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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.
Facilities should review their process systems to determine if they have valves installed that may be subject to this hazard. If so, facilities should conduct a detailed hazard analysis to determine the risk of valve failure. Detailed internal…
The practice of making gas mixtures in the laboratory should be eliminated, and gas mixtures with a known low hydrogen concentration should be purchased for use. The concentration of hydrogen used should be such that it is not possible to form an…
After this accident, a safety inspection team was organized. An investigation of this incident and an inspection of all other experimental equipment was conducted by the team. As a result of this inspection, the heaters are now hard-wired to the…
1. Management must ensure that operating decisions are not based primarily on cost and production. Performance goals and operating risks must be effectively communicated to all employees. Facility management must set safe, achievable operating…
In the future, refining, petrochemical, and chemical industries need to review material verification programs to ensure that the maintenance procedures include sufficient controls and positive material identification (PMI) testing to prevent…
This incident emphasizes the need for proper gas detection and ventilation systems, as well as fire suppression systems, in laboratories using and storing hydrogen. This is especially true when open flame burners are in close proximity.…
Because of the near invisibility of a hydrogen flame in daylight and hydrogen's extremely low ignition coefficient, if a known leak is present (e.g., an audible hissing), ignition should always be presumed. The primary cause of this incident…
Several procedural and design changes should be considered for the future:
Although the preparation-for-transport procedures were done the same way they were done for previous outreach programs, this time it proved to be a different situation. It is not clear what caused the ignition of the first balloon, which then set…
Safe storage and transportation of balloons filled with a hydrogen-oxygen mixture is a very risky undertaking. There are few scenarios that do not involve enclosed spaces (e.g., a car) and the potential for static discharge. Perhaps a mesh bag…
The ignition of the fireball could have been caused by any of the following mechanisms:
Key:
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