This occurrence points to the importance of gathering and organizing all applicable administrative controls and other commitments prior to commencing work. It also re-emphasizes the importance of attention to detail, not only by the person…

Implementing and enforcing the laboratory's stop work and restart policy and procedures in conjunction with peer reviews for new processes and experiments should help prevent future accidents due to a lack of recognition of potential reactions…

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.
3. …

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…

Personnel should be aware that items requiring special receiving inspections should still be verified/examined by the end user prior to use.

Given that the anaerobic chamber and associated nearby electrical equipment were not designed or…

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…

LESSONS LEARNED:

1. Compressed gas cylinder caps can be very difficult to open as rust often occurs in the threads.
2. There are wrenches specifically designed to remove…

1. Inadequate Safeguards - The system was designed with low-point drains to facilitate water removal, however, these were found to be inadequate in both location and size. The fact that the mixed feed pre-heat coil was not self-draining was…

In the future, refining, petrochemical, and chemical industries need to review material verification programs to ensure that the maintenance procedures include sufficient controls and positive material identification (PMI) testing to prevent…

• 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…

This incident led to several changes in procedure:

• The purity of any gas bottle connected is double-checked. The practice outlined in the SOP requires confirming the content of the cylinder via the cylinder label prior to…

Incident investigation findings for corrective actions were:
1. Install a valve after the regulator as an added precaution.
2. Clean the coupler at the end of the hydrogen delivery tube after each use to ensure that any catalyst residue…

After the aforementioned incident, a rigid cage was designed to protect the reactor from external conditions, and to protect the contents of the hood and any experimenter from the reactor, in the event of a pressure burst from the reactor cell.…

1. Revise fire protection operations surveillance tests to include a maximum of 110% of the agent net weight to prevent over-filled cylinders from being placed in service.
2. Identify cylinders currently in service that exceed the 110…

• The fuel cell vehicle that was involved in the accident has been retired. The fuel cell power plant from that vehicle has been removed and is being used in another fuel cell vehicle.
• The fuel cell vehicle accident reinforced the…

Proper installation of check valves and other equipment should be visually inspected prior to pressurization.

• A SOP should be developed which prohibits drivers from backing into the fill position.
• As a precautionary measure to mitigate similar events in the future, piping barriers should be installed which protect critical H₂…

• When truck drivers are carrying new trailers, with new load distribution characteristics, they need to exercise caution, especially on hazardous roadways such as the one described in this occurrence. If the trailer stack would have been…

Extra caution should be taken working around elevated pressure or low-temperature fluids and storage. Values should be checked and then verified by a second party, if possible.

Follow CGA G-5.5 vent end system designs.