CHECK OUT OUR MOST RELEVANT INCIDENT LISTINGS!
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.
- A SOP should be developed which prohibits drivers from backing into the fill position.
- As a precautionary measure to mitigate similar events in the future, piping barriers should be installed which protect critical H2…
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…
- Facilities housing battery charging systems need to ensure the ventilation systems are operational, and delivering enough outdoor air to properly ventilate the enclosure.
- Operators need to be aware of safe practices and proper…
The uncontrolled release of hydrogen occurred as a result of the rupture of the No. 6 hydrogen storage tube’s burst disc. This disc failed in response to being overloaded by mechanical stresses developed as water expanded and formed ice while in…
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.
…
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.…
- Operation and management of the hydrodesulfurization unit should be strengthened to account for abnormal phenomena such as local corrosion.
- The safety review system for remodeling existing equipment and facilities should be…
- Verify that all PRDs contain fuse-backed adapters.
- Explore elimination of rupture disk PRDs and substitution of spring-style relief valves.
- Develop new hydrogen unloading procedure using a written checklist. * Add…
Investigation determined that internal galling has caused the failure rendering the needle valve unusable. The galling was caused by a stainless steel stem acting against a stainless steel seat. This failure mode had been observed before and the…
Failure of a diaphragm is not infrequent, but the seizure of the main nut threads is very rare. The manufacturer claimed this had never occurred before with this type of unit. The broken plunger is likely the result of poor instructions/…
High-pressure fueling hoses should be examined daily for signs of external damage, including corrosion, abrasion, cuts, and kinking. High-use fueling hoses should be replaced every six months.
The combination of the cold water temperature (reducing the fatigue strength of the bolt), and the abnormally high number of cyclical stresses imposed by the imbalance from the hydraulic system check valve failure resulted in the failure of the…
1. Ensure that equipment and materials exposed to hydrogen are compatible with a hydrogen environment (even hydrogen-service-rated equipment).
2. Equipment designs in a hydrogen environment that use the fracture toughness for 17-4…
Mechanical pressure gauges tend to be imprecise if only used in a narrow portion of the full scale. Digital transducers, although slightly more expensive, offer much more precision. The event happened because the set pressure was only 10% of full…
1. The trailer involved in the incident used a frangible burst disk based upon the proprietary metal compound designated as Inconel #600. Random sampling of similar pressure relief devices from the same trailer showed that all of them failed at…
- Carefully revise the risk assessment process to evaluate any confined areas where hydrogen is handled.
- Separate the fire and gas detection alarm system from the process information to provide easy and clear identification.…
- Carbon steel Nelson curve methodology cannot be depended on to prevent HTHA equipment failures and cannot be reliably used to predict the occurrence of HTHA equipment damage. Revisions to recommended practices should be considered…
Maintain an internal process for verifying component wetted material compatibility for intended use as part of the procurement process for hydrogen system equipment. It is critical that component parts be appropriately rated for the materials,…
Key:
- = No Ignition
- = Explosion
- = Fire
Equipment / Cause | Equipment Design or Selection | Component Failure | Operational Error | Installation or Maintenance | Inadequate Gas or Flame Detection | Emergency Shutdown Response | Other or Unknown |
---|---|---|---|---|---|---|---|
Hydrogen Gas Metal Cylinder or Regulator | 3/31/2012 4/30/1995 2/6/2013 |
4/26/2010 | 12/31/1969 | 3/17/1999 11/1/2001 12/23/2003 |
|||
Piping/Valves | 4/4/2002 2/2/2008 5/11/1999 |
4/20/1987 11/4/1997 12/31/1969 8/19/1986 7/27/1991 12/19/2004 2/6/2008 10/3/2008 4/5/2006 5/1/2007 9/19/2007 10/31/1980 |
2/7/2009 | 1/24/1999 2/24/2006 6/8/1998 12/31/1969 2/7/2009 |
10/3/2008 | ||
Tubing/Fittings/Hose | 9/23/1999 8/2/2004 8/6/2008 9/19/2007 |
1/1/1982 | 9/30/2004 10/7/2005 |
10/7/2005 | |||
Compressor | 10/5/2009 6/10/2007 8/21/2008 1/15/2019 |
10/5/2009 | 8/21/2008 | ||||
Liquid Hydrogen Tank or Delivery Truck | 4/27/1989 | 12/19/2004 1/19/2009 |
8/6/2004 | 12/31/1969 | 1/1/1974 | 12/17/2004 | |
Pressure Relief Device | 7/25/2013 5/4/2012 |
1/15/2002 1/08/2007 |
12/31/1969 | ||||
Instrument | 1/15/2019 | 3/17/1999 12/31/1969 2/6/2013 |
11/13/73 | ||||
Hydrogen Generation Equipment | 7/27/1999 | 10/23/2001 | |||||
Vehicle or Lift Truck | 7/21/2011 | 2/8/2011 12/9/2010 |
|||||
Fuel Dispenser | 8/2/2004 5/1/2007 6/11/2007 9/19/2007 |
2/24/2006 1/22/2009 |
|||||
Fuel Cell Stack | |||||||
Hydrogen Cooled Generator | 12/31/1969 2/7/2009 |
||||||
Other (floor drain, lab anaerobic chamber, heated glassware, test chamber, gaseous hydrogen composite cylinder, delivery truck) |
11/14/1994 7/21/2011 |
7/27/1999 6/28/2010 8/21/2008 |
12/31/1969 3/22/2018 |
6/10/2019 |
- = No Ignition
- = Explosion
- = Fire