Cause and effect can sometimes be predicted by observing abnormal behavior even when the behavior is within specifications. Operators log equipment data and inform shift management when specifications are exceeded or when unusual equipment…

1. Parallel-path design activities require an increased level of management oversight and control to mitigate the risks inherent in this process.
2. Schedule pressure cannot be allowed to compromise the integrity of the design process…

In this case, failure to recognize a run of tubing still maintaining pressure could have been avoided if such information was provided in a safety briefing. Knowledge of any job is the utmost importance in promoting and maintaining a safe working…

This incident highlights the need to ensure that the performance of special procedures does not place facility equipment in a condition that could lead to entry into a LCO.

Installation

1. Fittings need to be visually inspected to insure ferules are in place and correctly positioned prior to swageing.
2. Research staff are responsible for communicating system specifications [gas type,…

The practice of making gas mixtures in the laboratory should be eliminated, and gas mixtures with a known low hydrogen concentration should be purchased for use. The concentration of hydrogen used should be such that it is not possible to form an…

After this accident, a safety inspection team was organized. An investigation of this incident and an inspection of all other experimental equipment was conducted by the team. As a result of this inspection, the heaters are now hard-wired to the…

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.…

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…

Because the bottle was located outside at the time of the event, and the hydrogen did not find a source of ignition while venting through the relief valve, nothing serious happened. The failed regulator was replaced and operations continued.…

As stated on the MSDS and also on the container labels, LiAlH4 should be handled under argon. LiAlH4 is advertised and sold as a powder. If the researcher had to scrape it out of the jar, then it was no longer a powder, which seems indicative of…

During charging, most batteries will off gas hydrogen, making adequate ventilation and the elimination of ignition sources critical attributes of the charging area. Data from the battery manufacturer should be consulted to determine appropriate…

1. Include the tanks in a regular inspection program. Evaluate their condition and replace if necessary.
2. Fill the tanks only half full with leach material.
3. Keep the material completely submerged in solution.
4. Install a…

1. The trailer involved in the incident used a frangible burst disk based upon the proprietary metal compound designated as Inconel #600. Random sampling of similar pressure relief devices from the same trailer showed that all of them failed at…

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. Increase physical protection, shielding, and securing of transported hydrogen tube valves, piping, and fittings from multi-directional forces that are likely to occur during accidents, including rollovers. Reference: 49 Code of Federal…

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. It is important to understand the requirements and standards associated with safe equipment design (especially electrical equipment containing an internal ignition source with flammable gas) in potentially explosive atmosphere environments.…

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…

1. Incorporate external operating experience lessons learned into site program controls. Other nuclear plants had similar strand failures and back-of-core issues that were not evaluated for impact on procedures or system/component health plans…