An explosion occurred in a 90-ton-per-day incinerator at a municipal refuse incineration facility. Three workers were seriously burned by high-temperature gas that spouted from the inspection door, and one of them died 10 days later. The accident happened during inspection and repair of the furnace ash chute damper. The workers injected water to remove some blockage, and the water reacted with incinerated aluminum ash to form hydrogen, which caused the explosion.

Workers noticed that the post-combustion zone was full of ash and the ash pusher was not working properly, so they tried to remove the ash from the inspection door with a shovel. They discovered a solid layer of "clinker", which is formed by solidification of molten material such as aluminum. The explosion 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

Installation of a 9000-gallon liquid hydrogen storage tank by a lessee at a building has not been evaluated for effect on the Safety Authorization Basis (SAB) of nearby facilities.

During review of an Emergency Management Hazard Assessment document, a reviewer questioned whether the SAB of nearby facilities had been reviewed for the effect of the installed 9000-gallon liquid hydrogen tank. Reviews by the facility management and facility safety personnel confirmed the evaluations have not been performed.

The direct cause was determined to be a management problem, with policy not adequately defined, disseminated, or enforced to integrate potential lessee hazards into the facility safety program documentation on the 9000-gallon hydrogen tank and delivery. The existing policy view more