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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.
Hazard assessment is critical during the design, fabrication, and installation of system modifications to ensure hazards and potential hazards are addressed prior to system start-up and operation.
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…
All chemicals, including gases, should be clearly labeled and expiration dates (if applicable) identified. Incidents are more common when incompatible chemicals are mixed or when chemicals are stored/transferred using incompatible equipment.…
The manufacturer will be notified of the failed parts identified as a result of the follow-up testing plan. These results may be useful to them for their information and forwarding to others with the same equipment.
Designs for high-tech systems/components evolve based on operating experience. The design changes should resolve identified deficiencies and are part of a continuous improvement process to increase reliability and productivity.
Laboratory accidents can happen despite the best preparation and careful attention to procedures. However, the lesson to be learned here is that employees must always be sure they understand the hazards of the activities, and that they know how…
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…
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 offgas 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…
Include the tanks in a regular inspection program. Evaluate their condition and replace if necessary.
Fill the tanks only half full with leach material.
Keep the material completely submerged in solution.
Install a fiberglass…
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:
Compressed gas cylinder caps can be very difficult to open as rust often occurs in the threads.
There are wrenches specifically designed to remove compressed gas cylinder caps. The lab had such a wrench and it was…
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…
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.
Verify that maintenance procedures used for liquid…
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…
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.…
The following corrective actions have been taken:
The non-return valve was dismantled, cleaned, and tested. Following positive testing, the system was restarted and pressurized without any further malfunctioning.
The hydrogen…
Specific response drills/exercises need to be conducted yearly. In this case, all safety systems worked as they should and outside emergency responders were not needed.
Performing other tasks while filling hydrogen tube trailers, such as…
Key:
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