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.
Standard procedure must be followed in all cases. Assumptions are made at great risk. Risk also increases with complacency.
Standard procedures must be followed at all times. The importance of doing so should be frequently reinforced through safety communications to all staff.
Because of the near invisibility of a hydrogen flame in daylight and hydrogen's extremely low ignition coefficient, if a known leak is present (e.g., an audible hissing), ignition should always be presumed. The primary cause of this incident…
Refueling operations need to be conducted in a careful and attentive manner, and operators need to be aware of the potential consequences of their actions.
Extra caution should be taken when working around elevated pressure storage tanks. Pressure relief valve settings should be checked and then verified by a second party if possible. Proper procedures need to be followed at all times.
Hazards should be eliminated to the extent possible rather than depending on workers to follow an operations manual.
Potassium carbonate draw-off operations should be improved, and the operations manual should be revised. The manual…
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