CHECK OUT OUR MOST RELEVANT INCIDENT LISTINGS! 

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.

Do not interconnect hydrogen drain trap lines with other drain lines

Thoroughly inspect equipment installation to manufacturer’s installation instructions

Warn against unauthorized field modifications

Consult the…

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…

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…

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 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 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…

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…

Several recommendations were outlined by the investigating committee to govern future operations of the hydrogen compressor in the synthetic liquid fuels laboratory:

Install a cutoff that will shut down the compressor when the suction…

Inadequate Safeguards - The system was designed with low-point drains to facilitate water removal, however, these were found to be inadequate in both location and size. The fact that the mixed feed pre-heat coil was not self-draining was unknown…

The visiting intern had several years of experience in research projects and tasks that were similar to those in progress at this laboratory. This led to the incorrect assumption that formal introductory training for this laboratory was…

Verify that all PRDs contain fuse-backed adapters.
Explore elimination of rupture disk PRDs and substitution of spring-style relief valves.
Develop new hydrogen unloading procedure using a written checklist. * Add instrumentation to…

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 purge and…

This incident illustrates the danger of hydrogen being inadvertently released through blown water seals. Similar incidents have occurred in non-nuclear industrial facilities, but offgas systems present a special hazard because of the…

Test safety system components even if they are new.
Do not rely on listening for valve movement as confirmation that a valve is closing; measure downstream pressure to determine if the valve is really sealing properly.
Lock the…

The practice of making gas mixtures in the laboratory should be eliminated, and gas mixtures with a known low hydrogen concentration should be purchased for use. The concentration of hydrogen used should be such that it is not possible to form an…

After this accident, a safety inspection team was organized. An investigation of this incident and an inspection of all other experimental equipment was conducted by the team. As a result of this inspection, the heaters are now hard-wired to the…

This event illustrates the importance of adequately planning and communicating work. Procedures should cover all types of equipment that will be utilized. Work packages should clearly describe the equipment that will be used and the surrounding…

Metal hydride materials of a composition which is not well characterized should be handled with procedures that assume a "worst case" for that class of materials, intermediates or precursors.
Laboratory procedures should be in…

Key:

  • = No Ignition
  • = Explosion
  • = Fire
Hydrogen Incident Summaries by Equipment and Primary Cause/Issue
Equipment / Cause Equipment Design or Selection Component Failure Operational Error Installation or Maintenance Inadequate Gas or Flame Detection Emergency Shutdown Response Other or Unknown
Hydrogen Gas Metal Cylinder or Regulator   3/31/2012
4/30/1995
2/6/2013
4/26/2010 12/31/1969     3/17/1999
11/1/2001
12/23/2003
Piping/Valves 4/4/2002
2/2/2008
5/11/1999
4/20/1987
11/4/1997
12/31/1969
8/19/1986
7/27/1991
12/19/2004
2/6/2008
10/3/2008
4/5/2006
5/1/2007
9/19/2007
10/31/1980
2/7/2009 1/24/1999
2/24/2006
6/8/1998
12/31/1969
2/7/2009

9/1/1992
10/31/1980

10/3/2008  
Tubing/Fittings/Hose   9/23/1999
8/2/2004
8/6/2008
9/19/2007
1/1/1982 9/30/2004
10/7/2005
  10/7/2005  
Compressor   10/5/2009
6/10/2007
8/21/2008
1/15/2019
    10/5/2009 8/21/2008  
Liquid Hydrogen Tank or Delivery Truck 4/27/1989 12/19/2004
1/19/2009
8/6/2004 12/31/1969   1/1/1974 12/17/2004
Pressure Relief Device 7/25/2013
5/4/2012
1/15/2002
1/08/2007
12/31/1969        
Instrument 1/15/2019 3/17/1999
12/31/1969
2/6/2013
    11/13/73    
Hydrogen Generation Equipment 7/27/1999     10/23/2001      
Vehicle or Lift Truck   7/21/2011         2/8/2011
12/9/2010
Fuel Dispenser   8/2/2004
5/1/2007
6/11/2007
9/19/2007
  2/24/2006
1/22/2009
     
Fuel Cell Stack            

5/3/2004
12/9/2010
2/8/2011

Hydrogen Cooled Generator       12/31/1969
2/7/2009
     
Other (floor drain, lab
anaerobic chamber,
heated glassware,
test chamber,
gaseous hydrogen
composite cylinder,
delivery truck)
  11/14/1994
7/21/2011
7/27/1999
6/28/2010
8/21/2008
12/31/1969
3/22/2018
    6/10/2019
  • = No Ignition
  • = Explosion
  • = Fire