LESSONS
LEARNED
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.
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.
Implement rigorous assembly, verification, and documentation procedures for equipment.
Increase automated leak detection frequency.
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:
Key:
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