The combination of the cold water temperature (reducing the fatigue strength of the bolt), and the abnormally high number of cyclical stresses imposed by the imbalance from the hydraulic system check valve failure resulted in the failure of the…

Proper installation of check valves and other equipment should be visually inspected prior to pressurization.

Maintenance on the low-pressure venting system was not occurring at regular intervals. Ventilation integrity is now checked before starting an experiment.

Excessive venting of hydrogen from the tank due to lower facility consumption, in combination with extreme temperature conditions, placed thermal stress on the gland nut, causing a leak. The low consumption of hydrogen resulted from the shutdown…

Disable the fueling process if the operator does not follow the proper sequence of steps in the fueling procedure. Improve the fueling procedure to make it inherently impossible for the sequence to be done improperly with the same result.

Shutoff valve location and/or redundant shutoff valves at storage vessels are important for containment to prevent escalation.
Consider design features within equipment skids to reduce the likelihood of cascading events.
Pressure-switch…

• Replace the existing copper and carbon steel hydrogen pipeline with ¾-inch schedule 40 stainless steel.
• Reroute the new hydrogen line in the preferred location.
• Locate new hydrogen shut-off valves in a more convenient…

1. A hydrogen tube pressure indication system needs to be developed that is robust enough to withstand an accident, indicates hydrogen pressure regardless of valve position, and would be visible from a safe distance during an accident…

1. Increased structural protection is needed at the back of a hydrogen tube trailer to protect the vulnerable hydrogen systems components in this location (valves, pressure-indicating devices, manifolds, piping) in case of an accident. Side…

1. A hydrogen tube pressure indication system needs to be developed that is robust enough to withstand an accident, indicates hydrogen pressure regardless of valve position, and would be visible from a safe distance during an accident…

1. Provide additional retraining of operators. Curriculum should emphasize the proper response to high oxygen in the hydrogen gas.
2. Evaluate current knowledge of operators. Operators should know…

A step was added to the laboratory procedure in which all catalyst waste is thoroughly dampened with water and sealed in a plastic bag before being placed into a waste container.

Safe work procedures will be prepared and followed. Hydrogen will be vented out of the system to create an inert atmosphere before working on system tubing and joints. The importance of purging hydrogen piping and equipment is discussed in the…

1. All samples with potential for hydrogen buildup should be limited to ground shipment only. (This shipment was by ground and air. If this incident were to have happened in an airplane, the consequences may have been worse.)

2. All…

1. Maintenance work scopes must be adhered to. If added work is approved, it must be tracked and reviewed to ensure that the equipment is inspected by operations personnel. Scheduled work and extra work should be listed and checked off for…

The following recommended actions were identified:

1. Reemphasize the current lab management policies and practices on how process changes are evaluated for direct/indirect impacts on the process.
2. Reinforce with lab workers…

1. Train personnel on delivery procedures and emphasize the safety aspects of hydrogen connections and disconnections, and verification of clearance for trailer movement prior to departure.
2. Provide site-specific delivery procedures…

1. Defects in equipment, such as welds, may not be evident during initial proof testing and operation.
2. When an equipment defect is found, check equipment for possible similar defects in other areas of the equipment.

1. Inadequate Safeguards - The system was designed with low-point drains to facilitate water removal, however, these were found to be inadequate in both location and size. The fact that the mixed feed pre-heat coil was not self-draining was…

Manuals showing the correct connecting and disconnecting procedures were established for each fueling dispenser. Separate manuals were needed since the shape of the grip differs from dispenser to dispenser.