Within the International Space Station (ISS) oxygen generator, an increase in differential pressure across a pump supplying return water to a PEM electrolyzer fuel cell stack had persisted over a 4-month period and was approaching the shut-off limit for the system. This decrease in performance was suspected to be caused by water-borne catalyst fines containing platinum black and TeflonĀ®* binder materials, shed by the fuel cell stack, and accumulated within the pump's inlet filter. Maintenance in the field was required.

The system had been designed for factory maintenance, and no contingency had been planned to handle field maintenance for such a circumstance. An initial assessment of hazards for the proposed filter maintenance raised the concern that opening the water line 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

The interior of a small high-temperature furnace, approximately 24 inches high by 18 inches wide, became contaminated with an unknown material later identified as magnesium. The furnace was disassembled to clean the unknown material from the interior surfaces, and while attempting to clean the bottom of the furnace, the technician tapped the upper lip of the furnace with a spatula and the magnesium flashed. The technician was stepping back from the furnace when the magnesium flashed. He received minor eye irritation and his eyebrows were singed.

Later that week the same technician was attempting to clean the interior surfaces of the top of the furnace and sprayed, as directed, the interior of the top with a water-based cleaning liquid which consisted of 91% water. He stepped view more

While research staff were working in a lab, a staff member opened the primary valve to a 0.2" (1500 psi) hydrogen gas line connected to a manifold supplying instruments in the lab. Upon opening the valve, the hydrogen gas line failed at a fitting on the switching manifold, releasing a small amount of hydrogen gas. The staff member closed the valve immediately, then inspected the gas line and found the front ferrule (of the compression-style fitting) to be missing. There were no injuries or damage to equipment.

In the follow-on discussion with research staff, it was learned that approximately one month earlier, a similar condition (front ferrule missing from a fitting) was found while performing a modification to a similar manifold. Following a critique, management expressed view more