Process changes have been implemented for development and review of safety basis documents that focus on a collaborative effort between the preparer and reviewers in order to provide a more in-depth review. This change is anticipated to provide…

1.  Combustible gas detectors calibrated for hydrogen can falsely report hydrogen alarms due the presence of other gases the detector may pick up, such as carbon monoxide from engine exhaust or other sources. Since this event occurred, two…

A hydrogen release of this type is a significant event. The event highlighted a number of procedural contributing factors that will influence the manner in which these fuel cell systems will be serviced in the future. A complicating factor in…

The project team concluded that the jar contained a sufficient vapor pressure of isopropanol to ignite when it came into contact with the decomposing hydride. The lesson learned was that hydrides react rapidly in air and can lead to combustion of…

Because the bottle was located outside at the time of the event, and the hydrogen did not find a source of ignition while venting through the relief valve, nothing serious happened. The failed regulator was replaced and operations continued.…

1. The hydrogen supplier installed a fire-resistant material board adjacent to the high-pressure hydrogen storage banks to prevent any potential jet flames from affecting adjacent high-pressure cylinders for several minutes. The 0.25 mm…

Personnel were focused on the AGES system test and results, not the compatibility of the test equipment. The manual valve was needed to successfully test the system, however the fact that this particular valve could not accommodate the full…

Now, when conducting a sulfur deprivation test, vessels are ventilated to prevent over pressurization and safely facilitate the release of excess hydrogen.

This incident led to several changes in procedure:

• The purity of any gas bottle connected is double-checked. The practice outlined in the SOP requires confirming the content of the cylinder via the cylinder label prior to…

• One needs to take extreme care with both new and supposedly spent hydride samples; the spent materials may contain pockets of unoxidized alanates that could react violently when being transferred.
• Work with small samples so if…

• Valve packing on ammonia tanks should be checked on a regular basis.
• If an ammonia smell becomes noticeable, the tank should be returned to the supplier.

• A redundant safety circuit was put into service and the tank returned to normal operation after the failure. Both rupture discs were replaced and the tank was inspected.
• Important to note that the safety system functioned as…

In the future, this mesoporous carbon material and ammonia borane:mesoporous carbon material will be handled under anaerobic conditions (glove box) to prevent further incidents.

No Lessons Learned, Specific Suggestions for Avoidance, or Mitigation Steps Taken.

• Unprotected hoses are susceptible to glass shards, abrasion, and burns during normal use. This leak was formed from a glass shard penetrating the tube wall.
• Flexible hoses require protective sheaves to avoid cuts, abrasions and…

This occurrence underscores the importance of appropriate design, equipment selection, and design review; the potential drawbacks of sharing utilities with other facilities; and the need to simplify [in this case, glove box atmosphere…

This occurrence underscores the importance of completing a hazard analysis for each different process. Non-safety-related systems or equipment may be used for purposes other than their primary purpose so long as potential hazards are identified…

• Equipment that is designed to provide a safety barrier must be stringently tested upon installation.
• A procedure requiring annual testing of both excess flow valves, which includes proper seating for closure and proper flow, has…

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…