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.

Three root-causes were noted during the investigation: (1) the use of incompatible materials in the manufacturing of the PRD valve, (2) improper assembly resulting in over-torquing of the inner assembly, and (3) over-hardening of the inner…

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…

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…

Upgrade the liquid hydrogen pump control system to shut down operation of the pump and protect the system when malfunctions like leaks, pump cavitation, or loss of purge gas occur.
Verify that maintenance procedures used for liquid…

Manuals showing the correct connecting and disconnecting procedures were established for each fueling dispenser. Separate manuals were needed since the shape of the grip differs from dispenser to dispenser.

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…

A step was added to the laboratory procedure in which all catalyst waste is thoroughly dampened with water and sealed in a plastic bag before being placed into a waste container.

Disable the fueling process if the operator does not follow the proper sequence of steps in the fueling procedure. Improve the fueling procedure to make it inherently impossible for the sequence to be done improperly with the same result.

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

Work documentation (work orders and baseline drawings) should reflect the current system configuration.

Recommendations

Develop procedures for temporary change configuration control of high-pressure systems. The overall work…

Diligence needs to be practiced when performing assigned work tasks. To guard against complacency, it is necessary to emphasize adherence to established procedures, including appropriate reviews of preventive maintenance instructions (PMI) and…

Whenever a new program or organization is created, management should ensure that program interfaces and new responsibilities are clearly defined. Effective program integration is necessary to ensure that all responsibilities and requirements are…

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