CHECK OUT OUR MOST RELEVANT INCIDENT LISTINGS! 

Disclaimer: The Lessons Learned Database includes the incidents that were voluntarily submitted. The database is not a comprehensive source for all incidents that have occurred.

Implement rigorous assembly, verification, and documentation procedures for equipment.

Increase automated leak detection frequency.

Do not interconnect hydrogen drain trap lines with other drain lines

Thoroughly inspect equipment installation to manufacturer’s installation instructions

Warn against unauthorized field modifications

Consult the…

Maintain an internal process for verifying component wetted material compatibility for intended use as part of the procurement process for hydrogen system equipment. 

Don’t rely solely on a manufacturer to provide appropriately rated…

The procedure for disposal of spent or partially spent AB has been modified so that it does not include the use of water. Instead, the AB is removed from containers and transferred for disposal by rinsing with mineral oil, silicone oil or other…

The researcher's failure to pull the fire alarm was an oversight of required facility practice. The alarm should have been triggered in consideration of the potential for greater harm to personnel and facilities.

Hot, reacting ammonia…

An investigative communication notes that "mechanical integrity programs at refineries repeatedly emphasize inspection strategies rather then the use of inherently safer design to control the damage mechanisms that ultimately cause major…

Carbon steel Nelson curve methodology cannot be depended on to prevent HTHA equipment failures and cannot be reliably used to predict the occurrence of HTHA equipment damage. Revisions to recommended practices should be considered regarding the…

An important aspect of the reliability of a valve is the condition of the stem seal which tends to deteriorate with time and wear. Valves used in hydrogen service should be packed with the correct valve packing material and periodically checked…

Personnel were focused on the AGES system test and results, not the compatibility of the test equipment. The manual valve was needed to successfully test the system, however the fact that this particular valve could not accommodate the full…

The hydrogen supplier installed a fire-resistant material board adjacent to the high-pressure hydrogen storage banks to prevent any potential jet flames from affecting adjacent high-pressure cylinders for several minutes. The 0.25 mm sandwich…

Three root-causes were noted during the investigation: (1) the use of incompatible materials in the manufacturing of the PRD valve, (2) improper assembly resulting in over-torquing of the inner assembly, and (3) over-hardening of the inner…

Because the bottle was located outside at the time of the event, and the hydrogen did not find a source of ignition while venting through the relief valve, nothing serious happened. The failed regulator was replaced and operations continued.…

The presence of other flammable impurities (e.g., oil carryover from compressors, hydrocarbon contamination of the gas) is an additional hazard and should be eliminated before cryogenic purification.Potential sources of oxygen in the system…

As stated on the MSDS and also on the container labels, LiAlH4 should be handled under argon. LiAlH4 is advertised and sold as a powder. If the researcher had to scrape it out of the jar, then it was no longer a powder, which seems indicative of…

The project team concluded that the jar contained a sufficient vapor pressure of isopropanol to ignite when it came into contact with the decomposing hydride. The lesson learned was that hydrides react rapidly in air and can lead to combustion of…

The company investigation revealed that the incident arose because insufficient water was added to the batch. This resulted in a rapid increase in temperature and evolution of hydrogen gas following the addition of aluminum powder in the last…

The following actions were proposed as a result of this incident: The company in charge of valve calibration and maintenance will be subject to approval of the plant service inspection team. Plant operating procedures will be improved. The…

The incident was the result of a combination of factors leading to exceptional temperature conditions that were not taken into account in the mechanical design of the reactor. Corrective actions that were implemented by the plant management…

In addition to the probable causes listed above, the lack of a standard operating procedure for hydrogen leak detection was one of the probable causes of this incident. Additional contributing factors included the following:
- Severe pipe…

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