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.
An investigative communication notes that "mechanical integrity programs at refineries repeatedly emphasize inspection strategies rather then the use of inherently safer design to control the damage mechanisms that ultimately cause major…
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…
Active GH2 sensors should be installed and continuously monitored in all enclosed buildings near GH2 sources. All buildings near areas where hydrogen is used should be designed to preclude GH2 entrapment (e.g., sloping roof with ventilation at…
Mounting hardware incorporated polymeric braces not suitable for long-term exposure to sunlight and temperature extremes. With time, the polymeric materials had disintegrated, allowing the mounting brackets to become loose. In addition, the…
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…
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…
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 should…
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…
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.
Quantitative control of tightening torque on bolts should be…
Work documentation (work orders and baseline drawings) should reflect the current system configuration.
Recommendations
Develop procedures for temporary change configuration control of high-pressure systems. The overall work…
Recommendation 1 - Overhaul and replace the diaphragms on all cells showing low-purity results. Check on a routine basis the individual cell purity levels to monitor the deterioration of performance of individual cells. Certain contaminants are…
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…
Frequently inspect and maintain all elements of hydrogen-related systems.
Key:
- = No Ignition
- = Explosion
- = Fire
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 |
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 | |||||||
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