LESSONS
LEARNED
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.

Contributing Factors

Damage and Injuries

Equipment

Probable Cause

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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.

H2 Lessons Learned

H2 Analytics

Lessons Learned Corner

Failure to Meet Safety Requirement for Flammable Gas System

A flammable gas explosion is an analyzed hazard and gas detection/shut off is a safety significant control system that requires a limiting condition for operation (LCO). The rigor of the evaluation of flammable gas systems was inadequate. There…

Refinery Hydrocracker Pipe Ruptures and Releases Explosive Mixture with Hydrogen

1. Management must ensure that operating decisions are not based primarily on cost and production. Performance goals and operating risks must be effectively communicated to all employees. Facility management must set safe, achievable operating…

Rupture of Refinery Heat Exchanger
  1. Carbon steel Nelson curve methodology cannot be depended on to prevent HTHA equipment failures and cannot be reliably used to predict the occurrence of HTHA equipment damage. Revisions to recommended practices should be considered…

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

This material was prepared as an account of work sponsored by an agency of the United States Government.
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