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.

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

A violent reaction occurred while hydrolyzing metal in water. The reactive metal treatment began with a review of the chemical inventory and setup of reaction vessels. The sodium metal was cut in shavings and added one at a time to the reaction vessel. After the second addition, an argon purge was added to disperse hydrogen gas faster. After approximately 10 pieces had been treated, the glass beaker shattered, releasing the contents of the reaction vessel (1 liter) inside the hood and causing the chemist's hand to receive superficial cuts. The process was being performed under a hood with all safety equipment in place. The employee was in personal protective equipment (PPE), but did receive two cuts on his hand through the glove. The treatment of reactive metals was being view more

A shop supervisor determined that a second shift would be necessary to complete some priority work on the spare hydrogen mitigation pump. The work scope for the shift would be dedicated to continued fabrication of designed tubing runs, repairs to existing tubing with known leaks and pressure testing of other various tubing runs. The shift craft complement would include three pipe fitters, one welder, one QC inspector and a shift supervisor.

The shift remained under normal operations prior to the event. There had been no existing problem up until the point that craft personnel implemented some hydrostatic pressure testing on some tubing runs on the spare hydrogen mitigation pump. Work activities associated with the hydrostatic testing were to be in accordance with the Hydrostatic 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

Overview
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.

Background
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

Overview
A hydrogen leak and fire occurred due to the installation of an incorrectly sized gasket at a solvent manufacturing plant. A worn gasket was accidentally replaced with a new gasket that was smaller than the standard one, and the system could not withstand the operational pressure of the hydrogen, causing the hydrogen to leak and ignite a small fire. Furthermore, a nearby gasket was damaged by the fire, causing a larger quantity of hydrogen to leak, and the fire spread. As nitrogen was substituted for the combustible hydrogen gas in the piping at an early stage of the fire, damage was limited to the immediate area. If the hydrogen had not been quickly purged from the system, the fire damage would have been greater. It is assumed that gasket management at a turnaround view more

Incident Synopsis
During transfer of liquid H2 from a commercial tank trailer to a receiving vessel, a leak developed in a bayonet fitting at the trailer/facility connection. The leak produced liquid H2 spray which enveloped the rear of the truck where the hand-operated shutoff valve was located. Emergency trained personnel, wearing protective clothing, except for proper shoes, entered the area and shut off the flow control valve. Reentry personnel suffered frost bite of their feet when shoes became frozen to the water-wetted rear deck of the truck.

Cause
A loose hose flange connection allowed leakage of cold fluid through the lubricated bayonet seal. This allowed cold fluid to contact and shrink the 'O' ring seal (made of Buna-N rubber), thus permitting view more

A small research sample of approximately 5 grams of aluminum hydride (alane) doped with 2-3 mol % TiCl3 contained within a glass ampoule ruptured after transit while stored in an office cabinet. The rupture was attributed to over-pressurization caused by hydrogen gas buildup within the sample over a four-month period. The glass ampoule, contained within a 0.2-inch thick cardboard shipping tube, was not a pressure-rated container. The rupture resulted in glass chards penetrating the protective cardboard shipping tube. The aluminum hydride, a fine powder, was released from the shipping tube during the pressure release. The fine aluminum powder leaked from the cabinet and set off a local smoke alarm that brought emergency responders to the scene. No personnel were present in the area when view more

A hydrogen leak at the flange of a 6-inch synthesis turbocharger valve in an ammonia production plant ignited and exploded. Hydrogen detectors and the fire alarm alerted the control room, which immediately shut down the plant, and the fire was then extinguished rapidly. There were no injuries caused by the accident, since the operator heard a wheezing sound and was able to run away just before the explosion occurred. The leaking gas was composed of 70% hydrogen at a flow rate of 15,000 cubic meters per hour. Property damages in the turbocharger included electrical cabling, melted siding, and heavily damaged pipes. The ammonia plant was shut down for more than a month.Five days before the incident, a problem with the CO2 absorber column led operators to open the vent downstream of the view more