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…

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.

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,…

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…

• All tank trailers should have a safely accessible auxiliary shut off valve in case of spills.
• Emergency personnel need to have access to all of the appropriate protective clothing, including shoes. Liquid hydrogen is stored at 20…

Normally hydrogen fires are not extinguished until the supply of hydrogen has been shut off due to the danger of re-ignition and explosion. During a gas leak/fire, it is important to shut off the source of the hydrogen if it is safe to do so. If…

Lessons Learned The site initiated the establishment of a field patrol and strengthened their onsite monitoring of mechanical equipment during a plant-wide temperature rise.

• Quantitative control of tightening torque on bolts…

In addition to the probable causes listed above, the lack of a standard operating procedure for hydrogen leak detection was one of the probable causes of this incident. Additional contributing factors included the following:
- Severe pipe…

The following actions were proposed as a result of this incident:

•  The company in charge of valve calibration and maintenance will be subject to approval of the plant service inspection team.
•  Plant operating…