What is Lessons Learned?

What is H2LL?

This database is supported by the U.S. Department of Energy. The safety event records have been contributed by a variety of global sources, including industrial, government and academic facilities.

H2LL is a database-driven website intended to facilitate the sharing of lessons learned and other relevant information gained from actual experiences using and working with hydrogen. The database also serves as a voluntary reporting tool for capturing records of events involving either hydrogen or hydrogen-related technologies.

The focus of the database is on characterization of hydrogen-related incidents and near-misses, and ensuing lessons learned from those events. All identifying information, including names of companies or organizations, locations, and the like, is removed to ensure confidentiality and to encourage the unconstrained future reporting of events as they occur.

The intended audience for this website is anyone who is involved in any aspect of hydrogen use. The existing safety event records are mainly focused on laboratory settings that offer valuable insights into the safe use of hydrogen in energy applications and R&D. It is hoped that users will come to this website both to learn valuable lessons from the experiences of others as well as to share information from their own experiences. Improved safety awareness benefits all.

Development of the database has been primarily supported by the U.S. Department of Energy. While every effort is made to verify the accuracy of information contained herein, no guarantee is expressed or implied with respect to the completeness, causal attribution, or suggested remedial measures for avoiding future events of a similar nature. The contents of this database are presented for informational purposes only. Design of any energy system should always be developed in close consultation with safety experts familiar with the particulars of the specific application.

We encourage you to browse through the safety event records on the website and send us your comments and suggestions. We will continue to add new records as they become available.

How does H2LL work?

If you have an incident you would like to include in the H2LL database, please click the "Submit an Incident" button at the top of the page. You will be asked for a wide range of information on your incident. Please enter as much of the information as possible. In order to protect your and your employer's identities, information that may distinguish an incident (your contact information, your company's name, the location of the incident, etc.) will not be displayed in the incident reports on H2LL.

Lessons Learned Corner

Visit the Lessons Learned Corner Archives.

Key themes from the H2Incidents database will be presented in the Lessons Learned Corner. Safety event records will be highlighted to illustrate the relevant lessons learned. Please let us know what you think and what themes you would like to see highlighted in this safety knowledge corner. You can find all the previous topics in the archives.

While research staff were working in a lab, a staff member opened the primary valve to a 0.2" (1500 psi) hydrogen gas line connected to a manifold supplying instruments in the lab. Upon opening the valve, the hydrogen gas line failed at a fitting on the switching manifold, releasing a small amount of hydrogen gas. The staff member closed the valve immediately, then inspected the gas line and found the front ferrule (of the compression-style fitting) to be missing. There were no injuries or damage to equipment.

In the follow-on discussion with research staff, it was learned that approximately one month earlier, a similar condition (front ferrule missing from a fitting) was found while performing a modification to a similar manifold. Following a critique, management expressed view more

A facility experienced a major fire in its Resid Hydrotreater Unit (RHU) that caused millions of dollars in property damage. One employee sustained a minor injury during the emergency unit shutdown and there were no fatalities.

The RHU incident investigation determined that an 8-inch diameter carbon steel elbow inadvertently installed in a high-pressure, high-temperature hydrogen line ruptured after operating for only 3 months. The escaping hydrogen gas from the ruptured elbow quickly ignited.

This incident occurred after a maintenance contractor accidentally replaced an alloy steel elbow with a carbon steel elbow during a scheduled heat exchanger overhaul. The alloy steel elbow was resistant to high-temperature hydrogen attack (HTHA), but the carbon steel elbow was not. view more

A rupture occurred in a 24-inch gas line in a reformer. The pipe contained hydrogen and carbon monoxide at a pressure of about 400 psi and a temperature of 930 °C. The ruptured section of pipe had a high-temperature alloy steel outer wall, a refractory liner, and a stainless steel inner liner. The refractory lining had been repaired several times before (including three months prior to the incident) because of localized deterioration and hot spots. The repair procedure consisted of cutting a section of pipe, re-pouring the refractory liner, and patch-welding the outer wall.

