The lesson to pass on is that ventilation is critical in UPS battery rooms. Great care should be taken to ensure that the ventilation system is operational and brings in enough outdoor air to properly ventilate the enclosure.

Electrical…

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…

This event illustrates the importance of adequately planning and communicating work. Procedures should cover all types of equipment that will be utilized. Work packages should clearly describe the equipment that will be used and the surrounding…

Attentiveness to proper procedure would have prevented this incident.
This incident also underscores is the need for rigorous training on hydrogen properties and behavior, not only for the operators of fueling equipment but also for…

This occurrence points to the importance of gathering and organizing all applicable administrative controls and other commitments prior to commencing work. It also re-emphasizes the importance of attention to detail, not only by the person…

The primary lesson learned was that the active hydrogen facility and existing operating procedure, at the time of the accident, were sound. While this now has been determined, the previous form(s) of this system, associated documentation, and…

Some hydride materials (e.g., sodium alanates) may be rapidly exothermic, even pyrophoric, if exposed to water or humid air or slowly exothermic, even pyrophoric, if exposed to oxygen. Reactive materials, including fine metal powders, should be…

The manager in charge acknowledged that, while he made relatively recent modifications to the high-pressure gas storage side of the system and had directed a major rebuilding of various units, the moderate-pressure interconnecting system (the…

This incident occurred due to moisture in the sample line monitoring system. Removing moisture from the sample line increases the reliability of the equipment. Further evaluations are being considered for improving system reliability.

Although most of the hydrogen fluoride piping system was open to the atmosphere before the elbow was cut, the lines were not purged. Two plugs of residual material on either side of the elbow remained in place, thus allowing hydrogen to be…

Follow-up investigation of this occurrence confirms that it was inadvertent. Attention to detail while performing any task is a must for all personnel. This is to insure the safety of both the individual performing the task and others that may…

Work pre-planning is essential whenever maintenance or work activities may have an adverse impact on everyday operations. When there are changes to the operational status of any critical system, especially a safety critical system, those changes…

The simplicity of this situation has made us aware that increased consideration must be given to all aspects of the workplace when preparing preliminary hazard assessments. Some hazardous situations appear so trivial that they can be easily…

Metal hydride materials of a composition which is not well characterized should be handled with procedures that assume a "worst case" for that class of materials, intermediates or precursors.
Laboratory procedures should be in…

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.

Incident investigation findings for corrective actions were:
1. Install a valve after the regulator as an added precaution.
2. Clean the coupler at the end of the hydrogen delivery tube after each use to ensure that any catalyst residue…

1. Flexible tubing should be secured so it cannot get dislodged during operations.
2. Fume hoods where hydrogen is used should not be made of combustible materials. 3. Preventative maintenance should be performed on equipment on a…