A partial pressure sensor for an automated gas environment system (AGES) was not functioning correctly for pure hydrogen flow. While personnel were troubleshooting the problem, a burst disk ruptured resulting in a leak of hydrogen gas and actuation of a flammable gas alarm.

System troubleshooting involved the installation of a small hydrogen gas cylinder and temporary manual valve in an engineered ventilated enclosure adjacent to an instrument sample well. A burst disk associated with the temporary manual valve ruptured upon opening of the gas cylinder valve. The vented gas, exhausting through an engineered exhaust system, triggered the flammable gas detector. Personnel promptly evacuated the area in accordance with established procedures. Appropriate personnel responded to the view more

A hydrogen monitor leak detector (HMLD) was out of service because of a failed membrane. The HMLD heater circuit and the ion pump and its associated controller were de-energized and red-tagged to ensure the system remained shut down. The ion pump and controller were later found energized. The ion pump circuit is a low-power (120-V, 1 amp) circuit and the pump operates in the micro-amp range. There was no damage to equipment from this inadvertent energization. There was also no personnel safety hazard since the tag out was not for maintenance purposes and since the system was in its normal operating configuration.

The direct cause is listed as personnel error, inattention to detail. This category most closely describes the inadvertent actuation of the controller toggle switch. view more