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

An unplanned shutdown of the hydrogen supply system occurred, affecting the hydrogen furnaces in the plant. The apparent cause was an inadvertent valve closing, which was contrary to the written procedure.

A preventative maintenance activity was being conducted on the hydrogen gas system. Shortly after starting that work, various hydrogen gas users notified the emergency response personnel that the hydrogen supply safety alarms sounded, indicating an interruption of the hydrogen gas supply. As a result, the hydrogen furnaces shut down. This shut down is an automated process which injects an inert gas (nitrogen or argon) to prevent the introduction of oxygen and its mixing with any hydrogen gas. All shut downs functioned as designed. As a precautionary measure, fire protection view more