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 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