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Roofing Work Condition Outside Authorization Basis

Severity
Non-Event
Was Hydrogen Released?
No
Was There Ignition?
No
Incident Date
Incident Attributes
Setting
Damage and Injuries
Probable Cause
Contributing Factors
When Incident Was Discovered
Describe the incident, including corrective steps taken and their result.

A facility manager was notified that an authorization basis requirement, associated with roofing contractor work, had not been met. The requirement was that an unused hydrogen gas cylinder adjacent to the building and not connected to a manifold be removed prior to the use of propane tanks for the hot tar portion of the work.

The project manager failed to remove the extra gas bottle as required because he did not recognize from the bottle color and lack of stencil that the bottle contained hydrogen.

An explicit checklist containing all the administrative controls and requiring careful inspection was not available at the time of the inspection. The checklist preparation also would have made obvious the fact that administrative controls had been established. The project manager paid insufficient attention to his inspection and did not notice that the extra gas bottle had a tag attached identifying its contents. Unlike the adjacent bottle that was connected to the manifold and therefore acceptable, the extra bottle was painted red only at the top and lacked the identifying stencil "HYDROGEN".

The root cause was that management did not require a consolidated checklist based on the controls identified by the facility as a part of the work planning and organization process and assure that the controls were in place prior to commencing the work.

Lessons Learned

This occurrence points to the importance of gathering and organizing all applicable administrative controls and other commitments prior to commencing work. It also re-emphasizes the importance of attention to detail, not only by the person responsible, but also by anyone confirming compliance.

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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