Overview
A solution of potassium carbonate was being drawn off to an inventory tank for a turnaround/shutdown maintenance activity at a refinery's hydrogen production unit. On the day of the incident, the solution level in the tower wasn't checked as it should have been, which resulted in hydrogen gas flowing back into the tank until the increased pressure caused the tank to explode. The direct cause of the incident was the workers neglecting to check the solution level in the tower. It is not known whether the potential for backflow of hydrogen gas into the inventory tank was understood beforehand or not.

Incident Synopsis
An explosion occurred due to unexpected backflow of hydrogen gas while a solution of potassium carbonate was being drawn off to an view more

A laboratory technician died and three others were injured when hydrogen gas being used in experiments leaked and ignited a flash fire.

The incident occurred in a 5,700-square-foot, single-story building of unprotected non-combustible construction. The building was not equipped with automatic gas detection or fire suppression systems.

Employees in the laboratory were conducting high-pressure, high-temperature experiments with animal and vegetable oils in a catalytic cracker under a gas blanket. They were using a liquefied petroleum gas burner to supply heat in the process.

Investigators believe that a large volume of hydrogen leaked into the room through a pump seal or a pipe union, spread throughout the laboratory, and ignited after coming into contact with the view more

An employee at a soap manufacturing plant died in a flash fire outside the facility's hydrogenation building. Responding personnel encountered a fire at the base of the plant's hydrogen storage towers, and they found the victim, who was burned over 90 percent of his body, some 50 feet away.

Officials determined that a pipe connection failed and that hydrogen, pressurized at 1,800 psi, ignited when it was released into the atmosphere, killing the plant operator.

According to reports, the pipe connection failure stemmed from pressures higher than design tolerance, which in turn were the result of over tightening that occurred during routine maintenance replacement. The new bolts were stronger than those they replaced, and the threads of the nuts had been partially view more

Overview
During start-up operation of a high-temperature, high-pressure plant using hydrogen, hydrogen gas leaked from the flange of a heat exchanger and a fire occurred. The leakage occurred for two reasons:

Insufficient tightening torque control was carried out during hot-bolting and an unbalanced force was generated across the bolts.
A temperature rise was induced across the heat exchanger as a result of a revamping activity, during a turnaround shutdown.

Background
Hot-bolting: In equipment and piping that operate at high temperatures, as the temperatures rise, the tightening force decreases, thus re-tightening of bolts is necessary. This work is called hot-bolting. The design conditions of the evaporator where the fire occurred were 2.4 MPaG, view more

On a given day personnel were removing a blind hub that had been used to temporarily isolate a portion of a gaseous hydrogen system. As a result of a sudden release of 2,800 psig gaseous nitrogen, sand and debris kicked up from the concrete pad and caused minor injury to two technicians.

During the investigation, it was found that:

The temporary configuration change to the gaseous hydrogen system was initiated on multiple work orders and by different individuals. There was no single document that documented the temporary system configuration.
The procedure for performing the work was written using a drawing that had not been updated to show the actual system configuration. Verbal field direction was given when it was discovered the system was not configured per view more