What is Lessons Learned?

What is H2LL?

This database is supported by the U.S. Department of Energy. The safety event records have been contributed by a variety of global sources, including industrial, government and academic facilities.

H2LL is a database-driven website intended to facilitate the sharing of lessons learned and other relevant information gained from actual experiences using and working with hydrogen. The database also serves as a voluntary reporting tool for capturing records of events involving either hydrogen or hydrogen-related technologies.

The focus of the database is on characterization of hydrogen-related incidents and near-misses, and ensuing lessons learned from those events. All identifying information, including names of companies or organizations, locations, and the like, is removed to ensure confidentiality and to encourage the unconstrained future reporting of events as they occur.

The intended audience for this website is anyone who is involved in any aspect of hydrogen use. The existing safety event records are mainly focused on laboratory settings that offer valuable insights into the safe use of hydrogen in energy applications and R&D. It is hoped that users will come to this website both to learn valuable lessons from the experiences of others as well as to share information from their own experiences. Improved safety awareness benefits all.

Development of the database has been primarily supported by the U.S. Department of Energy. While every effort is made to verify the accuracy of information contained herein, no guarantee is expressed or implied with respect to the completeness, causal attribution, or suggested remedial measures for avoiding future events of a similar nature. The contents of this database are presented for informational purposes only. Design of any energy system should always be developed in close consultation with safety experts familiar with the particulars of the specific application.

We encourage you to browse through the safety event records on the website and send us your comments and suggestions. We will continue to add new records as they become available.

How does H2LL work?

If you have an incident you would like to include in the H2LL database, please click the "Submit an Incident" button at the top of the page. You will be asked for a wide range of information on your incident. Please enter as much of the information as possible. In order to protect your and your employer's identities, information that may distinguish an incident (your contact information, your company's name, the location of the incident, etc.) will not be displayed in the incident reports on H2LL.

Lessons Learned Corner

Visit the Lessons Learned Corner Archives.

Key themes from the H2Incidents database will be presented in the Lessons Learned Corner. Safety event records will be highlighted to illustrate the relevant lessons learned. Please let us know what you think and what themes you would like to see highlighted in this safety knowledge corner. You can find all the previous topics in the archives.

A process area alarm activated. The alarm was caused by an instrument channel located above a reaction vessel off-gas system final HEPA filter canister, which indicated 25% of the lower explosive limit (LEL) for hydrogen. Since the only source of hydrogen is from the reaction vessel during the reaction of sodium with concentrated sodium hydroxide, the immediate actions were to shutdown the reaction process and place the facility in a safe condition.

The root cause was inadequate or defective design. Had the pre-filter drains been vented to outside the building, no hydrogen could accumulate in the process area. The corrective action for this is to complete an Engineering Task Authorization (ETA) to install a sample/drain collection system with loop seals to prevent any release of view more

While research staff were working in a lab, a staff member opened the primary valve to a 0.2" (1500 psi) hydrogen gas line connected to a manifold supplying instruments in the lab. Upon opening the valve, the hydrogen gas line failed at a fitting on the switching manifold, releasing a small amount of hydrogen gas. The staff member closed the valve immediately, then inspected the gas line and found the front ferrule (of the compression-style fitting) to be missing. There were no injuries or damage to equipment.

In the follow-on discussion with research staff, it was learned that approximately one month earlier, a similar condition (front ferrule missing from a fitting) was found while performing a modification to a similar manifold. Following a critique, management expressed view more

A deficiency was discovered in the application of a hydrogen sensor in the Rotary Mode Core Sampling (RMCS) portable exhauster. The sensor is installed in the flow stream of the exhauster designed to be used with a RMCS truck for core sampling of watch list tanks, and is part of the flammable gas detector system. During the previous week, a quarterly calibration of the sensor, per maintenance procedure, was attempted by Characterization Project Operations (CPO) technicians. Ambient temperatures during the sensor calibration were approximately 20 to 30 degrees F. Inconsistencies in calibration results and the failure of the sensor to meet the response-time calibration requirement lead to the conclusion that the unit could not reliably perform its safety function at low ambient view more

An operator went to purge a process tank per standard operating procedure. The operator reviewed the previous shift's purge time and determined the next required purge time. The operator found that the tank had been purged earlier than expected on the previous shift. Because the earlier purge time was not recognized, the 12-hour purge frequency was exceeded.

