On a given day personnel were removing a blind hub that had been used to temporarily isolate a portion of a gaseous hydrogen system. As a result of a sudden release of 2,800 psig gaseous nitrogen, sand and debris kicked up from the concrete pad and caused minor injury to two technicians.

During the investigation, it was found that:

The temporary configuration change to the gaseous hydrogen system was initiated on multiple work orders and by different individuals. There was no single document that documented the temporary system configuration.
The procedure for performing the work was written using a drawing that had not been updated to show the actual system configuration. Verbal field direction was given when it was discovered the system was not configured per view more

A subcontractor employee was using a band saw to cut a 1" metal pipe when a flash fire occurred on the third floor hydrogen fluoride area. Subcontractor employees were removing all piping associated with the Anhydrous Hydrofluoric Acid (AHF) system. These lines were being removed during plant decontamination and demolition (D&D). The subcontractor employee was attempting to cut a 90-degree elbow located at the highest elevation on the 1" line, but the lowest elevation of the overall piping run. Since hydrogen is lighter than air, it is speculated that a minute amount of hydrogen gas had accumulated in the elbow.

Even though Safe Shutdown personnel had previously opened the system and placed it in a safe configuration, residual hydrogen fluoride could have still view more