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.
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…
Recommendations:
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…
Safe storage and transportation of balloons filled with a hydrogen-oxygen mixture is a very risky undertaking. There are few scenarios that do not involve enclosed spaces (e.g., a car) and the potential for static discharge. Perhaps a mesh bag…
Do not interconnect hydrogen drain trap lines with other drain lines
Thoroughly inspect equipment installation to manufacturer’s installation instructions
Warn against unauthorized field modifications
Consult the…
Maintain an internal process for verifying component wetted material compatibility for intended use as part of the procurement process for hydrogen system equipment.
Don’t rely solely on a manufacturer to provide appropriately rated…
During charging, most batteries will offgas hydrogen, making adequate ventilation and the elimination of ignition sources critical attributes of the charging area. Data from the battery manufacturer should be consulted to determine appropriate…
Process changes have been implemented for development and review of safety basis documents that focus on a collaborative effort between the preparer and reviewers in order to provide a more in-depth review. This change is anticipated to provide…
1. Combustible gas detectors calibrated for hydrogen can falsely report hydrogen alarms due the presence of other gases the detector may pick up, such as carbon monoxide from engine exhaust or other sources. Since this event occurred, two…
Based on the results of the company investigation and analysis of an amateur video, the company determined that the incident could have been caused by the failure of one of the following plant components:
· pipes leading to the reactor…
The root cause of the fire that burned the evaporator pad and distorted the plastic evaporator pad bracket remains unknown. The initial investigation did not reveal any obvious signs of an ignition source in the vicinity of the forklift operation…
Key:
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