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.
The following corrective actions have been taken:
The non-return valve was dismantled, cleaned, and tested. Following positive testing, the system was restarted and pressurized without any further malfunctioning.
The hydrogen…
An investigation team was formed to determine the cause of this anomaly. The team performed a fault tree analysis which identified the following five main paths or gates: fault in the original weld, age, component not built per design intent,…
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…
The following corrective actions have been taken:
Personnel were focused on the AGES system test and results, not the compatibility of the test equipment. The manual valve was needed to successfully test the system, however the fact that this particular valve could not accommodate the full…
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…
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