Operators in a powdered metals production facility heard a hissing noise near one of the plant furnaces and determined that it was a gas leak in the trench below the furnaces. The trench carried hydrogen, nitrogen, and cooling water runoff pipes as well as a vent pipe for the furnaces.

Maintenance personnel presumed that the leak was nonflammable nitrogen because there had recently been a nitrogen piping leak elsewhere in the plant. Using the plant's overhead crane, they removed some of the heavy trench covers. They determined that the leak was in an area that the crane could not reach, so they brought in a forklift with a chain to remove the trench covers in that area.

Eyewitnesses stated that as the first trench cover was wrenched from its position by the forklift view more

On a given day personnel were removing a blind hub that had been used to temporarily isolate a portion of a gaseous hydrogen system. As a result of a sudden release of 2,800 psig gaseous nitrogen, sand and debris kicked up from the concrete pad and caused minor injury to two technicians.

During the investigation, it was found that:

The temporary configuration change to the gaseous hydrogen system was initiated on multiple work orders and by different individuals. There was no single document that documented the temporary system configuration.
The procedure for performing the work was written using a drawing that had not been updated to show the actual system configuration. Verbal field direction was given when it was discovered the system was not configured per view more