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 power plant reported a hydrogen leak inside an auxiliary building. The given plant was in cold shutdown at the time of the event. The discovery of this problem was as a result of an unassociated event involving the activation of a chlorine monitor in the control building. When additional samples indicated no chlorine gas, the shift supervisor ordered further investigation into other plant areas. Because there was no installed detection equipment, portable survey instruments were used to determine gaseous mixtures. Hydrogen was detected in the auxiliary building at 20 to 30 percent of the lower flammability limit (LFL) for hydrogen. A level of about 30 percent of LFL corresponds to about 1.2 percent hydrogen by volume.

When hydrogen was discovered in the auxiliary building, the view more

An offgas system mishap involved two explosions occurring within an interval of about 3 ½ hours. The first offgas explosion was reportedly caused by a welding operation on an air line adjacent to a hydrogen sensor line containing off gas. The welding arc initiated a detonation within the offgas piping. The detonation was contained by the piping system but blew out the water seal at the base of the vent stack.The second hydrogen explosion in this incident occurred in the stack base area. Hydrogen accumulated in the enclosed base area after the water seal had been blown in the first explosion. The stack base metal door was blown off its hinges from the second explosion, and the reinforced concrete stack was also damaged. A plant employee walking by the stack at the time of the explosion view more

A large, hydrogen-cooled generator is driven by steam turbines at a power station. During maintenance shutdowns, the hydrogen cooling loop in the generator is purged with carbon dioxide. After CO2 concentrations are measured with a densitometer to verify the complete removal of hydrogen, the generator is purged with air and the maintenance is performed.

This purging procedure was used prior to the explosion. The CO2 reading was reported to be 100 percent CO2 at the top of the generator. The cooling system was then purged with air and a 1/2 inch pipe in the cooling loop was cut to install some new instrumentation. When the pipe was cut, pressurized gas was emitted at the opening. Workers assumed the gas was either carbon dioxide or air and proceeded with the new instrument 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

Overview: A pipe end containing fuel oil corroded at the outlet of a heat exchanger on the outlet side of a desulfurization reactor. The corroded pipe end leaked hydrogen gas, which exploded, causing oil to leak from the heat exchanger. The leaking oil developed into an oil fire, and the damage spread. The causes of the pipe end corrosion include the following:

There was a high concentration of corrosive substances in the process injection water.
The concentration of corrosive substances increased due to re-molding the heat exchangers.
The shape of the pipe cap was dead end piping.

Incident: During normal operations at a fuel oil refinery, a pipe end in a desulfurization unit developed a hydrogen leak, which led to an explosion. The pipe end was located on 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

Summary
A faulty modification to a multiple-gas piping manifold allowed mixing of hydrogen and oxygen that resulted in a storage tube explosion. Several employees suffered severe burn injuries from the incident.

Incident Synopsis
An employee, without authorization, fabricated and installed an adapter to connect a hydrogen tube trailer manifold to an oxygen tube trailer manifold at a facility for filling compressed-gas cylinders for a variety of gases, including hydrogen, oxygen, nitrogen, and helium. A subsequent improper purging procedure allowed oxygen gas to flow into a partially filled hydrogen tube on a hydrogen tube trailer. An ignition occurred in the manifold piping system and a combustion front traveled into the hydrogen tube where, after traveling about a view more

An explosion occurred within the hydrogen processing system of a chemical plant that produces sodium chlorate for bleaching pulp and paper. The chemical process utilizes electrolytic cells and is pH-dependent. Hydrogen is produced as a byproduct and is utilized as a fuel.

At the time of the incident, the plant was at an abnormal operating level of 25% capacity. A non-routine maintenance operation to repair high-pH liquid piping was in progress. To assist, operations personnel rerouted the high-pH liquid stream to the plant sump. However, in doing this, the liquid eventually made its way back into the electrolytic process by design. Ultimately this created the root cause of the explosive condition in that the pH of the electrolytic process increased faster than the computer- view more

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