The investigation determined that hydrogen was formed by the reaction of hot aluminum and water, air was admitted via the inspection door, and the mixture was ignited by the hot clinker or sparks from the chisel. Aluminum should have been…

The ignition of the fireball could have been caused by any of the following mechanisms:

• The inverse Joule-Thompson effect of hydrogen (i.e., heating upon expansion)
• Some of the oil and light ends were above their auto-…

• Carefully revise the risk assessment process to evaluate any confined areas where hydrogen is handled.
• Separate the fire and gas detection alarm system from the process information to provide easy and clear identification.…

Based on the results of the company investigation and analysis of an amateur video, the company determined that the incident could have been caused by the failure of one of the following plant components:
· pipes leading to the reactor…

The root cause of the fire that burned the evaporator pad and distorted the plastic evaporator pad bracket remains unknown. The initial investigation did not reveal any obvious signs of an ignition source in the vicinity of the forklift operation…

It appears that this was an isolated event caused by human error. The lessons learned are: (1) to caution workers to maintain their focus during fuel cell stack assembly, (2) to require verification that all tools and spare parts are accounted…

Procedures for safe handling of compressed gas cylinders, marking design of gas cylinders and connecting lines, and arrangement of cylinders were reviewed and modified as necessary. The spectrometer was returned to the manufacturer for a careful…

In addition to the probable causes listed above, the lack of a standard operating procedure for hydrogen leak detection was one of the probable causes of this incident. Additional contributing factors included the following:
- Severe pipe…

The company investigation revealed that the incident arose because insufficient water was added to the batch. This resulted in a rapid increase in temperature and evolution of hydrogen gas following the addition of aluminum powder in the last…

The incident was the result of a combination of factors leading to exceptional temperature conditions that were not taken into account in the mechanical design of the reactor. Corrective actions that were implemented by the plant management…

The following actions were proposed as a result of this incident:

•  The company in charge of valve calibration and maintenance will be subject to approval of the plant service inspection team.
•  Plant operating…

1. The presence of other flammable impurities (e.g., oil carryover from compressors, hydrocarbon contamination of the gas) is an additional hazard and should be eliminated before cryogenic purification.
2. Potential sources of oxygen in…

Three root-causes were noted during the investigation: (1) the use of incompatible materials in the manufacturing of the PRD valve, (2) improper assembly resulting in over-torquing of the inner assembly, and (3) over-hardening of the inner…

An important aspect of the reliability of a valve is the condition of the stem seal which tends to deteriorate with time and wear. Valves used in hydrogen service should be packed with the correct valve packing material and periodically checked…

1. Carbon steel Nelson curve methodology cannot be depended on to prevent HTHA equipment failures and cannot be reliably used to predict the occurrence of HTHA equipment damage. Revisions to recommended practices should be considered…