The first rupture occurred when the 42-inch-long welded section of the pipe suddenly blew out. On-site employees heard a rumble and observed a flame above the ruptured pipe. Before the torch fire at the view more

Overview: A pipe end containing fuel oil corroded at the outlet of a heat exchanger on the outlet side of a desulfurization reactor. The corroded pipe end leaked hydrogen gas, which exploded, causing oil to leak from the heat exchanger. The leaking oil developed into an oil fire, and the damage spread. The causes of the pipe end corrosion include the following:

There was a high concentration of corrosive substances in the process injection water.
The concentration of corrosive substances increased due to re-molding the heat exchangers.
The shape of the pipe cap was dead end piping.

Incident: During normal operations at a fuel oil refinery, a pipe end in a desulfurization unit developed a hydrogen leak, which led to an explosion. The pipe end was located on view more

Overview

The catalyst in a dehydrogenation reactor, which was usually operated under a hydrogen atmosphere, was changed while the reactor was isolated from the peripheral equipment by closing a 20-inch remotely controlled valve. The hydrogen pressure in the peripheral equipment was set at 20 KPaG, and the reactor was opened to the atmosphere. Anticipating some hydrogen leakage, suction from the piping was accomplished with a vacuum device and, nitrogen sealing was performed. When the piping connections were restored after changing the catalyst, flames spouted from the flange clearance and two workers were burned. One cause of the fire was poor management of the catalyst replacement process.

Incident Synopsis

A catalyst exchange was carried out in a dehydrogenation view more

Overview

Hydrogen leaked from the outlet piping of a hydrogen heating furnace at a fuel oil desulfurization cracking unit during normal refinery operation. The leaking hydrogen caused a localized fire. Dilution water for cleaning polythionic acid collected in the drain nozzle after a turnaround shutdown. The chlorine concentration in this dilution water was high because its concentration in the industrial water was originally high. The chlorine in the industrial water was concentrated by the high temperature, after the plant was restarted, and stress corrosion cracking occurred. Hydrogen leaked and was ignited by static electricity or heat.

Incident 

A fire occurred at the fuel oil desulfurization cracking unit of a refinery 257 hours after startup of the plant, view more

Incident Synopsis
A technician was welding a cable suspended over a stainless steel H2 instrument line. During the welding process, two holes were accidentally burned through the hydrogen tubing. The operator heard a hissing sound and closed the valve, but the hydrogen had already ignited and it burned his hand while he was feeling for a leak.

Cause
A short during welding caused the pinholes in the tubing containing the gaseous H2.

A hydrogen reformer furnace at a refinery was shutdown for maintenance to remove and cap the inlet and outlet headers of some radiant tubes that had previously developed hot spots and been isolated by externally pinching them off at the inlet. A decision was made to leave steam in the steam-generating circuit during this maintenance operation to prevent freezing. After maintenance was complete, the startup procedure required the furnace to be first heated up to 350°C (662°F) prior to introducing 4136 kPa (600 psig) steam into the radiant tubes. Just after the 4136 kPa (600 psig) startup steam was introduced into the reformer furnace inlet, the control room alarm journal reported an extreme positive pressure spike at the same time a single loud bang was reported by the operations view more

An explosion occurred within the hydrogen processing system of a chemical plant that produces sodium chlorate for bleaching pulp and paper. The chemical process utilizes electrolytic cells and is pH-dependent. Hydrogen is produced as a byproduct and is utilized as a fuel.

At the time of the incident, the plant was at an abnormal operating level of 25% capacity. A non-routine maintenance operation to repair high-pH liquid piping was in progress. To assist, operations personnel rerouted the high-pH liquid stream to the plant sump. However, in doing this, the liquid eventually made its way back into the electrolytic process by design. Ultimately this created the root cause of the explosive condition in that the pH of the electrolytic process increased faster than the computer- view more