One morning a saltwell pump was placed in operation. Operation of this equipment requires that the Standard Hydrogen Monitoring System (SHMS) cabinet be in operation. Later that morning, during the morning surveillance rounds, the Standard Hydrogen Monitoring System (SHMS) cabinet was found not to be in the operational mode.

On the previous day, the night shift saltwell operator assigned to run the saltwell pump had placed the SHMS monitor in operational mode; however, the saltwell system was not started at this time. Shift turnover was conducted and the condition of the SHMS was turned over to the appropriate saltwell operator and shift manager. During the day shift the day shift operator assigned to the complex received approval from the operations engineer to place the SHMS view more

During a facility walk-through, it was noted that a combustible gas (hydrogen) monitoring system installed in a furnace room was inoperable (the system had been unplugged). This system is used to detect and warn facility employees of an explosive or flammable environment. An explosive or flammable environment can only occur if there is a leak in the system, which would not be expected to occur during normal operations. When the system was reactivated, no leaks were indicated.

The incident had the following three causes:

A procedure describing administrative controls necessary to ensure safe operations in the area should have been developed and implemented prior to disabling the hydrogen monitoring system.
The hydrogen monitor was not hard-wired, which allowed it view more

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

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 began preparations for a cleaning run, and was unaware that a maintenance task to calibrate a pressure transducer was scheduled to also take place that morning. The calibration required a break on a hydrogen line in order to install a Measuring and Test Equipment (M&TE) gage, which was used in the calibration. At the time the operator was informed of the calibration, the cleaning run procedure had been initiated but the actual cleaning had not yet begun. A discussion between his supervisor and the facility maintenance coordinator resulted in a decision to proceed with the maintenance task and suspend the cleaning run until afterwards.

The operator evacuated the hydrogen line and the hydrogen cylinder was valved out. The maintenance work package procedure had view more

As a prerequisite to a storage tank slurry pump run, a tank operator identified a Lower Flammability Limit (LFL) Analyzer surveillance reading to the control room that was out of limits low. The reading was a negative zero % LFL indication (-0 % LFL). The tank operator roundsheet limits are 0 to 10% LFL. The "null" value (value read on analyzer when air with 0% LFL is drawn through the analyzer) as directed by the LFL Analyzer loop calibration procedure is set between 0 and 4% LFL.

To alert personnel to the buildup of potentially dangerous levels of explosive gases in the tank, a Combustible Gas Detection System is used to monitor and analyze sample air drawn from the tank vapor space. This system consists of a sensing element, a 4-20 milliAmp direct current (mADC) view more