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.
In this case, failure to recognize a run of tubing still maintaining pressure could have been avoided if such information was provided in a safety briefing. Knowledge of any job is the utmost importance in promoting and maintaining a safe working…
This incident highlights the need to ensure that the performance of special procedures does not place facility equipment in a condition that could lead to entry into a LCO.
Installation
The practice of making gas mixtures in the laboratory should be eliminated, and gas mixtures with a known low hydrogen concentration should be purchased for use. The concentration of hydrogen used should be such that it is not possible to form an…
After this accident, a safety inspection team was organized. An investigation of this incident and an inspection of all other experimental equipment was conducted by the team. As a result of this inspection, the heaters are now hard-wired to the…
When performing maintenance evolutions, proper work control processes must be in place to insure that process systems are adequately prepared, remain in a safe energy state during the maintenance evolution, and are properly restored afterwards.…
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…
This incident illustrates how difficult it is to completely purge hydrogen out of a large, complex piece of equipment. Uniform mixing and dilution is unlikely in all the partially enclosed spaces, crevices, etc. If a hazardous operation such as…
On-site personnel performing treatment of reactive metals/chemicals must continue to exercise caution. Although there is an inherent risk in treating reactive metals/chemicals, personnel must adhere to conduct of operations principles to include…
Thoroughly plan and schedule work such that the correct tools are at the job site. If activities take place that take the job supervisor away from the job location while critical steps are to be performed, the work should be temporarily stopped.…
A flammable gas explosion is an analyzed hazard and gas detection/shut off is a safety significant control system that requires a limiting condition for operation (LCO). The rigor of the evaluation of flammable gas systems was inadequate. There…
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…
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…
Hazard assessment is critical during the design, fabrication, and installation of system modifications to ensure hazards and potential hazards are addressed prior to system start-up and operation.
All chemicals, including gases, should be clearly labeled and expiration dates (if applicable) identified. Incidents are more common when incompatible chemicals are mixed or when chemicals are stored/transferred using incompatible equipment.…
Diligence needs to be practiced when performing assigned work tasks. To guard against complacency, it is necessary to emphasize adherence to established procedures, including appropriate reviews of preventive maintenance instructions (PMI) and…
The lessons learned in this situation center around basic conduct of operations principles. Policies and procedures related to operations performance, safety performance, and management oversight were in place. They were not employed…
Procedures will be revised to include specific information about hydrogen sensors and alarm controls. Caution will be added about sparks and flames in the fuel cell operation area. Workers will be cautioned that shunt resistors may reach high…
Management should ensure that a complete and thorough review of the previous work activities identified in the work package is performed at the pre-job briefing for the planned work. Work activities should be discontinued if any confusion exists…
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