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.
- Redundant safety systems prevented this event from becoming an incident. The 1%-hydrogen-concentration-level-triggered fan was backed up by a 2%-hydrogen-concentration alarm. The alarm is continuously monitored (24/7) by a remote Network…
LESSONS LEARNED:
- Compressed gas cylinder caps can be very difficult to open as rust often occurs in the threads.
- There are wrenches specifically designed to remove…
1. The trailer involved in the incident used a frangible burst disk based upon the proprietary metal compound designated as Inconel #600. Random sampling of similar pressure relief devices from the same trailer showed that all of them failed at…
A tool is provided for removing the cylinder cap that cannot contact the valve.
Several best practices resulted from this incident and will be implemented if similar circumstances present themselves in the future.
- Close bay door.
- Keep within proximity of bay.
- Be aware of other bays…
A new best practice resulted resulted from this incident. It states that before any work is started, a third party should verify with a visual inspection that the actual equipment to be used matches the planned equipment list/protocol.
Process changes have been implemented for development and review of safety basis documents that focus on a collaborative effort between the preparer and reviewers in order to provide a more in-depth review. This change is anticipated to provide…
1. Combustible gas detectors calibrated for hydrogen can falsely report hydrogen alarms due the presence of other gases the detector may pick up, such as carbon monoxide from engine exhaust or other sources. Since this event occurred, two…
A hydrogen release of this type is a significant event. The event highlighted a number of procedural contributing factors that will influence the manner in which these fuel cell systems will be serviced in the future. A complicating factor in…
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…
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 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…
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…
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