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 occurrence points to the importance of gathering and organizing all applicable administrative controls and other commitments prior to commencing work. It also re-emphasizes the importance of attention to detail, not only by the person…
Some hydride materials (e.g., sodium alanates) may be rapidly exothermic, even pyrophoric, if exposed to water or humid air or slowly exothermic, even pyrophoric, if exposed to oxygen. Reactive materials, including fine metal powders, should be…
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…
This incident illustrates the danger of hydrogen being inadvertently released through blown water seals. Similar incidents have occurred in non-nuclear industrial facilities, but offgas systems present a special hazard because of the…
The mechanisms and rates by which hydrogen gas is generated and subsequently accumulated in the holding tank need to be fully understood by vendors and employees alike. Active venting, warning signs, and local alarms designed to activate when…
The hydrogen facility does not meet industrial guidelines for facilities of this type, from the standpoint of (1) the separation distance needed between a hydrogen pipe break and the building ventilation intake to prevent buildup of a flammable…
This incident highlights the need to properly design safety interlocks. These safety interlocks need to be carefully incorporated into the initial building/plant designs and should consider all of the unexpected occurrences, such as the…
The lessons of this event fall into five categories: (1) proper in-plant communications during events, (2) proper valve application for use with hydrogen, (3) excess flow check valve set point, (4) heating and ventilation and air conditioning (…
Work documentation (work orders and baseline drawings) should reflect the current system configuration.
Recommendations
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.…
In the future, the laboratory will issue a memorandum about this incident to illustrate the need to wear safety glasses with side shields, store chemicals compatibly, take care when placing chemicals in the refrigerators for storage, and keep the…
Recommended Actions:
In any event, the lesson that should be derived from this incident is the fact that the explosion could have been avoided either by using an inert gas instead of air across the diaphragm, or by monitoring the hydrogen concentration in the upper…
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…
In the future, refining, petrochemical, and chemical industries need to review material verification programs to ensure that the maintenance procedures include sufficient controls and positive material identification (PMI) testing to prevent…
The accident proves that under special circumstances, the potential hazard connected with unforeseen microbial gas formation and accumulation should not be neglected. Thus, to avoid new accidents at the paper mill described above, the tower has…
The lesson to pass on is that ventilation is critical in UPS battery rooms. Great care should be taken to ensure that the ventilation system is operational and brings in enough outdoor air to properly ventilate the enclosure.
Electrical…
In the future, this mesoporous carbon material and ammonia borane:mesoporous carbon material will be handled under anaerobic conditions (glove box) to prevent further incidents.
Key:
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