Work documentation (work orders and baseline drawings) should reflect the current system configuration.

Recommendations

1. Develop procedures for temporary change configuration control of high-pressure systems. The…

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…

Whenever a new program or organization is created, management should ensure that program interfaces and new responsibilities are clearly defined. Effective program integration is necessary to ensure that all responsibilities and requirements are…

1. Upgrade the liquid hydrogen pump control system to shut down operation of the pump and protect the system when malfunctions like leaks, pump cavitation, or loss of purge gas occur.
2. Verify that maintenance procedures used for liquid…

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…

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

A step was added to the laboratory procedure in which all catalyst waste is thoroughly dampened with water and sealed in a plastic bag before being placed into a waste container.

Manuals showing the correct connecting and disconnecting procedures were established for each fueling dispenser. Separate manuals were needed since the shape of the grip differs from dispenser to dispenser.

The investigation determined that hydrogen was formed by the reaction of hot aluminum and water, air was admitted via the inspection door, and the mixture was ignited by the hot clinker or sparks from the chisel. Aluminum should have been…

A hydrogen release of this type is a significant event. The event highlighted a number of procedural contributing factors that will influence the manner in which these fuel cell systems will be serviced in the future. A complicating factor in…

Three root-causes were noted during the investigation: (1) the use of incompatible materials in the manufacturing of the PRD valve, (2) improper assembly resulting in over-torquing of the inner assembly, and (3) over-hardening of the inner…

Disable the fueling process if the operator does not follow the proper sequence of steps in the fueling procedure. Improve the fueling procedure to make it inherently impossible for the sequence to be done improperly with the same result.