1. A hydrogen tube pressure indication system needs to be developed that is robust enough to withstand an accident, indicates hydrogen pressure regardless of valve position, and would be visible from a safe distance during an accident…

1. Provide additional retraining of operators. Curriculum should emphasize the proper response to high oxygen in the hydrogen gas.
2. Evaluate current knowledge of operators. Operators should know…

A step was added to the laboratory procedure in which all catalyst waste is thoroughly dampened with water and sealed in a plastic bag before being placed into a waste container.

Safe work procedures will be prepared and followed. Hydrogen will be vented out of the system to create an inert atmosphere before working on system tubing and joints. The importance of purging hydrogen piping and equipment is discussed in the…

1. All samples with potential for hydrogen buildup should be limited to ground shipment only. (This shipment was by ground and air. If this incident were to have happened in an airplane, the consequences may have been worse.)

2. All…

1. Maintenance work scopes must be adhered to. If added work is approved, it must be tracked and reviewed to ensure that the equipment is inspected by operations personnel. Scheduled work and extra work should be listed and checked off for…

The following recommended actions were identified:

1. Reemphasize the current lab management policies and practices on how process changes are evaluated for direct/indirect impacts on the process.
2. Reinforce with lab workers…

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…

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…

Metallurgical examination of the two failed disks by light optical microscopy (LOM), scanning electron microscopy (SEM), and energy-dispersive x-ray spectroscopic analysis (EDS) found them to be fabricated from pure nickel with evidence of…

Mounting hardware incorporated polymeric braces not suitable for long-term exposure to sunlight and temperature extremes. With time, the polymeric materials had disintegrated, allowing the mounting brackets to become loose. In addition, the…

The possible outcomes from new maintenance scenarios can be predicted by using an accurate simulation. The proposed filter change-out maintenance was studied to identify conditions to which the catalyst might be exposed and a mock-up of the…

1. 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…

1. Hydrogen safety training should be provided to local emergency responders.
2. Liquid hydrogen installations should be inspected by facility personnel on a frequent basis, consistent with NFPA 55, to verify proper operation and…

The SS 24-inch pipe that failed was replaced with 1-1/4 Cr 1/2 Mo alloy pipe that is corrosion-resistant to SCC. A revised HTS bypass piping layout was installed to prevent the hazardous conditions that lead to the failure. A detailed hazard…

1. Redundant safety systems prevented this event from becoming an incident. The 1%-hydrogen-concentration-level-triggered fan was backed up by a 2%-hydrogen-concentration alarm. The alarm is continuously monitored (24/7) by a remote Network…

1. Management must ensure that operating decisions are not based primarily on cost and production. Performance goals and operating risks must be effectively communicated to all employees. Facility management must set safe, achievable operating…

1. It is important to understand the requirements and standards associated with safe equipment design (especially electrical equipment containing an internal ignition source with flammable gas) in potentially explosive atmosphere environments…

1. Upgrade the liquid hydrogen pump control system to shut down operation of the pump and protect the system when malfunctions like leaks, pump cavitation, or loss of purge gas occur.
2. Verify that maintenance procedures used for…

1. Increase physical protection, shielding, and securing of transported hydrogen tube valves, piping, and fittings from multi-directional forces that are likely to occur during accidents, including rollovers. Reference: 49 Code of Federal…