The practice of making gas mixtures in the laboratory should be eliminated, and gas mixtures with a known low hydrogen concentration should be purchased for use. The concentration of hydrogen used should be such that it is not possible to form an…

This incident illustrates how difficult it is to completely purge hydrogen out of a large, complex piece of equipment. Uniform mixing and dilution is unlikely in all the partially enclosed spaces, crevices, etc. If a hazardous operation such as…

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…

1. Inadequate Safeguards - The system was designed with low-point drains to facilitate water removal, however, these were found to be inadequate in both location and size. The fact that the mixed feed pre-heat coil was not self-draining was…

• Metal hydride materials of a composition which is not well characterized should be handled with procedures that assume a "worst case" for that class of materials, intermediates or precursors.
• Laboratory procedures should be in…

• Metal hydride materials of a composition which is not well characterized should be handled with procedures that assume a "worst case" for that class of materials, intermediates or precursors.
• Laboratory procedures should be in…

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.

…

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…

• A SOP should be developed which prohibits drivers from backing into the fill position.
• As a precautionary measure to mitigate similar events in the future, piping barriers should be installed which protect critical H₂…

• When truck drivers are carrying new trailers, with new load distribution characteristics, they need to exercise caution, especially on hazardous roadways such as the one described in this occurrence. If the trailer stack would have been…

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…

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…

1. Place signs on all liquid hydrogen tanks indicating that no water is to be put on the vent stack.
2. An additional secondary backup vent stack was added to liquid hydrogen tanks. This secondary stack is designed to be used only if…