Facilities should review their process systems to determine if they have valves installed that may be subject to this hazard. If so, facilities should conduct a detailed hazard analysis to determine the risk of valve failure. Detailed internal…

1. Parallel-path design activities require an increased level of management oversight and control to mitigate the risks inherent in this process.
2. Schedule pressure cannot be allowed to compromise the integrity of the design process…

The lessons of this event fall into five categories: (1) proper in-plant communications during events, (2) proper valve application for use with hydrogen, (3) excess flow check valve set point, (4) heating and ventilation and air conditioning (…

These events show the importance of preventing combustible gas mixtures from accumulating in piping. In both of the above described events, hydrogen and oxygen gases apparently accumulated to a combustible level which then catastrophically failed…

1. Test safety system components even if they are new.
2. Do not rely on listening for valve movement as confirmation that a valve is closing; measure downstream pressure to determine if the valve is really sealing properly.
3. …

The simplicity of this situation has made us aware that increased consideration must be given to all aspects of the workplace when preparing preliminary hazard assessments. Some hazardous situations appear so trivial that they can be easily…

Designs for high-tech systems/components evolve based on operating experience. The design changes should resolve identified deficiencies and are part of a continuous improvement process to increase reliability and productivity.

All safety devices worked as designed thereby protecting the environment and laboratory personnel. Researchers involved in the experiment acted properly and with the parameters set forth in operational procedures.

Follow up: Stops have…

This occurrence demonstrated the use of data by engineering to evaluate equipment problems. As the data changed, highlighting a problem with one-half inch PVC ball valves, the facility redesigned the valve extension and valve handle to prevent…

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…

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…

Recommendation 1 - Overhaul and replace the diaphragms on all cells showing low-purity results. Check on a routine basis the individual cell purity levels to monitor the deterioration of performance of individual cells. Certain…

The lesson to pass on is that ventilation is critical in UPS battery rooms. Great care should be taken to ensure that the ventilation system is operational and brings in enough outdoor air to properly ventilate the enclosure.

Electrical…

Hydrogen distribution lines should be designed and carefully inspected to ensure process equipment in the area is correctly and safely installed. Equipment subject to vibration should not be placed in contact with hydrogen lines or with other…

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…

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…

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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