Operators in a powdered metals production facility heard a hissing noise near one of the plant furnaces and determined that it was a gas leak in the trench below the furnaces. The trench carried hydrogen, nitrogen, and cooling water runoff pipes as well as a vent pipe for the furnaces.

Maintenance personnel presumed that the leak was nonflammable nitrogen because there had recently been a nitrogen piping leak elsewhere in the plant. Using the plant's overhead crane, they removed some of the heavy trench covers. They determined that the leak was in an area that the crane could not reach, so they brought in a forklift with a chain to remove the trench covers in that area.

Eyewitnesses stated that as the first trench cover was wrenched from its position by the forklift view more

During start-up operation of a high-temperature, high-pressure plant using hydrogen, hydrogen gas leaked from the flange of a heat exchanger and a fire occurred. The leakage occurred for two reasons:

Insufficient tightening torque control was carried out during hot-bolting and an unbalanced force was generated across the bolts.
A temperature rise was induced across the heat exchanger as a result of a revamping activity, during a turnaround shutdown.

Hot-bolting: In equipment and piping that operate at high temperatures, as the temperatures rise, the tightening force decreases, thus re-tightening of bolts is necessary. This work is called hot-bolting. The design conditions of the evaporator where the fire occurred were 2.4 MPaG, view more

A hydrogen cylinder was initially located in an adjacent laboratory, with tubing going through the wall into the laboratory in use. When the cylinder was moved to the laboratory in use, a required leak check was not performed. Unfortunately, a leak had developed that was sufficient to cause an accumulation of hydrogen to a level above the Lower Flammability Limit. The hydrogen ignited when a computer power plug was pulled from an outlet. The exact configuration of the leak location and the outlet plug is unknown.