It is characteristic of silver/zinc batteries to outgas both hydrogen and oxygen for several hours after discharge. Also, in the future, the battery should be properly secured inside the container.

Refueling operations need to be conducted in a careful and attentive manner, and operators need to be aware of the potential consequences of their actions.

The site needs to implement a good Operational and Readiness Inspection procedure. System inspection deficiencies need to be identified, and (if possible) reviewed by a second party before future tests are conducted. This inspection could include…

Proper bolt identification can prevent similar occurrences in the future. This can be achieved by simply painting the critical bolt heads a certain color (or by purchasing bolts with painted bolt heads). An explanation form should then be clearly…

Extra caution should be taken when working around elevated pressure storage tanks. Pressure relief valve settings should be checked and then verified by a second party if possible. Proper procedures need to be followed at all times.

• Facilities housing battery charging systems need to ensure the ventilation systems are operational, and delivering enough outdoor air to properly ventilate the enclosure.
• Operators need to be aware of safe practices and proper…

Normally hydrogen fires are not extinguished until the supply of hydrogen has been shut off due to the danger of re-ignition and explosion. During a gas leak/fire, it is important to shut off the source of the hydrogen if it is safe to do so. If…

1. Follow the rules (e.g., using a torque-amplifying device requires supervisor approval).
2. Some valves are susceptible to disassembly, with potentially significant consequences, if excessive torque is applied to the handwheel.…

The investigation team concluded that hydrogen gas was released through a failed 19-inch diameter gasket and ignited under the roof of the compressor shed where it was partially confined. Some gas escaped from the shed prior to the explosion, but…

The investigation determined that hydrogen was formed by the reaction of hot aluminum and water, air was admitted via the inspection door, and the mixture was ignited by the hot clinker or sparks from the chisel. Aluminum should have been…

The ignition of the fireball could have been caused by any of the following mechanisms:

• The inverse Joule-Thompson effect of hydrogen (i.e., heating upon expansion)
• Some of the oil and light ends were above their auto-…

• Carefully revise the risk assessment process to evaluate any confined areas where hydrogen is handled.
• Separate the fire and gas detection alarm system from the process information to provide easy and clear identification.…

Process changes have been implemented for development and review of safety basis documents that focus on a collaborative effort between the preparer and reviewers in order to provide a more in-depth review. This change is anticipated to provide…

1.  Combustible gas detectors calibrated for hydrogen can falsely report hydrogen alarms due the presence of other gases the detector may pick up, such as carbon monoxide from engine exhaust or other sources. Since this event occurred, two…

Based on the results of the company investigation and analysis of an amateur video, the company determined that the incident could have been caused by the failure of one of the following plant components:
· pipes leading to the reactor…

The root cause of the fire that burned the evaporator pad and distorted the plastic evaporator pad bracket remains unknown. The initial investigation did not reveal any obvious signs of an ignition source in the vicinity of the forklift operation…

It appears that this was an isolated event caused by human error. The lessons learned are: (1) to caution workers to maintain their focus during fuel cell stack assembly, (2) to require verification that all tools and spare parts are accounted…

A hydrogen release of this type is a significant event. The event highlighted a number of procedural contributing factors that will influence the manner in which these fuel cell systems will be serviced in the future. A complicating factor in…

Procedures for safe handling of compressed gas cylinders, marking design of gas cylinders and connecting lines, and arrangement of cylinders were reviewed and modified as necessary. The spectrometer was returned to the manufacturer for a careful…

In addition to the probable causes listed above, the lack of a standard operating procedure for hydrogen leak detection was one of the probable causes of this incident. Additional contributing factors included the following:
- Severe pipe…