What is Lessons Learned?

What is H2LL?

This database is supported by the U.S. Department of Energy. The safety event records have been contributed by a variety of global sources, including industrial, government and academic facilities.

H2LL is a database-driven website intended to facilitate the sharing of lessons learned and other relevant information gained from actual experiences using and working with hydrogen. The database also serves as a voluntary reporting tool for capturing records of events involving either hydrogen or hydrogen-related technologies.

The focus of the database is on characterization of hydrogen-related incidents and near-misses, and ensuing lessons learned from those events. All identifying information, including names of companies or organizations, locations, and the like, is removed to ensure confidentiality and to encourage the unconstrained future reporting of events as they occur.

The intended audience for this website is anyone who is involved in any aspect of hydrogen use. The existing safety event records are mainly focused on laboratory settings that offer valuable insights into the safe use of hydrogen in energy applications and R&D. It is hoped that users will come to this website both to learn valuable lessons from the experiences of others as well as to share information from their own experiences. Improved safety awareness benefits all.

Development of the database has been primarily supported by the U.S. Department of Energy. While every effort is made to verify the accuracy of information contained herein, no guarantee is expressed or implied with respect to the completeness, causal attribution, or suggested remedial measures for avoiding future events of a similar nature. The contents of this database are presented for informational purposes only. Design of any energy system should always be developed in close consultation with safety experts familiar with the particulars of the specific application.

We encourage you to browse through the safety event records on the website and send us your comments and suggestions. We will continue to add new records as they become available.

How does H2LL work?

If you have an incident you would like to include in the H2LL database, please click the "Submit an Incident" button at the top of the page. You will be asked for a wide range of information on your incident. Please enter as much of the information as possible. In order to protect your and your employer's identities, information that may distinguish an incident (your contact information, your company's name, the location of the incident, etc.) will not be displayed in the incident reports on H2LL.

Lessons Learned Corner

Visit the Lessons Learned Corner Archives.

Key themes from the H2Incidents database will be presented in the Lessons Learned Corner. Safety event records will be highlighted to illustrate the relevant lessons learned. Please let us know what you think and what themes you would like to see highlighted in this safety knowledge corner. You can find all the previous topics in the archives.

While research staff were working in a lab, a staff member opened the primary valve to a 0.2" (1500 psi) hydrogen gas line connected to a manifold supplying instruments in the lab. Upon opening the valve, the hydrogen gas line failed at a fitting on the switching manifold, releasing a small amount of hydrogen gas. The staff member closed the valve immediately, then inspected the gas line and found the front ferrule (of the compression-style fitting) to be missing. There were no injuries or damage to equipment.

In the follow-on discussion with research staff, it was learned that approximately one month earlier, a similar condition (front ferrule missing from a fitting) was found while performing a modification to a similar manifold. Following a critique, management expressed view more

A subcontractor employee was using a band saw to cut a 1" metal pipe when a flash fire occurred on the third floor hydrogen fluoride area. Subcontractor employees were removing all piping associated with the Anhydrous Hydrofluoric Acid (AHF) system. These lines were being removed during plant decontamination and demolition (D&D). The subcontractor employee was attempting to cut a 90-degree elbow located at the highest elevation on the 1" line, but the lowest elevation of the overall piping run. Since hydrogen is lighter than air, it is speculated that a minute amount of hydrogen gas had accumulated in the elbow.

Even though Safe Shutdown personnel had previously opened the system and placed it in a safe configuration, residual hydrogen fluoride could have still view more

An unplanned shutdown of the hydrogen supply system occurred, affecting the hydrogen furnaces in the plant. The apparent cause was an inadvertent valve closing, which was contrary to the written procedure.

