Overview: A hydrogen leak and explosion occurred due to the installation of an incorrectly sized gasket at the suction line of a hydrogen compressor in a refinery hydrodesulfurization plant. The incorrectly sized gasket was mounted during the startup of the plant in 2001 and had never being inspected nor replaced.

Incident synopsis: The operating conditions were stable when the operator received an alarm indicating pressure loss in the circuit. He immediately instructed his field personnel to inspect the area. The hydrogen leak was confined inside the compressor room because the walls and roof were not provided with ventilation devices. An explosion occurred, causing two fatalities and the destruction of the compressor room and some of the surrounding area.

Incident Synopsis
One man was killed and another severely injured while working with a portable battery power supply.

At a test facility, a water-submersible portable battery power supply was used to power lighting. The battery power supply contained two 12-volt lead-acid automotive batteries, a wiring harness, and switching relays mounted in an air-tight case suitable for submersion in water. The case possessed ½-inch aluminum walls and a 13.8-pound lid. The box had been used periodically over two years.

After charging all night, the battery power supply was moved into place and connected to the lighting. Two technicians started to test the unit. One technician rested his hand on the case lid while the second leaned over the lid and threw the switch to activate view more