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.

Personnel were focused on the AGES system test and results, not the compatibility of the test equipment. The manual valve was needed to successfully test the system, however the fact that this particular valve could not accommodate the full…

Procedures for safe handling of compressed gas cylinders, marking design of gas cylinders and connecting lines, and arrangement of cylinders were reviewed and modified as necessary. The spectrometer was returned to the manufacturer for a careful…

A hydrogen release of this type is a significant event. The event highlighted a number of procedural contributing factors that will influence the manner in which these fuel cell systems will be serviced in the future. A complicating factor in…

It appears that this was an isolated event caused by human error. The lessons learned are: (1) to caution workers to maintain their focus during fuel cell stack assembly, (2) to require verification that all tools and spare parts are accounted…

Process changes have been implemented for development and review of safety basis documents that focus on a collaborative effort between the preparer and reviewers in order to provide a more in-depth review. This change is anticipated to provide…

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…

Follow the rules (e.g., using a torque-amplifying device requires supervisor approval).
Some valves are susceptible to disassembly, with potentially significant consequences, if excessive torque is applied to the handwheel.

The lessons learned from this incident are:

Verify the gas that you are using.
Avoid using "quick-disconnect" fittings in this type of situation. If they are absolutely needed, there are sets available that ensure that…

Several procedural and design changes should be considered for the future:

Replace the use of pure hydrogen with a 95:5 mixture of nitrogen and hydrogen to reduce the possibility of an explosive atmosphere occurring. Laboratory personnel…

Place signs on all liquid hydrogen tanks indicating that no water is to be put on the vent stack.
An additional secondary backup vent stack was added to liquid hydrogen tanks. This secondary stack is designed to be used only if needed in…

A new best practice resulted resulted from this incident. It states that before any work is started, a third party should verify with a visual inspection that the actual equipment to be used matches the planned equipment list/protocol.

Many accidents reported from paper mills have much in common with this incident. Microorganisms in the process water with pulp produce hydrogen gas that mixes with air to form an explosive atmosphere. The ignition source is typically sparks…

LESSONS LEARNED:

Compressed gas cylinder caps can be very difficult to open as rust often occurs in the threads.
There are wrenches specifically designed to remove compressed gas cylinder caps. The lab had such a wrench and it was…

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…

Mechanical pressure gauges tend to be imprecise if only used in a narrow portion of the full scale. Digital transducers, although slightly more expensive, offer much more precision. The event happened because the set pressure was only 10% of full…

Consider periodic testing of breakaway device.
Consider determining shear force limit of vehicle receptacle adapter fittings.

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…

Proper installation of check valves and other equipment should be visually inspected prior to pressurization.

The fuel cell vehicle that was involved in the accident has been retired. The fuel cell power plant from that vehicle has been removed and is being used in another fuel cell vehicle.
The fuel cell vehicle accident reinforced the need for…

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