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.
LESSONS LEARNED:
1. Management must ensure that operating decisions are not based primarily on cost and production. Performance goals and operating risks must be effectively communicated to all employees. Facility management must set safe, achievable operating…
This incident led to several changes in procedure:
Implementing and enforcing the laboratory's stop work and restart policy and procedures in conjunction with peer reviews for new processes and experiments should help prevent future accidents due to a lack of recognition of potential reactions…
Many accidents reported from paper mills have much in common with this incident. Microorganisms in the process water with pulp produce hydrogen gas that mixes with air to form an explosive atmosphere. The ignition source is typically sparks…
Several procedural and design changes should be considered for the future:
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…
Key:
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