All safety devices worked as designed thereby protecting the environment and laboratory personnel. Researchers involved in the experiment acted properly and with the parameters set forth in operational procedures.

Follow up: Stops have…

Whenever a new program or organization is created, management should ensure that program interfaces and new responsibilities are clearly defined. Effective program integration is necessary to ensure that all responsibilities and requirements are…

Procedures will be revised to include specific information about hydrogen sensors and alarm controls. Caution will be added about sparks and flames in the fuel cell operation area. Workers will be cautioned that shunt resistors may reach high…

Management should ensure that a complete and thorough review of the previous work activities identified in the work package is performed at the pre-job briefing for the planned work. Work activities should be discontinued if any confusion exists…

This occurrence demonstrated the use of data by engineering to evaluate equipment problems. As the data changed, highlighting a problem with one-half inch PVC ball valves, the facility redesigned the valve extension and valve handle to prevent…

This occurrence highlights the need for ensuring work is organized and planned in a manner that is practical and efficient. The primary lesson learned from this occurrence is that personnel must be cognizant of the impact of their actions on…

Cause and effect can sometimes be predicted by observing abnormal behavior even when the behavior is within specifications. Operators log equipment data and inform shift management when specifications are exceeded or when unusual equipment…

1. Parallel-path design activities require an increased level of management oversight and control to mitigate the risks inherent in this process.
2. Schedule pressure cannot be allowed to compromise the integrity of the design process…

In this case, failure to recognize a run of tubing still maintaining pressure could have been avoided if such information was provided in a safety briefing. Knowledge of any job is the utmost importance in promoting and maintaining a safe working…

This incident highlights the need to ensure that the performance of special procedures does not place facility equipment in a condition that could lead to entry into a LCO.

Installation

1. Fittings need to be visually inspected to insure ferules are in place and correctly positioned prior to swageing.
2. Research staff are responsible for communicating system specifications [gas type,…

Hydrogen distribution lines should be designed and carefully inspected to ensure process equipment in the area is correctly and safely installed. Equipment subject to vibration should not be placed in contact with hydrogen lines or with other…

When performing maintenance evolutions, proper work control processes must be in place to insure that process systems are adequately prepared, remain in a safe energy state during the maintenance evolution, and are properly restored afterwards.…

This occurrence points to the importance of gathering and organizing all applicable administrative controls and other commitments prior to commencing work. It also re-emphasizes the importance of attention to detail, not only by the person…

Some hydride materials (e.g., sodium alanates) may be rapidly exothermic, even pyrophoric, if exposed to water or humid air or slowly exothermic, even pyrophoric, if exposed to oxygen. Reactive materials, including fine metal powders, should be…

The manager in charge acknowledged that, while he made relatively recent modifications to the high-pressure gas storage side of the system and had directed a major rebuilding of various units, the moderate-pressure interconnecting system (the…

This incident occurred due to moisture in the sample line monitoring system. Removing moisture from the sample line increases the reliability of the equipment. Further evaluations are being considered for improving system reliability.

Follow-up investigation of this occurrence confirms that it was inadvertent. Attention to detail while performing any task is a must for all personnel. This is to insure the safety of both the individual performing the task and others that may…

Work pre-planning is essential whenever maintenance or work activities may have an adverse impact on everyday operations. When there are changes to the operational status of any critical system, especially a safety critical system, those changes…

The simplicity of this situation has made us aware that increased consideration must be given to all aspects of the workplace when preparing preliminary hazard assessments. Some hazardous situations appear so trivial that they can be easily…