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.

A facility experienced a major fire in its Resid Hydrotreater Unit (RHU) that caused millions of dollars in property damage. One employee sustained a minor injury during the emergency unit shutdown and there were no fatalities.

The RHU incident investigation determined that an 8-inch diameter carbon steel elbow inadvertently installed in a high-pressure, high-temperature hydrogen line ruptured after operating for only 3 months. The escaping hydrogen gas from the ruptured elbow quickly ignited.

This incident occurred after a maintenance contractor accidentally replaced an alloy steel elbow with a carbon steel elbow during a scheduled heat exchanger overhaul. The alloy steel elbow was resistant to high-temperature hydrogen attack (HTHA), but the carbon steel elbow was not. 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

DESCRIPTION: On a Friday afternoon in 2007 a traffic accident occurred at the corner of two urban streets. Two vehicles were involved. Each vehicle contained a single driver (no passengers). Vehicle 1 was a Fuel Cell Vehicle. Vehicle 2 was a conventional Toyota Camry. Vehicle 1 was traveling west, approaching an intersection with a green light, and proceeded into the intersection. Vehicle 2 was traveling north on a cross street. The driver of Vehicle 2 incorrectly perceived a green light and proceeded into the intersection. The vehicles collided in the intersection.

RESPONSE: The police were coincidentally in the area and able to respond quickly to the site. The vehicles were moved out of the intersection. Vehicle 1 (fuel cell vehicle) shut down upon impact and was pushed out of view more

Overview

The catalyst in a dehydrogenation reactor, which was usually operated under a hydrogen atmosphere, was changed while the reactor was isolated from the peripheral equipment by closing a 20-inch remotely controlled valve. The hydrogen pressure in the peripheral equipment was set at 20 KPaG, and the reactor was opened to the atmosphere. Anticipating some hydrogen leakage, suction from the piping was accomplished with a vacuum device and, nitrogen sealing was performed. When the piping connections were restored after changing the catalyst, flames spouted from the flange clearance and two workers were burned. One cause of the fire was poor management of the catalyst replacement process.

Incident Synopsis

A catalyst exchange was carried out in a dehydrogenation view more

A laboratory technician died and three others were injured when hydrogen gas being used in experiments leaked and ignited a flash fire.

The incident occurred in a 5,700-square-foot, single-story building of unprotected non-combustible construction. The building was not equipped with automatic gas detection or fire suppression systems.

Employees in the laboratory were conducting high-pressure, high-temperature experiments with animal and vegetable oils in a catalytic cracker under a gas blanket. They were using a liquefied petroleum gas burner to supply heat in the process.

Investigators believe that a large volume of hydrogen leaked into the room through a pump seal or a pipe union, spread throughout the laboratory, and ignited after coming into contact with the 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

Incident Synopsis
While disconnecting a liquid H2 fill line from a liquid H2 trailer, liquid H2 escaped, burning a second man who was holding the hose. The man was burned on his hands and on his stomach.

Cause
The liquid H2 shut off valve was partially open, but both men assumed it was closed. Prescribed clothing was being worn.

On a given day personnel were removing a blind hub that had been used to temporarily isolate a portion of a gaseous hydrogen system. As a result of a sudden release of 2,800 psig gaseous nitrogen, sand and debris kicked up from the concrete pad and caused minor injury to two technicians.

During the investigation, it was found that:

The temporary configuration change to the gaseous hydrogen system was initiated on multiple work orders and by different individuals. There was no single document that documented the temporary system configuration.
The procedure for performing the work was written using a drawing that had not been updated to show the actual system configuration. Verbal field direction was given when it was discovered the system was not configured per view more

An accident occurred during setup for a popular hydrogen-oxygen balloon science demonstration at a local public school. The demonstrator suffered painful second-degree burns to his right forearm and was taken to the hospital. The paramedics feared that grave respiratory damage (due to flame inhalation) might have occurred.

The demonstrator had transported 15 helium-quality balloons, pre-filled with a hydrogen-oxygen mixture, in a large, black, polyethylene garbage bag. During the setup, he opened the bag to remove a single balloon for stringing and floating. Without warning, the entire bag of balloons detonated violently. Fortunately, the incident occurred an hour prior to the program and no one else was near. It was also fortunate that only a small box caught fire and none of view more

During the early morning hours on a Tuesday, a university support staff member was preparing for an off-campus community outreach program for high-school-age students in the community. One of the program demonstrations was to show students the reaction energy and properties of the hydrogen + oxygen = water chemical reaction. It was a demonstration that the professor and the staff member overseeing the program had done for over 15 years with no incidents ever occurring.

To prepare for the demonstration, eight balloons were filled, four with pure hydrogen and four with the proper combination of hydrogen and oxygen. The balloons were placed into a larger plastic garbage bag and carried outside to a university-owned SUV located next to the building's loading dock. The bag of view more