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.
The ignition of the fireball could have been caused by any of the following mechanisms:
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 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:
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…
Maintain an internal process for verifying component wetted material compatibility for intended use as part of the procurement process for hydrogen system equipment. It is critical that component parts be appropriately rated for the materials,…
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