First Name
Andy
Last Name
Piatt
Severity
Near-Miss
Was Hydrogen Released?
No
Was There Ignition?
No
Incident Date
Mar 22, 1999
Equipment
  • Safety Systems
  • Measurement / Sensing Device
Damage and Injuries
When Incident Was Discovered
Lessons Learned

The lessons learned in this situation center around basic conduct of operations principles. Policies and procedures related to operations performance, safety performance, and management oversight were in place. They were not employed appropriately.

There were approved operations procedures in place to provide direction to personnel to ensure that the SHMS would be operated within its design basis. Those approved and available procedures provided the needed operational direction to accomplish safety, process quality, and control activities. Had the operator made use of the available procedures, the incident very likely would not have occurred.

When operational direction is available (procedures, turnover logs, etc), compliance with that operational direction is required. Communications and shift turnover protocols in this situation were wholly inadequate. Accurate communication is essential for the safe and efficient operation of facilities, systems, and equipment; highly reliable communication provides accurate transmission of information within a facility. That transmission of communication did not occur in this situation. The facility operations personnel should have known the status of all equipment and systems, and should have been able to maintain control at all times. The saltwell pumping activities require interface and coordination between roving operators, specific evolution-related operators, and shift supervisors. That integrative communication did not take place. From the shift supervisor on down, shift personnel should have been aware of operations planned or in progress; status of facility systems and equipment; and any abnormal conditions which may have existed. That information was not effectively documented or transmitted. In addition, the authorization, communication, and documentation of status changes was not thoroughly executed.

Startup and shutdown of systems and equipment require assessing status on a continuing basis. Notification of changes in system status by operators and shift supervisors must be comprehensive and complete to ensure an understanding of and adherence to precautions and prerequisites for safe shift evolutions.

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