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

A subcontractor employee was using a band saw to cut a 1" metal pipe when a flash fire occurred on the third floor hydrogen fluoride area. Subcontractor employees were removing all piping associated with the Anhydrous Hydrofluoric Acid (AHF) system. These lines were being removed during plant decontamination and demolition (D&D). The subcontractor employee was attempting to cut a 90-degree elbow located at the highest elevation on the 1" line, but the lowest elevation of the overall piping run. Since hydrogen is lighter than air, it is speculated that a minute amount of hydrogen gas had accumulated in the elbow.

Even though Safe Shutdown personnel had previously opened the system and placed it in a safe configuration, residual hydrogen fluoride could have still view more

An apprentice mechanic lacerated his right forearm while quickly sliding out from under a hydrogen prototype bus when the bus slipped off a hydraulic jack. The apprentice and another mechanic had raised the bus about 1 foot from the ground to position it on jack stands when the hydraulic jack tipped over. The apprentice went to the site medical facility, where he needed five stitches to close the wound in his forearm.

The mechanics were raising the rear of a hydrogen prototype bus, like the one in the figure below, and placing it on jack stands. After chocking the wheels, they used bottle jacks on each side of the rear axle to raise the bus high enough to place a 20-ton hydraulic jack under the differential. With the bus resting on a pair of small jack stands, they raised the view more