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…

• One needs to take extreme care with both new and supposedly spent hydride samples; the spent materials may contain pockets of unoxidized alanates that could react violently when being transferred.
• Work with small samples so if…

• Valve packing on ammonia tanks should be checked on a regular basis.
• If an ammonia smell becomes noticeable, the tank should be returned to the supplier.

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…

1. Flexible tubing should be secured so it cannot get dislodged during operations.
2. Fume hoods where hydrogen is used should not be made of combustible materials. 3. Preventative maintenance should be performed on equipment on a…

• Metal hydride materials of a composition which is not well characterized should be handled with procedures that assume a "worst case" for that class of materials, intermediates or precursors.
• Laboratory procedures should be in…

• A redundant safety circuit was put into service and the tank returned to normal operation after the failure. Both rupture discs were replaced and the tank was inspected.
• Important to note that the safety system functioned as…

Hazard analysis should consider potential leak locations, potential ignition sources in the vicinity, and the potential for accumulating flammable gases in that area.

Users should leak-check all cylinders upon installation. This event…

In the future, this mesoporous carbon material and ammonia borane:mesoporous carbon material will be handled under anaerobic conditions (glove box) to prevent further incidents.

No Lessons Learned, Specific Suggestions for Avoidance, or Mitigation Steps Taken.

• 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…

• Unprotected hoses are susceptible to glass shards, abrasion, and burns during normal use. This leak was formed from a glass shard penetrating the tube wall.
• Flexible hoses require protective sheaves to avoid cuts, abrasions and…

This occurrence underscores the importance of appropriate design, equipment selection, and design review; the potential drawbacks of sharing utilities with other facilities; and the need to simplify [in this case, glove box atmosphere…

1. There should have been greater awareness during the design and installation of the burn box regarding the static pressure limitations of the exhaust fan in relation to the anticipated static pressure buildup across the HEPA filter.
…

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…

This occurrence underscores the importance of completing a hazard analysis for each different process. Non-safety-related systems or equipment may be used for purposes other than their primary purpose so long as potential hazards are identified…

The risk of a serious fire occurring inside the chemistry laboratory hood from use of hydrogen gas and/or presence of a small quantity of hydrazine-hydrate was underestimated. Additional control measures were required to reduce the risk of fire…

• Equipment that is designed to provide a safety barrier must be stringently tested upon installation.
• A procedure requiring annual testing of both excess flow valves, which includes proper seating for closure and proper flow, has…

All safety devices worked as designed thereby protecting the environment and laboratory personnel. Researchers involved in the experiment acted properly and with the parameters set forth in operational procedures.

Follow up: Stops have…

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…