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…

The lessons of this event fall into five categories: (1) proper in-plant communications during events, (2) proper valve application for use with hydrogen, (3) excess flow check valve set point, (4) heating and ventilation and air conditioning (…

In the future, refining, petrochemical, and chemical industries need to review material verification programs to ensure that the maintenance procedures include sufficient controls and positive material identification (PMI) testing to prevent…

These events show the importance of preventing combustible gas mixtures from accumulating in piping. In both of the above described events, hydrogen and oxygen gases apparently accumulated to a combustible level which then catastrophically failed…

Recommendation 1 - Overhaul and replace the diaphragms on all cells showing low-purity results. Check on a routine basis the individual cell purity levels to monitor the deterioration of performance of individual cells. Certain…

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…

Batteries stored on a charger can explode during use if overcharged.

Recommendations

1. Use automatic current limiting or timed circuit chargers when charging batteries.
2. Operators should be aware of safe…

Personnel should be properly supervised, and supervisors should be aware of the activities of their personnel. Personnel must be motivated to adhere to established policies and procedures. All personnel associated with potentially hazardous work…

• Battery power supplies require adequate ventilation for all operations, or the battery box should be designed to:
  • Eliminate all sparking devices
  • Ventilate during charging operations
  • Provide inert gas…

Immediate Corrective Actions

1. Fuel cell test stand was shutdown and sent to manufacturer for investigation.
2. Carbon dioxide fire extinguisher installed in laboratory.
3. Formal process hazard review performed…

In addition to resealing the glove box window, a positive pressure of argon gas was maintained inside the glove box while the course of action was planned. Subsequently, the glove box was cleaned up by specialized hazardous materials personnel…

• A SOP should be developed which prohibits drivers from backing into the fill position.
• As a precautionary measure to mitigate similar events in the future, piping barriers should be installed which protect critical H₂…

• When truck drivers are carrying new trailers, with new load distribution characteristics, they need to exercise caution, especially on hazardous roadways such as the one described in this occurrence. If the trailer stack would have been…

• All tank trailers should have a safely accessible auxiliary shut off valve in case of spills.
• Emergency personnel need to have access to all of the appropriate protective clothing, including shoes. Liquid hydrogen is stored at 20…

Standard procedure must be followed in all cases. Assumptions are made at great risk. Risk also increases with complacency.

Standard procedures must be followed at all times. The importance of doing so should be frequently reinforced through safety communications to all staff.

The use of inerting gas or other means of separation should be employed when conducting mechanical work where hydrogen gas could be present. More importantly, per CGA S1.3, the vessel should be equipped with a dual relief system that can isolate…

Extra caution should be taken working around elevated pressure or low-temperature fluids and storage. Values should be checked and then verified by a second party, if possible.