A flammable gas explosion is an analyzed hazard and gas detection/shut off is a safety significant control system that requires a limiting condition for operation (LCO). The rigor of the evaluation of flammable gas systems was inadequate. There…

1. Test safety system components even if they are new.
2. Do not rely on listening for valve movement as confirmation that a valve is closing; measure downstream pressure to determine if the valve is really sealing properly.
3. …

Recommended Actions:

• The recommended safe storage time for AHF is two years. Contact the vendor for pick up and disposal for cylinders more than two years old. (Unused gas should also be returned, even if it has been less than two…

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.

Hazard assessment is critical during the design, fabrication, and installation of system modifications to ensure hazards and potential hazards are addressed prior to system start-up and operation.

1. There should have been greater awareness during the design and installation of the burn box regarding the static pressure limitations of the exhaust fan in relation to the anticipated static pressure buildup across the HEPA filter.
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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…

Whenever a new program or organization is created, management should ensure that program interfaces and new responsibilities are clearly defined. Effective program integration is necessary to ensure that all responsibilities and requirements are…

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…

• 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…

Failure of a diaphragm is not infrequent, but the seizure of the main nut threads is very rare. The manufacturer claimed this had never occurred before with this type of unit. The broken plunger is likely the result of poor instructions/…

Hazards should be eliminated to the extent possible rather than depending on workers to follow an operations manual.

Potassium carbonate draw-off operations should be improved, and the operations manual should be revised. The manual…

1. The plant tried to increase production and decrease workload, but failed to notice the potential negative outcomes of this change.
2. It is necessary to thoroughly simulate all potential negative outcomes of a change in procedures…

A step was added to the laboratory procedure in which all catalyst waste is thoroughly dampened with water and sealed in a plastic bag before being placed into a waste container.