CHECK OUT OUR MOST RELEVANT INCIDENT LISTINGS! 

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.

The researcher's failure to pull the fire alarm was an oversight of required facility practice. The alarm should have been triggered in consideration of the potential for greater harm to personnel and facilities.

Hot, reacting ammonia…

Carbon steel Nelson curve methodology cannot be depended on to prevent HTHA equipment failures and cannot be reliably used to predict the occurrence of HTHA equipment damage. Revisions to recommended practices should be considered regarding the…

An important aspect of the reliability of a valve is the condition of the stem seal which tends to deteriorate with time and wear. Valves used in hydrogen service should be packed with the correct valve packing material and periodically checked…

Three root-causes were noted during the investigation: (1) the use of incompatible materials in the manufacturing of the PRD valve, (2) improper assembly resulting in over-torquing of the inner assembly, and (3) over-hardening of the inner…

A hydrogen release of this type is a significant event. The event highlighted a number of procedural contributing factors that will influence the manner in which these fuel cell systems will be serviced in the future. A complicating factor in…

Carefully revise the risk assessment process to evaluate any confined areas where hydrogen is handled.
Separate the fire and gas detection alarm system from the process information to provide easy and clear identification.
Refresh…

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 in…

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.…

Routine maintenance activities on pressurized hydrogen systems should be conducted per written design specifications. The procedures should provide detailed oversight regarding bolt, nut and fitting replacements or repairs. A formal review…

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.Hydrogen…

The site needs to implement a good Operational and Readiness Inspection procedure. System inspection deficiencies need to be identified, and (if possible) reviewed by a second party before future tests are conducted. This inspection could include…

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.

First, it appears that the system may not have been vented properly. CGA G-5.5 should be used for determining safe locations based on the variables of the specific setup. Also, if the compressor was tied to a storage system, a backflow prevention…

The accident proves that under special circumstances, the potential hazard connected with unforeseen microbial gas formation and accumulation should not be neglected. Thus, to avoid new accidents at the paper mill described above, the tower has…

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…

The mechanisms and rates by which hydrogen gas is generated and subsequently accumulated in the holding tank need to be fully understood by vendors and employees alike. Active venting, warning signs, and local alarms designed to activate when…

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…

This occurrence underscores the importance of appropriate design, equipment selection, and design review; the potential drawbacks of sharing utilities with other facilities; and the need to simplify [in this case, glove box atmosphere…

This event illustrates the importance of adequately planning and communicating work. Procedures should cover all types of equipment that will be utilized. Work packages should clearly describe the equipment that will be used and the surrounding…

Key:

  • = No Ignition
  • = Explosion
  • = Fire
Hydrogen Incident Summaries by Equipment and Primary Cause/Issue
Equipment / Cause Equipment Design or Selection Component Failure Operational Error Installation or Maintenance Inadequate Gas or Flame Detection Emergency Shutdown Response Other or Unknown
Hydrogen Gas Metal Cylinder or Regulator   3/31/2012
4/30/1995
2/6/2013
4/26/2010 12/31/1969     3/17/1999
11/1/2001
12/23/2003
Piping/Valves 4/4/2002
2/2/2008
5/11/1999
4/20/1987
11/4/1997
12/31/1969
8/19/1986
7/27/1991
12/19/2004
2/6/2008
10/3/2008
4/5/2006
5/1/2007
9/19/2007
10/31/1980
2/7/2009 1/24/1999
2/24/2006
6/8/1998
12/31/1969
2/7/2009

9/1/1992
10/31/1980

10/3/2008  
Tubing/Fittings/Hose   9/23/1999
8/2/2004
8/6/2008
9/19/2007
1/1/1982 9/30/2004
10/7/2005
  10/7/2005  
Compressor   10/5/2009
6/10/2007
8/21/2008
1/15/2019
    10/5/2009 8/21/2008  
Liquid Hydrogen Tank or Delivery Truck 4/27/1989 12/19/2004
1/19/2009
8/6/2004 12/31/1969   1/1/1974 12/17/2004
Pressure Relief Device 7/25/2013
5/4/2012
1/15/2002
1/08/2007
12/31/1969        
Instrument 1/15/2019 3/17/1999
12/31/1969
2/6/2013
    11/13/73    
Hydrogen Generation Equipment 7/27/1999     10/23/2001      
Vehicle or Lift Truck   7/21/2011         2/8/2011
12/9/2010
Fuel Dispenser   8/2/2004
5/1/2007
6/11/2007
9/19/2007
  2/24/2006
1/22/2009
     
Fuel Cell Stack            

5/3/2004
12/9/2010
2/8/2011

Hydrogen Cooled Generator       12/31/1969
2/7/2009
     
Other (floor drain, lab
anaerobic chamber,
heated glassware,
test chamber,
gaseous hydrogen
composite cylinder,
delivery truck)
  11/14/1994
7/21/2011
7/27/1999
6/28/2010
8/21/2008
12/31/1969
3/22/2018
    6/10/2019
  • = No Ignition
  • = Explosion
  • = Fire