Disclaimer: The Lessons Learned Database includes the incidents that were voluntarily submitted. The database is not a comprehensive source for all incidents that have occurred.
After this accident, a safety inspection team was organized. An investigation of this incident and an inspection of all other experimental equipment was conducted by the team. As a result of this inspection, the heaters are now hard-wired to the…
The mechanisms and rates by which hydrogen gas is generated and subsequently accumulated in the holding tank need to be fully understood by vendors and employees alike. Active venting, warning signs, and local alarms designed to activate when…
The investigative report noted that the explosion could have been prevented by (among other things) a continuous gas analyzer test of oxygen and hydrogen product purity. The continuous analyzer should be interlocked to shut the electrolyzer down…
This occurrence underscores the importance of appropriate design, equipment selection, and design review; the potential drawbacks of sharing utilities with other facilities; and the need to simplify [in this case, glove box atmosphere…
The risk of a serious fire occurring inside the chemistry laboratory hood from use of hydrogen gas and/or presence of a small quantity of hydrazine-hydrate was underestimated. Additional control measures were required to reduce the risk of fire…
The accident proves that under special circumstances, the potential hazard connected with unforeseen microbial gas formation and accumulation should not be neglected. Thus, to avoid new accidents at the paper mill described above, the tower has…
This event illustrates the importance of adequately planning and communicating work. Procedures should cover all types of equipment that will be utilized. Work packages should clearly describe the equipment that will be used and the surrounding…
The site needs to implement a good Operational and Readiness Inspection procedure. System inspection deficiencies need to be identified, and (if possible) reviewed by a second party before future tests are conducted. This inspection could include…
Although a functional fire protection system would have helped to extinguish the fire, a properly installed hydrogen detection system, coupled with a properly designed ventilation system, could have prevented the incident altogether.
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Routine maintenance activities on pressurized hydrogen systems should be conducted per written design specifications. The procedures should provide detailed oversight regarding bolt, nut and fitting replacements or repairs. A formal review…
This incident emphasizes the need for proper gas detection and ventilation systems, as well as fire suppression systems, in laboratories using and storing hydrogen. This is especially true when open flame burners are in close proximity.…
Fail-safe position of control valves in supply lines must be set correctly to prevent damage to pressure vessels.
Recommendation
Set all valves for fail safe operation (open or closed) according to needs before installation…
The use of inerting gas or other means of separation should be employed when conducting mechanical work where hydrogen gas could be present. More importantly, per CGA S1.3, the vessel should be equipped with a dual relief system that can isolate…
Extra caution should be taken working around elevated pressure or low-temperature fluids and storage. Values should be checked and then verified by a second party, if possible.
First, it appears that the system may not have been vented properly. CGA G-5.5 should be used for determining safe locations based on the variables of the specific setup. Also, if the compressor was tied to a storage system, a backflow prevention…
A hydrogen release of this type is a significant event. The event highlighted a number of procedural contributing factors that will influence the manner in which these fuel cell systems will be serviced in the future. A complicating factor in…
Three root-causes were noted during the investigation: (1) the use of incompatible materials in the manufacturing of the PRD valve, (2) improper assembly resulting in over-torquing of the inner assembly, and (3) over-hardening of the inner…
An important aspect of the reliability of a valve is the condition of the stem seal which tends to deteriorate with time and wear. Valves used in hydrogen service should be packed with the correct valve packing material and periodically checked…
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