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.
Normally hydrogen fires are not extinguished until the supply of hydrogen has been shut off due to the danger of re-ignition and explosion. During a gas leak/fire, it is important to shut off the source of the hydrogen if it is safe to do so. If…
Lessons Learned The site initiated the establishment of a field patrol and strengthened their onsite monitoring of mechanical equipment during a plant-wide temperature rise.
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,…
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.
Implement rigorous assembly, verification, and documentation procedures for equipment.
Increase automated leak detection frequency.
Do not interconnect hydrogen drain trap lines with other drain lines
Thoroughly inspect equipment installation to manufacturer’s installation instructions
Warn against unauthorized field modifications
Consult the…
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…
In addition to the probable causes listed above, the lack of a standard operating procedure for hydrogen leak detection was one of the probable causes of this incident. Additional contributing factors included the following:
- Severe pipe…
The company investigation revealed that the incident arose because insufficient water was added to the batch. This resulted in a rapid increase in temperature and evolution of hydrogen gas following the addition of aluminum powder in the last…
The following actions were proposed as a result of this incident:
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