A refinery hydrocracker effluent pipe section ruptured and released a mixture of gases, including hydrogen, which instantly ignited on contact with the air, causing an explosion and a fire. Excessive high temperature, likely in excess of 1400°F (760°C), initiated in one of the reactor beds spread to adjacent beds and raised the temperature and pressure of the effluent piping to the point where it failed. An operator who was checking a field temperature panel at the base of the reactor and trying to diagnose the high-temperature problem was killed. A total of 46 other plant personnel were injured and 13 of these were taken to local hospitals, treated, and released. There were no reported injuries to the public.

Property damage included an 18-inch (46-centimeter) long tear in the view more

Incident Synopsis
While a hot air dryer was being used to free a coupling in a hydrogen cryostat (an apparatus used to maintain constant low temperatures), a flash fire occurred. The H2 cryostat was being dismantled.

The temperature at the center of the cryostat was sufficiently low to liquefy air. The prescribed requirements for purging and bringing the cryostat to room temperature were circumvented. The H2 - air mixture was formed and ignition was assumed to be a spark from an open filament of the dryer.

Incident Synopsis
A technician was welding a cable suspended over a stainless steel H2 instrument line. During the welding process, two holes were accidentally burned through the hydrogen tubing. The operator heard a hissing sound and closed the valve, but the hydrogen had already ignited and it burned his hand while he was feeling for a leak.

A short during welding caused the pinholes in the tubing containing the gaseous H2.

Incident Synopsis
One man was killed and another severely injured while working with a portable battery power supply.

At a test facility, a water-submersible portable battery power supply was used to power lighting. The battery power supply contained two 12-volt lead-acid automotive batteries, a wiring harness, and switching relays mounted in an air-tight case suitable for submersion in water. The case possessed ½-inch aluminum walls and a 13.8-pound lid. The box had been used periodically over two years.

After charging all night, the battery power supply was moved into place and connected to the lighting. Two technicians started to test the unit. One technician rested his hand on the case lid while the second leaned over the lid and threw the switch to activate view more

An unplanned shutdown of the hydrogen supply system occurred, affecting the hydrogen furnaces in the plant. The apparent cause was an inadvertent valve closing, which was contrary to the written procedure.

A preventative maintenance activity was being conducted on the hydrogen gas system. Shortly after starting that work, various hydrogen gas users notified the emergency response personnel that the hydrogen supply safety alarms sounded, indicating an interruption of the hydrogen gas supply. As a result, the hydrogen furnaces shut down. This shut down is an automated process which injects an inert gas (nitrogen or argon) to prevent the introduction of oxygen and its mixing with any hydrogen gas. All shut downs functioned as designed. As a precautionary measure, fire protection view more

A brazing retort in a shop malfunctioned and resulted in an explosion that propelled the retort shell to the roof of the brazing area and then back to the floor. There were no injuries but damage was sustained by the furnace housing and the retort shell.

Administrative personnel were soon on the scene to make a preliminary assessment of the situation. An expert safety team was retained to assist in the investigation of the explosion. The safety team conducted their initial field investigation on the afternoon of the explosion and again on the following day.

Once it was determined that the explosion was the result of an ignition of a flammable mixture of hydrogen and air, the next step was to determine how air ended up in the retort, given that the retort is nominally view more

An employee noticed an unusual smell in a fuel cell laboratory. A shunt inside experimental equipment overheated and caused insulation on conductors to burn. Flames were approximately one inch high and very localized. The employee de-energized equipment and blew out the flames. No combustible material was in the vicinity of the experiment. The fire was contained within the fuel cell and resulted in no damage to equipment.

The employee was conducting work with a fuel cell supplied by oxygen gas. The hazard control plan (HCP) associated with the work was for use with fuel cells supplied by air or hydrogen, but not for oxygen, which yields a higher current density. The technician had set up the station wiring to handle a current of 100 amps and the shunt was configured to handle a view more