The lessons of this event fall into five categories: (1) proper in-plant communications during events, (2) proper valve application for use with hydrogen, (3) excess flow check valve set point, (4) heating and ventilation and air conditioning (…

Personnel should be properly supervised, and supervisors should be aware of the activities of their personnel. Personnel must be motivated to adhere to established policies and procedures. All personnel associated with potentially hazardous work…

• All tank trailers should have a safely accessible auxiliary shut off valve in case of spills.
• Emergency personnel need to have access to all of the appropriate protective clothing, including shoes. Liquid hydrogen is stored at 20…

Standard procedure must be followed in all cases. Assumptions are made at great risk. Risk also increases with complacency.

Fail-safe position of control valves in supply lines must be set correctly to prevent damage to pressure vessels.

Recommendation

Set all valves for fail safe operation (open or closed) according to needs before installation…

1. The plant tried to increase production and decrease workload, but failed to notice the potential negative outcomes of this change.
2. It is necessary to thoroughly simulate all potential negative outcomes of a change in procedures…