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.
1. Evaluate any change in normal procedures or conditions for storage of aluminum hydride products. In this case, the aluminum hydride material was typically stored at -35°C in the glove box freezer. However, due to a change in glove boxes, this…
Operation and management of the hydrodesulfurization unit should be strengthened to account for abnormal phenomena such as local corrosion.
The safety review system for remodeling existing equipment and facilities should be strengthened.…
The plant tried to increase production and decrease workload, but failed to notice the potential negative outcomes of this change.
It is necessary to thoroughly simulate all potential negative outcomes of a change in procedures.
…
The dilution water for making a polythionic acid aqueous solution was changed from industrial water to pure water to lower the chlorine concentration in the piping.
Water that accumulated in the drain was removed before heating began.…
Lessons Learned
Construction errors are difficult to detect once construction is complete. It is important to develop and use a systematic oversight process for minimizing construction errors during the construction process.
…
Lessons Learned The site initiated the establishment of a field patrol and strengthened their onsite monitoring of mechanical equipment during a plant-wide temperature rise.
Quantitative control of tightening torque on bolts should be…
Normally hydrogen fires are not extinguished until the supply of hydrogen has been shut off due to the danger of re-ignition and explosion. During a gas leak/fire, it is important to shut off the source of the hydrogen if it is safe to do so. If…
All tank trailers should have a safely accessible auxiliary shut off valve in case of spills.
Emergency personnel need to have access to all of the appropriate protective clothing, including shoes. Liquid hydrogen is stored at 20.28 Kelvin…
In addition to resealing the glove box window, a positive pressure of argon gas was maintained inside the glove box while the course of action was planned. Subsequently, the glove box was cleaned up by specialized hazardous materials personnel…
The above described events are an indication of a potential licensee/vendor interface problem. Based on the information received, the vendor was not completely informed via the purchase specifications regarding the service condition to which the…
An important lesson to be derived from this incident is the need to carefully engineer and test all repairs and modifications to high-pressure process equipment.
Installation
Fittings need to be visually inspected to insure ferules are in place and correctly positioned prior to swageing.
Research staff are responsible for communicating system specifications [gas type, Maximum Allowable…
This occurrence underscores the importance of completing a hazard analysis for each different process. Non-safety-related systems or equipment may be used for purposes other than their primary purpose so long as potential hazards are identified…
Hazard analysis should consider potential leak locations, potential ignition sources in the vicinity, and the potential for accumulating flammable gases in that area.
Users should leak-check all cylinders upon installation. This event…
Key:
- = No Ignition
- = Explosion
- = Fire
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 |
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 |
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Fuel Dispenser | 8/2/2004 5/1/2007 6/11/2007 9/19/2007 |
2/24/2006 1/22/2009 |
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Fuel Cell Stack | |||||||
Hydrogen Cooled Generator | 12/31/1969 2/7/2009 |
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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