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.
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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
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 |
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 | |||||||
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