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.
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…
The company investigation revealed that the incident arose because insufficient water was added to the batch. This resulted in a rapid increase in temperature and evolution of hydrogen gas following the addition of aluminum powder in the last…
The incident was the result of a combination of factors leading to exceptional temperature conditions that were not taken into account in the mechanical design of the reactor. Corrective actions that were implemented by the plant management…
The following actions were proposed as a result of this incident:
The project team concluded that the jar contained a sufficient vapor pressure of isopropanol to ignite when it came into contact with the decomposing hydride. The lesson learned was that hydrides react rapidly in air and can lead to combustion of…
Three root-causes were noted during the investigation: (1) the use of incompatible materials in the manufacturing of the PRD valve, (2) improper assembly resulting in over-torquing of the inner assembly, and (3) over-hardening of the inner…
Personnel were focused on the AGES system test and results, not the compatibility of the test equipment. The manual valve was needed to successfully test the system, however the fact that this particular valve could not accommodate the full…
An important aspect of the reliability of a valve is the condition of the stem seal which tends to deteriorate with time and wear. Valves used in hydrogen service should be packed with the correct valve packing material and periodically checked…
An investigative communication notes that "mechanical integrity programs at refineries repeatedly emphasize inspection strategies rather then the use of inherently safer design to control the damage mechanisms that ultimately cause major process…
The researcher's failure to pull the fire alarm was an oversight of required facility practice. The alarm should have been triggered in consideration of the potential for greater harm to personnel and facilities.
Hot, reacting ammonia…
The procedure for disposal of spent or partially spent AB has been modified so that it does not include the use of water. Instead, the AB is removed from containers and transferred for disposal by rinsing with mineral oil, silicone oil or other…
Maintain an internal process for verifying component wetted material compatibility for intended use as part of the procurement process for hydrogen system equipment. It is critical that component parts be appropriately rated for the materials,…
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