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.
The turbine components that caused the vibrations were a retrofit design which had been in service for about two years and were under warranty from the vendor. The root cause analysis of the event determined that the damage was caused by a defect…
Recommendations:
Although the preparation-for-transport procedures were done the same way they were done for previous outreach programs, this time it proved to be a different situation. It is not clear what caused the ignition of the first balloon, which then set…
Safe storage and transportation of balloons filled with a hydrogen-oxygen mixture is a very risky undertaking. There are few scenarios that do not involve enclosed spaces (e.g., a car) and the potential for static discharge. Perhaps a mesh bag…
The incident resulted from an inadequate design for the storage location of the copper gas supply tubing (too close to an electrical outlet). The gas supply tubing was too long for its intended purpose and posed a hazard in its coiled state near…
The direct cause of the over-pressurization of the two drums was the repackaging of the phosphoric acid into metal UN1A1 drums and the resultant hydrogen gas generation within the sealed drums. At the time of this incident (1997), 49 CFR and…
The lessons learned from this incident are:
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…
The ignition of the fireball could have been caused by any of the following mechanisms:
Based on the results of the company investigation and analysis of an amateur video, the company determined that the incident could have been caused by the failure of one of the following plant components:
· pipes leading to the reactor…
The root cause of the fire that burned the evaporator pad and distorted the plastic evaporator pad bracket remains unknown. The initial investigation did not reveal any obvious signs of an ignition source in the vicinity of the forklift operation…
It appears that this was an isolated event caused by human error. The lessons learned are: (1) to caution workers to maintain their focus during fuel cell stack assembly, (2) to require verification that all tools and spare parts are accounted…
As stated on the MSDS and also on the container labels, LiAlH4 should be handled under argon. LiAlH4 is advertised and sold as a powder. If the researcher had to scrape it out of the jar, then it was no longer a powder, which seems indicative of…
During charging, most batteries will off gas hydrogen, making adequate ventilation and the elimination of ignition sources critical attributes of the charging area. Data from the battery manufacturer should be consulted to determine appropriate…
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…
Key:
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