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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.
Installation
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.…
Although most of the hydrogen fluoride piping system was open to the atmosphere before the elbow was cut, the lines were not purged. Two plugs of residual material on either side of the elbow remained in place, thus allowing hydrogen to be…
Diligence needs to be practiced when performing assigned work tasks. To guard against complacency, it is necessary to emphasize adherence to established procedures, including appropriate reviews of preventive maintenance instructions (PMI) and…
This event illustrates the importance of adequately planning and communicating work. Procedures should cover all types of equipment that will be utilized. Work packages should clearly describe the equipment that will be used and the surrounding…
Routine maintenance activities on pressurized hydrogen systems should be conducted per written design specifications. The procedures should provide detailed oversight regarding bolt, nut and fitting replacements or repairs. A formal review…
All valves and connectors should be clearly labeled to minimize chances for mis-connection. All technicians must be trained on proper procedures for both taking systems offline and bringing them back online.
Valves for compressed hydrogen…
Corrective actions included replacing the breakaway with a new one, which restored normal operation of the dispenser.
Verify and periodically inspect the pull/separation force adjustment if the breakaway is so equipped.
Additional…
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…
Maintenance on the low-pressure venting system was not occurring at regular intervals. Ventilation integrity is now checked before starting an experiment.
Key:
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