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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.
Operation and management of the hydrodesulfurization unit should be strengthened to account for abnormal phenomena such as local corrosion.
The safety review system for remodeling existing equipment and facilities should be strengthened.…
The plant tried to increase production and decrease workload, but failed to notice the potential negative outcomes of this change.
It is necessary to thoroughly simulate all potential negative outcomes of a change in procedures.
…
The dilution water for making a polythionic acid aqueous solution was changed from industrial water to pure water to lower the chlorine concentration in the piping.
Water that accumulated in the drain was removed before heating began.…
Because of the near invisibility of a hydrogen flame in daylight and hydrogen's extremely low ignition coefficient, if a known leak is present (e.g., an audible hissing), ignition should always be presumed. The primary cause of this incident…
The tube was 403 stainless steel, which is subject to hydrogen embrittlement. It is requested that all gauges that have bourdon tubes be replaced with 303 stainless steel.
A web-based resource developed by Sandia National Laboratories 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…
Recommendation 1 - Overhaul and replace the diaphragms on all cells showing low-purity results. Check on a routine basis the individual cell purity levels to monitor the deterioration of performance of individual cells. Certain contaminants are…
These events show the importance of preventing combustible gas mixtures from accumulating in piping. In both of the above described events, hydrogen and oxygen gases apparently accumulated to a combustible level which then catastrophically failed…
In the future, refining, petrochemical, and chemical industries need to review material verification programs to ensure that the maintenance procedures include sufficient controls and positive material identification (PMI) testing to prevent…
The lessons of this event fall into five categories: (1) proper in-plant communications during events, (2) proper valve application for use with hydrogen, (3) excess flow check valve set point, (4) heating and ventilation and air conditioning (…
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…
This incident illustrates how difficult it is to completely purge hydrogen out of a large, complex piece of equipment. Uniform mixing and dilution is unlikely in all the partially enclosed spaces, crevices, etc. If a hazardous operation such as…
An important lesson to be derived from this incident is the need to carefully engineer and test all repairs and modifications to high-pressure process equipment.
Installation
Fittings need to be visually inspected to insure ferules are in place and correctly positioned prior to swageing.
Research staff are responsible for communicating system specifications [gas type, Maximum Allowable…
Management should ensure that a complete and thorough review of the previous work activities identified in the work package is performed at the pre-job briefing for the planned work. Work activities should be discontinued if any confusion exists…
Hydrogen distribution lines should be designed and carefully inspected to ensure process equipment in the area is correctly and safely installed. Equipment subject to vibration should not be placed in contact with hydrogen lines or with other…
Although most of the hydrogen fluoride piping system was open to the atmosphere before the elbow was cut, the lines were not purged. Two plugs of residual material on either side of the elbow remained in place, thus allowing hydrogen to be…
When performing maintenance evolutions, proper work control processes must be in place to insure that process systems are adequately prepared, remain in a safe energy state during the maintenance evolution, and are properly restored afterwards.…
In this case, failure to recognize a run of tubing still maintaining pressure could have been avoided if such information was provided in a safety briefing. Knowledge of any job is the utmost importance in promoting and maintaining a safe working…
Key:
- = No Ignition
- = Explosion
- = Fire
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 |
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 | |||||||
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