A preventative maintenance activity was being conducted on the hydrogen gas system. Shortly after starting that work, various hydrogen gas users notified the emergency response personnel that the hydrogen supply safety alarms sounded, indicating an interruption of the hydrogen gas supply. As a result, the hydrogen furnaces shut down. This shut down is an automated process which injects an inert gas (nitrogen or argon) to prevent the introduction of oxygen and its mixing with any hydrogen gas. All shut downs functioned as designed. As a precautionary measure, fire protection view more

An operator began preparations for a cleaning run, and was unaware that a maintenance task to calibrate a pressure transducer was scheduled to also take place that morning. The calibration required a break on a hydrogen line in order to install a Measuring and Test Equipment (M&TE) gage, which was used in the calibration. At the time the operator was informed of the calibration, the cleaning run procedure had been initiated but the actual cleaning had not yet begun. A discussion between his supervisor and the facility maintenance coordinator resulted in a decision to proceed with the maintenance task and suspend the cleaning run until afterwards.

The operator evacuated the hydrogen line and the hydrogen cylinder was valved out. The maintenance work package procedure had view more

An apprentice mechanic lacerated his right forearm while quickly sliding out from under a hydrogen prototype bus when the bus slipped off a hydraulic jack. The apprentice and another mechanic had raised the bus about 1 foot from the ground to position it on jack stands when the hydraulic jack tipped over. The apprentice went to the site medical facility, where he needed five stitches to close the wound in his forearm.

The mechanics were raising the rear of a hydrogen prototype bus, like the one in the figure below, and placing it on jack stands. After chocking the wheels, they used bottle jacks on each side of the rear axle to raise the bus high enough to place a 20-ton hydraulic jack under the differential. With the bus resting on a pair of small jack stands, they raised the view more

A hose clamp failed on a low-pressure vent line from a hydrogen reactor experiment and effluent was leaked into the laboratory. Unburnt hydrogen in the effluent stream triggered the low-level hydrogen alarm. The hose clamp was resecured and other hose clamps were checked for proper tightness.

An employee at a soap manufacturing plant died in a flash fire outside the facility's hydrogenation building. Responding personnel encountered a fire at the base of the plant's hydrogen storage towers, and they found the victim, who was burned over 90 percent of his body, some 50 feet away.

Officials determined that a pipe connection failed and that hydrogen, pressurized at 1,800 psi, ignited when it was released into the atmosphere, killing the plant operator.

According to reports, the pipe connection failure stemmed from pressures higher than design tolerance, which in turn were the result of over tightening that occurred during routine maintenance replacement. The new bolts were stronger than those they replaced, and the threads of the nuts had been partially view more

Incident Synopsis

A hydrogen compressor had been shut down for repairs and was being put back into service when an explosion occurred, resulting in property damage. The compressor was equipped with interchangeable intake and outlet valves.

Cause

The discharge valve was installed in the intake valve position, causing the cylinder head to blow off and release H2 to the atmosphere. The ignition source was not indicated.

A leaking liquid hydrogen cryogenic pump shaft during the process of filling a gaseous tube delivery trailer to 2400 psi at a liquid hydrogen transfilling location caused a series of explosions and a fire. After approximately 30 minutes of filling, the operator heard a single loud explosion and then saw flames and ripples from heat generation near the ground in the hydrogen fill area. The operator quickly actuated the emergency alarm system that shut down the cryogenic pump and closed the air-actuated valves on the cryogenic pump supply line. After this shutdown, three smaller explosions were heard as well as the sound of gas releasing from a safety relief valve. The fire department was called to the scene and participated in the final shutdown of the hydrogen system as the fire was view more

A previously identified generator hydrogen gas leakage into the stator cooling water system exceeded the predetermined maximum operational allowance and the nuclear plant was shut down from 100 percent power in accordance with plant operating procedures. The leak was identified by monitoring the stator water cooling system detraining tank. Following reactor shut down and generator rotor removal, a small hole was located in the collector end winding area of a slot on the top stator bar. A small particle of carbon steel (estimated to be 2 mm/0.078 inch by 0.6 mm/0.023 inch) is believed to have caused the damage. The source of the carbon steel particle was either foreign material introduced during previous generator internal work or from a phenomenon called "back-of-core burning view more