1. Increase physical protection, shielding, and securing of transported hydrogen tube valves, piping, and fittings from multi-directional forces that are likely to occur during accidents, including rollovers. Reference: 49 Code of Federal…

1. All samples with potential for hydrogen buildup should be limited to ground shipment only. (This shipment was by ground and air. If this incident were to have happened in an airplane, the consequences may have been worse.)

2. All samples…

1. A hydrogen tube pressure indication system needs to be developed that is robust enough to withstand an accident, indicates hydrogen pressure regardless of valve position, and would be visible from a safe distance during an accident situation…

Hazard analysis should consider potential leak locations, potential ignition sources in the vicinity, and the potential for accumulating flammable gases in that area.

Users should leak-check all cylinders upon installation. This event…

No Lessons Learned, Specific Suggestions for Avoidance, or Mitigation Steps Taken.

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…

This occurrence highlights the need for ensuring work is organized and planned in a manner that is practical and efficient. The primary lesson learned from this occurrence is that personnel must be cognizant of the impact of their actions on…

1. Parallel-path design activities require an increased level of management oversight and control to mitigate the risks inherent in this process.
2. Schedule pressure cannot be allowed to compromise the integrity of the design process…

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

1. Fittings need to be visually inspected to insure ferules are in place and correctly positioned prior to swageing.
2. Research staff are responsible for communicating system specifications [gas type,…

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…

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.…