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.

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…

The root cause of the fire that burned the evaporator pad and distorted the plastic evaporator pad bracket remains unknown. The initial investigation did not reveal any obvious signs of an ignition source in the vicinity of the forklift operation…

Based on the results of the company investigation and analysis of an amateur video, the company determined that the incident could have been caused by the failure of one of the following plant components:
· pipes leading to the reactor…

1.  Combustible gas detectors calibrated for hydrogen can falsely report hydrogen alarms due the presence of other gases the detector may pick up, such as carbon monoxide from engine exhaust or other sources. Since this event occurred, two…

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…

During charging, most batteries will offgas hydrogen, making adequate ventilation and the elimination of ignition sources critical attributes of the charging area. Data from the battery manufacturer should be consulted to determine appropriate…

Carefully revise the risk assessment process to evaluate any confined areas where hydrogen is handled.
Separate the fire and gas detection alarm system from the process information to provide easy and clear identification.
Refresh…

Include the tanks in a regular inspection program. Evaluate their condition and replace if necessary.
Fill the tanks only half full with leach material.
Keep the material completely submerged in solution.
Install a fiberglass…

The ignition of the fireball could have been caused by any of the following mechanisms:

The inverse Joule-Thompson effect of hydrogen (i.e., heating upon expansion)
Some of the oil and light ends were above their auto-ignition…

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…

The investigation team concluded that hydrogen gas was released through a failed 19-inch diameter gasket and ignited under the roof of the compressor shed where it was partially confined. Some gas escaped from the shed prior to the explosion, but…

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…

The incident resulted from an inadequate design for the storage location of the copper gas supply tubing (too close to an electrical outlet). The gas supply tubing was too long for its intended purpose and posed a hazard in its coiled state near…

The direct cause of the over-pressurization of the two drums was the repackaging of the phosphoric acid into metal UN1A1 drums and the resultant hydrogen gas generation within the sealed drums. At the time of this incident (1997), 49 CFR and…

Active GH2 sensors should be installed and continuously monitored in all enclosed buildings near GH2 sources. All buildings near areas where hydrogen is used should be designed to preclude GH2 entrapment (e.g., sloping roof with ventilation at…

Safe storage and transportation of balloons filled with a hydrogen-oxygen mixture is a very risky undertaking. There are few scenarios that do not involve enclosed spaces (e.g., a car) and the potential for static discharge. Perhaps a mesh bag…

Although the preparation-for-transport procedures were done the same way they were done for previous outreach programs, this time it proved to be a different situation. It is not clear what caused the ignition of the first balloon, which then set…

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