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.
No Lessons Learned, Specific Suggestions for Avoidance, or Mitigation Steps Taken.
Proper bolt identification can prevent similar occurrences in the future. This can be achieved by simply painting the critical bolt heads a certain color (or by purchasing bolts with painted bolt heads). An explanation form should then be clearly…
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.
Personnel should be properly supervised, and supervisors should be aware of the activities of their personnel. Personnel must be motivated to adhere to established policies and procedures. All personnel associated with potentially hazardous work…
In addition to resealing the glove box window, a positive pressure of argon gas was maintained inside the glove box while the course of action was planned. Subsequently, the glove box was cleaned up by specialized hazardous materials personnel…
Standard procedure must be followed in all cases. Assumptions are made at great risk. Risk also increases with complacency.
This incident emphasizes the need for proper gas detection and ventilation systems, as well as fire suppression systems, in laboratories using and storing hydrogen. This is especially true when open flame burners are in close proximity.…
Fail-safe position of control valves in supply lines must be set correctly to prevent damage to pressure vessels.
Recommendation
Set all valves for fail safe operation (open or closed) according to needs before installation…
The use of inerting gas or other means of separation should be employed when conducting mechanical work where hydrogen gas could be present. More importantly, per CGA S1.3, the vessel should be equipped with a dual relief system that can isolate…
Extra caution should be taken working around elevated pressure or low-temperature fluids and storage. Values should be checked and then verified by a second party, if possible.
The charging characteristics of a battery vary with the condition of the battery and are proportional to the ampere-hour capacity of the battery. During charging, when a battery is close to being fully charged, hydrogen and oxygen both offgas in…
It is characteristic of silver/zinc batteries to outgas both hydrogen and oxygen for several hours after discharge. Also, in the future, the battery should be properly secured inside the container.
Refueling operations need to be conducted in a careful and attentive manner, and operators need to be aware of the potential consequences of their actions.
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.
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