Disclaimer: The Lessons Learned Database includes the incidents that were voluntarily submitted. The database is not a comprehensive source for all incidents that have occurred.
The above described events are an indication of a potential licensee/vendor interface problem. Based on the information received, the vendor was not completely informed via the purchase specifications regarding the service condition to which the…
Work documentation (work orders and baseline drawings) should reflect the current system configuration.
Recommendations
Work pre-planning is essential whenever maintenance or work activities may have an adverse impact on everyday operations. When there are changes to the operational status of any critical system, especially a safety critical system, those changes…
The lessons learned in this situation center around basic conduct of operations principles. Policies and procedures related to operations performance, safety performance, and management oversight were in place. They were not employed…
Management should ensure that a complete and thorough review of the previous work activities identified in the work package is performed at the pre-job briefing for the planned work. Work activities should be discontinued if any confusion exists…
1. Management must ensure that operating decisions are not based primarily on cost and production. Performance goals and operating risks must be effectively communicated to all employees. Facility management must set safe, achievable operating…
Failure of a diaphragm is not infrequent, but the seizure of the main nut threads is very rare. The manufacturer claimed this had never occurred before with this type of unit. The broken plunger is likely the result of poor instructions/…
Standard procedure must be followed in all cases. Assumptions are made at great risk. Risk also increases with complacency.
A hydrogen release of this type is a significant event. The event highlighted a number of procedural contributing factors that will influence the manner in which these fuel cell systems will be serviced in the future. A complicating factor in…
Three root-causes were noted during the investigation: (1) the use of incompatible materials in the manufacturing of the PRD valve, (2) improper assembly resulting in over-torquing of the inner assembly, and (3) over-hardening of the inner…
Do not interconnect hydrogen drain trap lines with other drain lines
Thoroughly inspect equipment installation to manufacturer’s installation instructions
Warn against unauthorized field modifications
Consult the…
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