A tool is provided for removing the cylinder cap that cannot contact the valve.

Consider design review of all adapter fittings.

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…

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.…

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…

LESSONS LEARNED:

1. Compressed gas cylinder caps can be very difficult to open as rust often occurs in the threads.
2. There are wrenches specifically designed to remove…

The following corrective actions have been taken:

• The non-return valve was dismantled, cleaned, and tested. Following positive testing, the system was restarted and pressurized without any further malfunctioning.
• The hydrogen…

The packing in the flow control valve should be replaced periodically. A planned investigation will determine the optimum time period for packing replacement.

The following recommended actions were identified:

1. Reemphasize the current lab management policies and practices on how process changes are evaluated for direct/indirect impacts on the process.
2. Reinforce with lab workers 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 samples…

Hydrogen distribution lines should be designed and carefully inspected to ensure process equipment in the area is correctly and safely installed. Equipment subject to vibration should not be placed in contact with hydrogen lines or with other…

Now, when conducting a sulfur deprivation test, vessels are ventilated to prevent over pressurization and safely facilitate the release of excess hydrogen.

This incident led to several changes in procedure:

• The purity of any gas bottle connected is double-checked. The practice outlined in the SOP requires confirming the content of the cylinder via the cylinder label prior to…

• One needs to take extreme care with both new and supposedly spent hydride samples; the spent materials may contain pockets of unoxidized alanates that could react violently when being transferred.
• Work with small samples so if…

• Valve packing on ammonia tanks should be checked on a regular basis.
• If an ammonia smell becomes noticeable, the tank should be returned to the supplier.

The hydrogen facility does not meet industrial guidelines for facilities of this type, from the standpoint of (1) the separation distance needed between a hydrogen pipe break and the building ventilation intake to prevent buildup of a flammable…

The lessons of this event fall into five categories: (1) proper in-plant communications during events, (2) proper valve application for use with hydrogen, (3) excess flow check valve set point, (4) heating and ventilation and air conditioning (…