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.
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…
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…
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.
Installation
The manager in charge acknowledged that, while he made relatively recent modifications to the high-pressure gas storage side of the system and had directed a major rebuilding of various units, the moderate-pressure interconnecting system (the…
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…
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…
This incident highlights the need to properly design safety interlocks. These safety interlocks need to be carefully incorporated into the initial building/plant designs and should consider all of the unexpected occurrences, such as 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 (…
These events show the importance of preventing combustible gas mixtures from accumulating in piping. In both of the above described events, hydrogen and oxygen gases apparently accumulated to a combustible level which then catastrophically failed…
On-site personnel performing treatment of reactive metals/chemicals must continue to exercise caution. Although there is an inherent risk in treating reactive metals/chemicals, personnel must adhere to conduct of operations principles to include…
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…
In the future, the laboratory will issue a memorandum about this incident to illustrate the need to wear safety glasses with side shields, store chemicals compatibly, take care when placing chemicals in the refrigerators for storage, and keep the…
Frequently inspect and maintain all elements of hydrogen-related systems.
Recommended Actions:
In any event, the lesson that should be derived from this incident is the fact that the explosion could have been avoided either by using an inert gas instead of air across the diaphragm, or by monitoring the hydrogen concentration in the upper…
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…
This incident illustrates how a hydrogen fire which appears to be 'quite small' can actually be only the visible portion of a much larger fire. Observation alone is not a reliable technique for detecting pure hydrogen fires and/or assessing their…
Key:
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