CHECK OUT OUR MOST RELEVANT INCIDENT LISTINGS! 

Disclaimer: The Lessons Learned Database includes the incidents that were voluntarily submitted. The database is not a comprehensive source for all incidents that have occurred.

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…

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…

Redundant safety systems prevented this event from becoming an incident. The 1%-hydrogen-concentration-level-triggered fan was backed up by a 2%-hydrogen-concentration alarm. The alarm is continuously monitored (24/7) by a remote Network…

The following corrective actions have been taken:

The non-return valve was dismantled, cleaned, and tested. Following positive testing, the system was restarted and pressurized without any further malfunctioning.
The hydrogen…

Safe work procedures will be prepared and followed. Hydrogen will be vented out of the system to create an inert atmosphere before working on system tubing and joints. The importance of purging hydrogen piping and equipment is discussed in the…

Utilize a Six Sigma Black Belt to statistically evaluate LFL monitor reliability and determine the failure rate based on the existing technology.

Revise the tank uncertainty calculation and surveillance to include a wider "Required…

The lessons learned in this situation center around basic conduct of operations principles. Policies and procedures related to operations performance, safety performance, and management oversight were in place. They were not employed…

Frequently inspect and maintain all elements of hydrogen-related systems.

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…

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…

Hazard assessment is critical during the design, fabrication, and installation of system modifications to ensure hazards and potential hazards are addressed prior to system start-up and operation.

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…

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

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 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.

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.

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…

Key:

  • = No Ignition
  • = Explosion
  • = Fire
Hydrogen Incident Summaries by Equipment and Primary Cause/Issue
Equipment / Cause Equipment Design or Selection Component Failure Operational Error Installation or Maintenance Inadequate Gas or Flame Detection Emergency Shutdown Response Other or Unknown
Hydrogen Gas Metal Cylinder or Regulator   3/31/2012
4/30/1995
2/6/2013
4/26/2010 12/31/1969     3/17/1999
11/1/2001
12/23/2003
Piping/Valves 4/4/2002
2/2/2008
5/11/1999
4/20/1987
11/4/1997
12/31/1969
8/19/1986
7/27/1991
12/19/2004
2/6/2008
10/3/2008
4/5/2006
5/1/2007
9/19/2007
10/31/1980
2/7/2009 1/24/1999
2/24/2006
6/8/1998
12/31/1969
2/7/2009

9/1/1992
10/31/1980

10/3/2008  
Tubing/Fittings/Hose   9/23/1999
8/2/2004
8/6/2008
9/19/2007
1/1/1982 9/30/2004
10/7/2005
  10/7/2005  
Compressor   10/5/2009
6/10/2007
8/21/2008
1/15/2019
    10/5/2009 8/21/2008  
Liquid Hydrogen Tank or Delivery Truck 4/27/1989 12/19/2004
1/19/2009
8/6/2004 12/31/1969   1/1/1974 12/17/2004
Pressure Relief Device 7/25/2013
5/4/2012
1/15/2002
1/08/2007
12/31/1969        
Instrument 1/15/2019 3/17/1999
12/31/1969
2/6/2013
    11/13/73    
Hydrogen Generation Equipment 7/27/1999     10/23/2001      
Vehicle or Lift Truck   7/21/2011         2/8/2011
12/9/2010
Fuel Dispenser   8/2/2004
5/1/2007
6/11/2007
9/19/2007
  2/24/2006
1/22/2009
     
Fuel Cell Stack            

5/3/2004
12/9/2010
2/8/2011

Hydrogen Cooled Generator       12/31/1969
2/7/2009
     
Other (floor drain, lab
anaerobic chamber,
heated glassware,
test chamber,
gaseous hydrogen
composite cylinder,
delivery truck)
  11/14/1994
7/21/2011
7/27/1999
6/28/2010
8/21/2008
12/31/1969
3/22/2018
    6/10/2019
  • = No Ignition
  • = Explosion
  • = Fire