systems and the need to activate these systems.

6. Management must develop written operating procedures for all phases of hydrocracker operations. The procedures should include operating limits and consequences of deviation from the limits. The procedures should be reviewed regularly and updated to reflect changes in equipment, process chemistry, and operation. As appropriate, the procedures should be updated to include recommendations from process hazard analysis and incident investigations.

7. Process hazard analysis must be based on actual equipment and operating conditions that exist at the time of the analysis. The analysis should include the failure of critical operating systems, such as temperature monitors or emergency operating systems. A Management of Change review should be conducted for all changes to equipment or processes, as necessary, and should include a safety hazard review of the changes.

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