Severity
Incident
Leak
Yes
Ignition
No

Incident Synopsis

A technician accidentally loosened critical bolts holding a fitting to the top of an H2 tank, which caused a large hydrogen leak in the dewar. The fitting contained various instruments, and upon loosening the third bolt, H2 gas exited through an opening in the seal. The Viton or neoprene O-ring was blown out of its groove and was immediately frozen, making it impossible to reseal the fitting cover. The area was evacuated, the dewar was vented and the gasket was replaced. The ullage space was not purged with helium gas during the gasket replacement, which may have been responsible for small leaks which developed during the transfer.

Cause

The fitting containing the instruments was mounted on a flange, which was in turn secured to another flange. Long bolts and short bolts were used to retain the components. The bolt heads were identical and not identified, hence leading to the error in loosening the wrong bolts. The leaks that occurred after the gasket was replaced were probably due to moisture condensation on related vent valve components.

Incident Date
Dec 31, 1969
Setting
Equipment
  • Hydrogen Storage Equipment
  • Dewar
Damage and Injuries
Contributing Factors
Characteristics
When Incident Discovered
Lessons Learned

Proper bolt identification can prevent similar occurrences in the future. This can be achieved by simply painting the critical bolt heads a certain color (or by purchasing bolts with painted bolt heads). An explanation form should then be clearly posted, which indicates which bolts are critical, and which aren't. This information should then be disseminated to all of the relevant technicians.

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