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.
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 proper…
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…
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.
Provide additional retraining of operators. Curriculum should emphasize the proper response to high oxygen in the hydrogen gas.
Evaluate current knowledge of operators. Operators should know proper response, such as contacting engineering…
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 situation.…
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…
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 situation.…
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 location.…
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-…
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…
Maintenance on the low-pressure venting system was not occurring at regular intervals. Ventilation integrity is now checked before starting an experiment.
Proper installation of check valves and other equipment should be visually inspected prior to pressurization.
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…
An investigation team was formed to determine the cause of this anomaly. The team performed a fault tree analysis which identified the following five main paths or gates: fault in the original weld, age, component not built per design intent,…
The fuel cell vehicle that was involved in the accident has been retired. The fuel cell power plant from that vehicle has been removed and is being used in another fuel cell vehicle.
The fuel cell vehicle accident reinforced the need for…
Revise fire protection operations surveillance tests to include a maximum of 110% of the agent net weight to prevent over-filled cylinders from being placed in service.
Identify cylinders currently in service that exceed the 110% maximum…
High-pressure fueling hoses should be examined daily for signs of external damage, including corrosion, abrasion, cuts, and kinking. High-use fueling hoses should be replaced every six months.
After the aforementioned incident, a rigid cage was designed to protect the reactor from external conditions, and to protect the contents of the hood and any experimenter from the reactor, in the event of a pressure burst from the reactor cell.…
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