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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 company investigation revealed that the incident arose because insufficient water was added to the batch. This resulted in a rapid increase in temperature and evolution of hydrogen gas following the addition of aluminum powder in the last…
Disable the fueling process if the operator does not follow the proper sequence of steps in the fueling procedure. Improve the fueling procedure to make it inherently impossible for the sequence to be done improperly with the same result.
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