CHECK OUT OUR MOST RELEVANT INCIDENT LISTINGS!
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.
An investigative communication notes that "mechanical integrity programs at refineries repeatedly emphasize inspection strategies rather then the use of inherently safer design to control the damage mechanisms that ultimately cause major…
Three root-causes were noted during the investigation: (1) the use of incompatible materials in the manufacturing of the PRD valve, (2) improper assembly resulting in over-torquing of the inner assembly, and (3) over-hardening of the inner…
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: The company in charge of valve calibration and maintenance will be subject to approval of the plant service inspection team. Plant operating procedures will be improved. The…
The incident was the result of a combination of factors leading to exceptional temperature conditions that were not taken into account in the mechanical design of the reactor. Corrective actions that were implemented by the plant management…
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…
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…
To prevent a similar flashback, the following measures have been taken:
The valve is opened slowly to avoid a major leading shock into the venting line.
A special nozzle (Laval or similar) is mounted directly after the opening…
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…
Mechanical pressure gauges tend to be imprecise if only used in a narrow portion of the full scale. Digital transducers, although slightly more expensive, offer much more precision. The event happened because the set pressure was only 10% of full…
Several recommendations were outlined by the investigating committee to govern future operations of the hydrogen compressor in the synthetic liquid fuels laboratory:
Install a cutoff that will shut down the compressor when the suction…
Key:
- = No Ignition
- = Explosion
- = Fire
Equipment / Cause | Equipment Design or Selection | Component Failure | Operational Error | Installation or Maintenance | Inadequate Gas or Flame Detection | Emergency Shutdown Response | Other or Unknown |
---|---|---|---|---|---|---|---|
Hydrogen Gas Metal Cylinder or Regulator | 3/31/2012 4/30/1995 2/6/2013 |
4/26/2010 | 12/31/1969 | 3/17/1999 11/1/2001 12/23/2003 |
|||
Piping/Valves | 4/4/2002 2/2/2008 5/11/1999 |
4/20/1987 11/4/1997 12/31/1969 8/19/1986 7/27/1991 12/19/2004 2/6/2008 10/3/2008 4/5/2006 5/1/2007 9/19/2007 10/31/1980 |
2/7/2009 | 1/24/1999 2/24/2006 6/8/1998 12/31/1969 2/7/2009 |
10/3/2008 | ||
Tubing/Fittings/Hose | 9/23/1999 8/2/2004 8/6/2008 9/19/2007 |
1/1/1982 | 9/30/2004 10/7/2005 |
10/7/2005 | |||
Compressor | 10/5/2009 6/10/2007 8/21/2008 1/15/2019 |
10/5/2009 | 8/21/2008 | ||||
Liquid Hydrogen Tank or Delivery Truck | 4/27/1989 | 12/19/2004 1/19/2009 |
8/6/2004 | 12/31/1969 | 1/1/1974 | 12/17/2004 | |
Pressure Relief Device | 7/25/2013 5/4/2012 |
1/15/2002 1/08/2007 |
12/31/1969 | ||||
Instrument | 1/15/2019 | 3/17/1999 12/31/1969 2/6/2013 |
11/13/73 | ||||
Hydrogen Generation Equipment | 7/27/1999 | 10/23/2001 | |||||
Vehicle or Lift Truck | 7/21/2011 | 2/8/2011 12/9/2010 |
|||||
Fuel Dispenser | 8/2/2004 5/1/2007 6/11/2007 9/19/2007 |
2/24/2006 1/22/2009 |
|||||
Fuel Cell Stack | |||||||
Hydrogen Cooled Generator | 12/31/1969 2/7/2009 |
||||||
Other (floor drain, lab anaerobic chamber, heated glassware, test chamber, gaseous hydrogen composite cylinder, delivery truck) |
11/14/1994 7/21/2011 |
7/27/1999 6/28/2010 8/21/2008 |
12/31/1969 3/22/2018 |
6/10/2019 |
- = No Ignition
- = Explosion
- = Fire