Background: On the previous day, during the night shift, an operator performed 12-hour hydrogen purges per the requirements of the standard operating procedure. Each of the hydrogen purges was completed within the required time limits. The operator correctly recorded the time and date that the next hydrogen purges would be required. The following morning, shift turnover was conducted. The direct and root cause of this view more

A demolition technician noted an elevated combustible gas lower explosive limit (LEL) on a pipe that was being tested prior to cutting (No. 2 pipe). The No. 2 pipe was one of four pipes being tested. The other three pipes tested less than detectable for combustible hydrogen gas. Testing involves tapping the pipe and connecting the pipe to an Explosive Gas Detector via a tube. When an elevated LEL is identified, the pipe is allowed to vent and then retested prior to cutting. After tapping the No. 2 pipe, the work crew left the pipe open to vent and departed the area for the end of shift.

At approximately 7"45 PM on the same day, a crew was on overtime to support roofing activities. Since additional workers were available, the craft supervisor decided to re-enter the viewing view more

An explosion occurred in a Microbiological Anaerobic Chamber of approximately 2 m3 capacity that contained an explosive mixture of hydrogen and air. A fire followed the explosion, but was rapidly extinguished by staff using fire extinguishers prior to the arrival of fire service personnel. The pressure wave from the explosion blew windows out of the laboratory, with glass hitting a passerby on a path outside and glass shards landing up to 30 m away. Ceiling panels were dislodged in the laboratory and adjacent rooms, and a worker using the apparatus at the time was taken to the hospital by ambulance for burn treatment. The worker subsequently fully recovered. Another worker in the lab at the time required medical observation, but was otherwise unharmed.

Mixtures of inert gases view more

An incident involved an explosion of an oven that was heating decaborane for vaporization. In this incident, the heater controller was defective so the heating element was disconnected from the controller and plugged directly into a wall outlet. This situation allowed the oven to reach temperatures in excess of 400 °C within 20 minutes. While the temperature increased, the decaborane continued to expand, causing a significant pressure build-up within the oven. The pressure increase eventually caused the oven's viewing window to burst. A burst of burning hydrogen was emitted from the window and burned the face of a researcher who was hospitalized for approximately three weeks.

A subcontractor employee was using a band saw to cut a 1" metal pipe when a flash fire occurred on the third floor hydrogen fluoride area. Subcontractor employees were removing all piping associated with the Anhydrous Hydrofluoric Acid (AHF) system. These lines were being removed during plant decontamination and demolition (D&D). The subcontractor employee was attempting to cut a 90-degree elbow located at the highest elevation on the 1" line, but the lowest elevation of the overall piping run. Since hydrogen is lighter than air, it is speculated that a minute amount of hydrogen gas had accumulated in the elbow.

Even though Safe Shutdown personnel had previously opened the system and placed it in a safe configuration, residual hydrogen fluoride could have still view more

A brazing retort in a shop malfunctioned and resulted in an explosion that propelled the retort shell to the roof of the brazing area and then back to the floor. There were no injuries but damage was sustained by the furnace housing and the retort shell.

Administrative personnel were soon on the scene to make a preliminary assessment of the situation. An expert safety team was retained to assist in the investigation of the explosion. The safety team conducted their initial field investigation on the afternoon of the explosion and again on the following day.

Once it was determined that the explosion was the result of an ignition of a flammable mixture of hydrogen and air, the next step was to determine how air ended up in the retort, given that the retort is nominally view more

A large, hydrogen-cooled generator is driven by steam turbines at a power station. During maintenance shutdowns, the hydrogen cooling loop in the generator is purged with carbon dioxide. After CO2 concentrations are measured with a densitometer to verify the complete removal of hydrogen, the generator is purged with air and the maintenance is performed.

This purging procedure was used prior to the explosion. The CO2 reading was reported to be 100 percent CO2 at the top of the generator. The cooling system was then purged with air and a 1/2 inch pipe in the cooling loop was cut to install some new instrumentation. When the pipe was cut, pressurized gas was emitted at the opening. Workers assumed the gas was either carbon dioxide or air and proceeded with the new instrument view more