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.
Metal hydride materials of a composition which is not well characterized should be handled with procedures that assume a "worst case" for that class of materials, intermediates or precursors.
Laboratory procedures should be in…
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…
1. Increase physical protection, shielding, and securing of transported hydrogen tube valves, piping, and fittings from multi-directional forces that are likely to occur during accidents, including rollovers. Reference: 49 Code of Federal…
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 unknown…
This event illustrates the importance of adequately planning and communicating work. Procedures should cover all types of equipment that will be utilized. Work packages should clearly describe the equipment that will be used and the surrounding…
- Metal hydride materials of a composition which is not well characterized should be handled with procedures that assume a "worst case" for that class of materials, intermediates or precursors.
- Laboratory procedures should be in…
This event illustrates the importance of adequately planning and communicating work. Procedures should cover all types of equipment that will be utilized. Work packages should clearly describe the equipment that will be used and the surrounding…
The practice of making gas mixtures in the laboratory should be eliminated, and gas mixtures with a known low hydrogen concentration should be purchased for use. The concentration of hydrogen used should be such that it is not possible to form an…
After this accident, a safety inspection team was organized. An investigation of this incident and an inspection of all other experimental equipment was conducted by the team. As a result of this inspection, the heaters are now hard-wired to the…
- Test safety system components even if they are new.
- Do not rely on listening for valve movement as confirmation that a valve is closing; measure downstream pressure to determine if the valve is really sealing properly.
- …
This incident illustrates the danger of hydrogen being inadvertently released through blown water seals. Similar incidents have occurred in non-nuclear industrial facilities, but offgas systems present a special hazard because of the…
Personnel should be properly supervised, and supervisors should be aware of the activities of their personnel. Personnel must be motivated to adhere to established policies and procedures. All personnel associated with potentially hazardous work…
- Battery power supplies require adequate ventilation for all operations, or the battery box should be designed to:
- Eliminate all sparking devices
- Ventilate during charging operations
- Provide inert gas…
- Verify that all PRDs contain fuse-backed adapters.
- Explore elimination of rupture disk PRDs and substitution of spring-style relief valves.
- Develop new hydrogen unloading procedure using a written checklist. * Add…
The visiting intern had several years of experience in research projects and tasks that were similar to those in progress at this laboratory. This led to the incorrect assumption that formal introductory training for this laboratory was…
- 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…
Several recommendations were outlined by the investigating committee to govern future operations of the hydrogen compressor in the synthetic liquid fuels laboratory:
- Install a cutoff that will shut down the compressor when the…
1. Increase physical protection, shielding, and securing of transported hydrogen tube valves, piping, and fittings from multi-directional forces that are likely to occur during accidents, including rollovers. Reference: 49 Code of Federal…
The investigation team concluded that hydrogen gas was released through a failed 19-inch diameter gasket and ignited under the roof of the compressor shed where it was partially confined. Some gas escaped from the shed prior to the explosion, but…
The investigation determined that hydrogen was formed by the reaction of hot aluminum and water, air was admitted via the inspection door, and the mixture was ignited by the hot clinker or sparks from the chisel. Aluminum should have been…
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 |
|||||
Fuel Dispenser | 8/2/2004 5/1/2007 6/11/2007 9/19/2007 |
2/24/2006 1/22/2009 |
|||||
Fuel Cell Stack | |||||||
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