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

A water treatment plant used an electrolytic process to generate sodium hypochlorite (NaOCl) from sodium chloride (NaCl). The strategy of using liquid sodium hypochlorite for disinfecting water instead of gaseous chlorine (CL2) is popular because the liquid is generally safer and falls under fewer OSHA and EPA standards. The further idea of generating the liquid sodium hypochlorite on an as-needed basis and in limited quantities also has certain obvious safety advantages.

One of the disadvantages of the electrolytic process is that hydrogen gas is also created as a byproduct. The hydrogen is supposed to be vented, by design, to the atmosphere before the liquid sodium hypochlorite passes into a holding tank.

For various reasons, in this instance it is believed that the view more