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.

A process area alarm activated. The alarm was caused by an instrument channel located above a reaction vessel off-gas system final HEPA filter canister, which indicated 25% of the lower explosive limit (LEL) for hydrogen. Since the only source of hydrogen is from the reaction vessel during the reaction of sodium with concentrated sodium hydroxide, the immediate actions were to shutdown the reaction process and place the facility in a safe condition.

The root cause was inadequate or defective design. Had the pre-filter drains been vented to outside the building, no hydrogen could accumulate in the process area. The corrective action for this is to complete an Engineering Task Authorization (ETA) to install a sample/drain collection system with loop seals to prevent any release of 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

An anhydrous hydrogen fluoride (AHF) lecture bottle spontaneously exploded in a laboratory. No one was injured, but the lab was extensively damaged. The lecture bottle had split along its seam. Its cap and valve assembly were located to the immediate left.

Cause
The explosion was caused by hydrogen gas pressure build up in the cylinder. AHF comes in carbon steel cylinders as a liquefied gas under a pressure of 0.9 psi at 70 oF (i.e., the vapor pressure of the liquid). Though cylinders should be passivated with fluorine, which forms a protective coating, over time AHF may slowly react with the iron in a cylinder to form iron fluoride and hydrogen gas. The generation of hydrogen gas may produce cylinder pressures as high as several hundred psi.

A person working in a hydrogen lab unknowingly closed the wrong hydrogen valve and proceeded to loosen a fitting in one of the hydrogen gas lines. The pressure in the 1/4"-diameter hydrogen line was approximately 110 psig. Hydrogen escaped from the loosened fitting and the pressure release resulted in the tubing completely detaching and falling to the floor. The person noted seeing a white stream around the hydrogen jet leak. The person noted a color change and noise change as the leak ignited (this happened in a matter seconds and he did not have a chance to react). The person left the lab and pushed the emergency stop button. Someone else pulled the fire alarm. Both of these actions were designed to close the main hydrogen solenoid (shutoff) valve. The local emergency response view more

Facility management confirmed that a hydrogen gas cylinder did not comply with the limiting condition for operation (LCO) for flammable gas control systems in the lab's safety requirements. Earlier erroneous calculations had shown that a release of the entire contents of the cylinder into the hood could not reach the lower flammability limit (LFL).

The facility manager determined that the LCO was applicable and immediately entered the action statement in the safety system, which required immediate termination of normal operations in the affected wing of the building. Because normal operations had already been terminated in the wing for HVAC maintenance, further efforts to terminate normal operations were not necessary. The hydrogen cylinder was removed from the hood, thus view more

A 2000-psia-rated gas cylinder (nominal size 10"x1 1/2") was being filled with hydrogen to a target pressure of 1500 psia. The cylinder suffered a failure at an indicated pressure of 1500 psia during filling. Investigation of the failure subsequently revealed that a faulty digital readout had allowed the cylinder to be over-pressurized. There were no safety consequences due to the failure and no damage to the facility or equipment. The cylinder was being filled in a test vault that was specially designed for the high-pressure burst testing of pressure vessels and components. While no over-pressure cylinders were released from the laboratory for use, this incident is being reported to address the potential and subsequent lessons learned.

Investigations revealed that the view more

Installation of a 9000-gallon liquid hydrogen storage tank by a lessee at a building has not been evaluated for effect on the Safety Authorization Basis (SAB) of nearby facilities.

During review of an Emergency Management Hazard Assessment document, a reviewer questioned whether the SAB of nearby facilities had been reviewed for the effect of the installed 9000-gallon liquid hydrogen tank. Reviews by the facility management and facility safety personnel confirmed the evaluations have not been performed.

The direct cause was determined to be a management problem, with policy not adequately defined, disseminated, or enforced to integrate potential lessee hazards into the facility safety program documentation on the 9000-gallon hydrogen tank and delivery. The existing policy view more

While attempting to light the hydrogen flare inside a Metalorganic Chemical Vapor Deposition (MOCVD) system burn box, a small explosion occurred, blowing the back section of the burn box off. Hydrogen flow was shut down immediately, and this MOCVD operation was suspended. Researchers made the determination that this was a minor incident and there were no injuries.

The follow-up investigation determined that the MOCVD HEPA filter had become sufficiently loaded to the point where performance of the burn box exhaust ventilation system was significantly degraded. The static pressure created across the "loaded" HEPA filter equaled the operating static pressure of the exhaust ventilation system servicing the burn box. This resulted in a region of "dead air" in the view more

A single-stage diaphragm compressor failed during boosting of high-pressure hydrogen ground storage banks. The compressor sources hydrogen from a 44 MPa storage bank as suction and discharges it at a stop set point of 85 MPa. The compressor capacity is 0.71 m3/min (25 scfm).

The original notice of failure was through an inter-diaphragm pressure indication and alarm. There should not be any pressure build-up between the layers of the diaphragm. Upon opening, hydraulic oil was found, leading to the assumption that the hydraulic-side diaphragm was leaking. Although spare diaphragms and seals were available for on-site repair, difficulty was encountered in attempting to remove the compressor nut above the diaphragms. Similar difficulties were encountered when the unit was returned view more