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.
Although most of the hydrogen fluoride piping system was open to the atmosphere before the elbow was cut, the lines were not purged. Two plugs of residual material on either side of the elbow remained in place, thus allowing hydrogen to be…
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…
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…
An investigative communication notes that "mechanical integrity programs at refineries repeatedly emphasize inspection strategies rather then the use of inherently safer design to control the damage mechanisms that ultimately cause major process…
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