Because the bottle was located outside at the time of the event, and the hydrogen did not find a source of ignition while venting through the relief valve, nothing serious happened. The failed regulator was replaced and operations continued.…

1. The trailer involved in the incident used a frangible burst disk based upon the proprietary metal compound designated as Inconel #600. Random sampling of similar pressure relief devices from the same trailer showed that all of them failed at…

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…

1. All samples with potential for hydrogen buildup should be limited to ground shipment only. (This shipment was by ground and air. If this incident were to have happened in an airplane, the consequences may have been worse.)

2. All samples…

Hydrogen distribution lines should be designed and carefully inspected to ensure process equipment in the area is correctly and safely installed. Equipment subject to vibration should not be placed in contact with hydrogen lines or with other…

Now, when conducting a sulfur deprivation test, vessels are ventilated to prevent over pressurization and safely facilitate the release of excess hydrogen.

• One needs to take extreme care with both new and supposedly spent hydride samples; the spent materials may contain pockets of unoxidized alanates that could react violently when being transferred.
• Work with small samples so if…

• Valve packing on ammonia tanks should be checked on a regular basis.
• If an ammonia smell becomes noticeable, the tank should be returned to the supplier.

• A redundant safety circuit was put into service and the tank returned to normal operation after the failure. Both rupture discs were replaced and the tank was inspected.
• Important to note that the safety system functioned as…

No Lessons Learned, Specific Suggestions for Avoidance, or Mitigation Steps Taken.

• Unprotected hoses are susceptible to glass shards, abrasion, and burns during normal use. This leak was formed from a glass shard penetrating the tube wall.
• Flexible hoses require protective sheaves to avoid cuts, abrasions and…

This occurrence underscores the importance of completing a hazard analysis for each different process. Non-safety-related systems or equipment may be used for purposes other than their primary purpose so long as potential hazards are identified…

• Equipment that is designed to provide a safety barrier must be stringently tested upon installation.
• A procedure requiring annual testing of both excess flow valves, which includes proper seating for closure and proper flow, has…

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…

This occurrence demonstrated the use of data by engineering to evaluate equipment problems. As the data changed, highlighting a problem with one-half inch PVC ball valves, the facility redesigned the valve extension and valve handle to prevent…

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…

1. Parallel-path design activities require an increased level of management oversight and control to mitigate the risks inherent in this process.
2. Schedule pressure cannot be allowed to compromise the integrity of the design process…

In this case, failure to recognize a run of tubing still maintaining pressure could have been avoided if such information was provided in a safety briefing. Knowledge of any job is the utmost importance in promoting and maintaining a safe working…

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.

A gas detector was added in close proximity to the compressor shaft and a vibration switch is under consideration. Additional predictive measures are being considered to predict bearing failure. In addition, the manufacturer has been contacted…