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.
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…
1. Evaluate any change in normal procedures or conditions for storage of aluminum hydride products. In this case, the aluminum hydride material was typically stored at -35°C in the glove box freezer. However, due to a change in glove boxes, this…
1. Ensure that equipment and materials exposed to hydrogen are compatible with a hydrogen environment (even hydrogen-service-rated equipment).
2. Equipment designs in a hydrogen environment that use the fracture toughness for 17-4…
The packing in the flow control valve should be replaced periodically. A planned investigation will determine the optimum time period for packing replacement.
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…
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…
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…
Procedures will be revised to include specific information about hydrogen sensors and alarm controls. Caution will be added about sparks and flames in the fuel cell operation area. Workers will be cautioned that shunt resistors may reach high…
Management should ensure that a complete and thorough review of the previous work activities identified in the work package is performed at the pre-job briefing for the planned work. Work activities should be discontinued if any confusion exists…
This occurrence demonstrated the use of data by engineering to evaluate equipment problems. As the data changed, highlighting a problem with one-half inch PVC ball valves, the facility redesigned the valve extension and valve handle to prevent…
This occurrence highlights the need for ensuring work is organized and planned in a manner that is practical and efficient. The primary lesson learned from this occurrence is that personnel must be cognizant of the impact of their actions on…
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