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.
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…
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.
When performing maintenance evolutions, proper work control processes must be in place to insure that process systems are adequately prepared, remain in a safe energy state during the maintenance evolution, and are properly restored afterwards.…
Utilize a Six Sigma Black Belt to statistically evaluate LFL monitor reliability and determine the failure rate based on the existing technology.
Revise the tank uncertainty calculation and surveillance to include a wider "Required…
Frequently inspect and maintain all elements of hydrogen-related systems.
This incident occurred due to moisture in the sample line monitoring system. Removing moisture from the sample line increases the reliability of the equipment. Further evaluations are being considered for improving system reliability.
Follow-up investigation of this occurrence confirms that it was inadvertent. Attention to detail while performing any task is a must for all personnel. This is to insure the safety of both the individual performing the task and others that may…
Work pre-planning is essential whenever maintenance or work activities may have an adverse impact on everyday operations. When there are changes to the operational status of any critical system, especially a safety critical system, those changes…
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.
The lessons learned in this situation center around basic conduct of operations principles. Policies and procedures related to operations performance, safety performance, and management oversight were in place. They were not employed…
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…
The following corrective actions have been taken:
The tube was 403 stainless steel, which is subject to hydrogen embrittlement. It is requested that all gauges that have bourdon tubes be replaced with 303 stainless steel.
A web-based resource developed by Sandia National Laboratories to…
Safe work procedures will be prepared and followed. Hydrogen will be vented out of the system to create an inert atmosphere before working on system tubing and joints. The importance of purging hydrogen piping and equipment is discussed in the…
1. Combustible gas detectors calibrated for hydrogen can falsely report hydrogen alarms due the presence of other gases the detector may pick up, such as carbon monoxide from engine exhaust or other sources. Since this event occurred, two…
Personnel were focused on the AGES system test and results, not the compatibility of the test equipment. The manual valve was needed to successfully test the system, however the fact that this particular valve could not accommodate the full…
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