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.
This incident illustrates the danger of hydrogen being inadvertently released through blown water seals. Similar incidents have occurred in non-nuclear industrial facilities, but offgas systems present a special hazard because of the…
An important lesson to be derived from this incident is the need to carefully engineer and test all repairs and modifications to high-pressure process equipment.
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…
Recommendations:
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…
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…
Key:
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