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Contributing Factors

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Damage and Injuries

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Equipment

Valve

Probable Cause

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Contributing Factors

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Damage and Injuries

Any

Equipment

Valve
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Probable Cause

Any
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CHECK OUT OUR MOST RELEVANT INCIDENT LISTINGS!

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.

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.…

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…

The packing in the flow control valve should be replaced periodically. A planned investigation will determine the optimum time period for packing replacement.

  • Attentiveness to proper procedure would have prevented this incident.
  • This incident also underscores is the need for rigorous training on hydrogen properties and behavior, not only for the operators of fueling equipment but also for…
  • 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.

This occurrence underscores the importance of appropriate design, equipment selection, and design review; the potential drawbacks of sharing utilities with other facilities; and the need to simplify [in this case, glove box atmosphere…

  • 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…

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…

Facilities should review their process systems to determine if they have valves installed that may be subject to this hazard. If so, facilities should conduct a detailed hazard analysis to determine the risk of valve failure. Detailed internal…

Included inspection on monthly preventive maintenance plan and evaluated alternate materials for better cold-weather performance.

  1. Maintenance work scopes must be adhered to. If added work is approved, it must be tracked and reviewed to ensure that the equipment is inspected by operations personnel. Scheduled work and extra work should be listed and checked off for…

Installation

  1. Fittings need to be visually inspected to insure ferules are in place and correctly positioned prior to swageing.
  2. Research staff are responsible for communicating system specifications [gas type,…

Hazard assessment is critical during the design, fabrication, and installation of system modifications to ensure hazards and potential hazards are addressed prior to system start-up and operation.

Diligence needs to be practiced when performing assigned work tasks. To guard against complacency, it is necessary to emphasize adherence to established procedures, including appropriate reviews of preventive maintenance instructions (PMI) and…

  1. Test safety system components even if they are new.
  2. Do not rely on listening for valve movement as confirmation that a valve is closing; measure downstream pressure to determine if the valve is really sealing properly.

As demonstrated by the fire discussed above, lack of adequate maintenance, system monitoring and oversight of maintenance of these facilities can contribute to the ignition of a fire that is difficult to extinguish and poses an extreme danger to…

The above described events are an indication of a potential licensee/vendor interface problem. Based on the information received, the vendor was not completely informed via the purchase specifications regarding the service condition to which the…

The lessons of this event fall into five categories: (1) proper in-plant communications during events, (2) proper valve application for use with hydrogen, (3) excess flow check valve set point, (4) heating and ventilation and air conditioning (…

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…

  • All tank trailers should have a safely accessible auxiliary shut off valve in case of spills.
  • Emergency personnel need to have access to all of the appropriate protective clothing, including shoes. Liquid hydrogen is stored at 20…

Key:

  • = No Ignition
  • = Explosion
  • = Fire
Hydrogen Incident Summaries by Equipment and Primary Cause/Issue
Equipment / CauseEquipment Design or SelectionComponent FailureOperational ErrorInstallation or MaintenanceInadequate Gas or Flame DetectionEmergency Shutdown ResponseOther or Unknown
Hydrogen Gas Metal Cylinder or Regulator 3/31/2012
4/30/1995
2/6/2013
4/26/201012/31/1969  3/17/1999
11/1/2001
12/23/2003
Piping/Valves4/4/2002
2/2/2008
5/11/1999
4/20/1987
11/4/1997
12/31/1969
8/19/1986
7/27/1991
12/19/2004
2/6/2008
10/3/2008
4/5/2006
5/1/2007
9/19/2007
10/31/1980
2/7/20091/24/1999
2/24/2006
6/8/1998
12/31/1969
2/7/2009
9/1/1992
10/31/1980
10/3/2008 
Tubing/Fittings/Hose 9/23/1999
8/2/2004
8/6/2008
9/19/2007
1/1/19829/30/2004
10/7/2005
 10/7/2005 
Compressor 10/5/2009
6/10/2007
8/21/2008
1/15/2019
  10/5/20098/21/2008 
Liquid Hydrogen Tank or Delivery Truck4/27/198912/19/2004
1/19/2009
8/6/200412/31/1969 1/1/197412/17/2004
Pressure Relief Device7/25/2013
5/4/2012
1/15/2002
1/08/2007
12/31/1969    
Instrument1/15/20193/17/1999
12/31/1969
2/6/2013
  11/13/73  
Hydrogen Generation Equipment7/27/1999  10/23/2001   
Vehicle or Lift Truck 7/21/2011    2/8/2011
12/9/2010
Fuel Dispenser 8/2/2004
5/1/2007
6/11/2007
9/19/2007
 2/24/2006
1/22/2009
   
Fuel Cell Stack      5/3/2004
12/9/2010
2/8/2011
Hydrogen Cooled Generator   12/31/1969
2/7/2009
   
Other (floor drain, lab
anaerobic chamber,
heated glassware,
test chamber,
gaseous hydrogen
composite cylinder,
delivery truck)
 11/14/1994
7/21/2011
7/27/1999
6/28/2010
8/21/2008
12/31/1969
3/22/2018
  6/10/2019
  • = No Ignition
  • = Explosion
  • = Fire
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