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.
Installation
After this accident, a safety inspection team was organized. An investigation of this incident and an inspection of all other experimental equipment was conducted by the team. As a result of this inspection, the heaters are now hard-wired to the…
The above described events are an indication of a potential licensee/vendor interface problem. Based on the information received, the vendor was not completely informed via the purchase specifications regarding the service condition to which the…
The investigative report noted that the explosion could have been prevented by (among other things) a continuous gas analyzer test of oxygen and hydrogen product purity. The continuous analyzer should be interlocked to shut the electrolyzer down…
Work documentation (work orders and baseline drawings) should reflect the current system configuration.
Recommendations
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…
An important lesson to be derived from this incident is the need to carefully engineer and test all repairs and modifications to high-pressure process equipment.
This occurrence underscores the importance of completing a hazard analysis for each different process. Non-safety-related systems or equipment may be used for purposes other than their primary purpose so long as potential hazards are identified…
1. Evaluate any change in normal procedures or conditions for storage of aluminum hydride products. In this case, the aluminum hydride material was typically stored at -35°C in the glove box freezer. However, due to a change in glove boxes, this…
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 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…
Hazard analysis should consider potential leak locations, potential ignition sources in the vicinity, and the potential for accumulating flammable gases in that area.
Users should leak-check all cylinders upon installation. This event…
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.
Normally hydrogen fires are not extinguished until the supply of hydrogen has been shut off due to the danger of re-ignition and explosion. During a gas leak/fire, it is important to shut off the source of the hydrogen if it is safe to do so. If…
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.
Lessons Learned
Construction errors are difficult to detect once construction is complete. It is important to develop and use a systematic oversight process for minimizing construction errors during the construction process.
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Although a functional fire protection system would have helped to extinguish the fire, a properly installed hydrogen detection system, coupled with a properly designed ventilation system, could have prevented the incident altogether.
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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…
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