1. It is important to understand the requirements and standards associated with safe equipment design (especially electrical equipment containing an internal ignition source with flammable gas) in potentially explosive atmosphere environments.…

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…

1. Inadequate Safeguards - The system was designed with low-point drains to facilitate water removal, however, these were found to be inadequate in both location and size. The fact that the mixed feed pre-heat coil was not self-draining was…

1. Provide additional retraining of operators. Curriculum should emphasize the proper response to high oxygen in the hydrogen gas.
2. Evaluate current knowledge of operators. Operators should know…

1. Train personnel on delivery procedures and emphasize the safety aspects of hydrogen connections and disconnections, and verification of clearance for trailer movement prior to departure.
2. Provide site-specific delivery procedures…

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…

The primary lesson learned was that the active hydrogen facility and existing operating procedure, at the time of the accident, were sound. While this now has been determined, the previous form(s) of this system, associated documentation, and…

Personnel should be properly supervised, and supervisors should be aware of the activities of their personnel. Personnel must be motivated to adhere to established policies and procedures. All personnel associated with potentially hazardous work…

• Battery power supplies require adequate ventilation for all operations, or the battery box should be designed to:
  • Eliminate all sparking devices
  • Ventilate during charging operations
  • Provide inert gas…

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…

Refueling operations need to be conducted in a careful and attentive manner, and operators need to be aware of the potential consequences of their actions.

Extra caution should be taken when working around elevated pressure storage tanks. Pressure relief valve settings should be checked and then verified by a second party if possible. Proper procedures need to be followed at all times.