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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.
Manuals showing the correct connecting and disconnecting procedures were established for each fueling dispenser. Separate manuals were needed since the shape of the grip differs from dispenser to dispenser.
Work documentation (work orders and baseline drawings) should reflect the current system configuration.
Recommendations
The investigation determined that hydrogen was formed by the reaction of hot aluminum and water, air was admitted via the inspection door, and the mixture was ignited by the hot clinker or sparks from the chisel. Aluminum should have been…
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