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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.
Metallurgical examination of the two failed disks by light optical microscopy (LOM), scanning electron microscopy (SEM), and energy-dispersive x-ray spectroscopic analysis (EDS) found them to be fabricated from pure nickel with evidence of…
Mounting hardware incorporated polymeric braces not suitable for long-term exposure to sunlight and temperature extremes. With time, the polymeric materials had disintegrated, allowing the mounting brackets to become loose. In addition, the…
The possible outcomes from new maintenance scenarios can be predicted by using an accurate simulation. The proposed filter change-out maintenance was studied to identify conditions to which the catalyst might be exposed and a mock-up of the…
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…
LESSONS LEARNED:
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…
To prevent a similar flashback, the following measures have been taken:
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.
All installed and certified safety and emergency systems functioned as designed.
1. The fuel cell turned off immediately after fire detection.
2. The fire suppression system was immediately initiated thereafter.
3. The physical…
Several procedural and design changes should be considered for the future:
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…
Included inspection on monthly preventive maintenance plan and evaluated alternate materials for better cold-weather performance.
The fitting was an SAE straight thread and was likely loosened by torque applied to the fueling hose. After the incident, these fittings had additional means applied to restrict loosening, a cover installed to deflect any leakage, and means taken…
The following corrective actions have been taken:
1. Evaluate any change in normal procedures or conditions for storage of aluminum hydride products. In this case, the aluminum hydride material was typically stored at -35°C in the glove box freezer. However, due to a change in glove boxes, this…
Key:
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