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Contributing Factors

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Damage and Injuries

Any

Equipment

Piping

Probable Cause

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Contributing Factors

Any
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Damage and Injuries

Any
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Equipment

Piping
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Probable Cause

Any
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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.

Because the bottle was located outside at the time of the event, and the hydrogen did not find a source of ignition while venting through the relief valve, nothing serious happened. The failed regulator was replaced and operations continued.…

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…

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…

  1. 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.
  2. Water that accumulated in the drain was removed before heating…
  1. The plant tried to increase production and decrease workload, but failed to notice the potential negative outcomes of this change.
  2. It is necessary to thoroughly simulate all potential negative outcomes of a change in procedures…
  • 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…

For the use of mechanical fittings in hydrogen service, administrative controls should be in place, as in this case, to ensure that leak testing is conducted on a regular basis. It should never be assumed that every fitting is tight. Additional…

  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. 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…

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 hydrogen…
  1. 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…
  • Replace the existing copper and carbon steel hydrogen pipeline with ¾-inch schedule 40 stainless steel.
  • Reroute the new hydrogen line in the preferred location.
  • Locate new hydrogen shut-off valves in a more convenient…

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…

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…

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…

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…

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…

Installation

  1. Fittings need to be visually inspected to insure ferules are in place and correctly positioned prior to swageing.
  2. Research staff are responsible for communicating system specifications [gas type,…

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.…

Key:

  • = No Ignition
  • = Explosion
  • = Fire
Hydrogen Incident Summaries by Equipment and Primary Cause/Issue
Equipment / CauseEquipment Design or SelectionComponent FailureOperational ErrorInstallation or MaintenanceInadequate Gas or Flame DetectionEmergency Shutdown ResponseOther or Unknown
Hydrogen Gas Metal Cylinder or Regulator 3/31/2012
4/30/1995
2/6/2013
4/26/201012/31/1969  3/17/1999
11/1/2001
12/23/2003
Piping/Valves4/4/2002
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
2/7/20091/24/1999
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
1/1/19829/30/2004
10/7/2005
 10/7/2005 
Compressor 10/5/2009
6/10/2007
8/21/2008
1/15/2019
  10/5/20098/21/2008 
Liquid Hydrogen Tank or Delivery Truck4/27/198912/19/2004
1/19/2009
8/6/200412/31/1969 1/1/197412/17/2004
Pressure Relief Device7/25/2013
5/4/2012
1/15/2002
1/08/2007
12/31/1969    
Instrument1/15/20193/17/1999
12/31/1969
2/6/2013
  11/13/73  
Hydrogen Generation Equipment7/27/1999  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
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