A small hydrogen fire occurred in a chemical process hood. A chemist was performing an experiment reacting manganese dioxide with hydrogen to produce manganese oxide and water. The chemist had left the process, which would take approximately one hour to complete, and was working in a nearby lab. While the chemist was gone, a second worker heard a pop, saw the hydrogen fire in the hood, and requested the activation of a fire alarm. A third employee in the area activated a manual fire alarm. The chemist, upon hearing the fire alarm, returned to the room, shut off the hydrogen fuel supply, and evacuated the facility. The hydrogen fire lasted for approximately one minute. The remaining small fire was extinguished about 10 minutes later with a HALON portable fire extinguisher by a view more
An unplanned shutdown of the hydrogen supply system occurred, affecting the hydrogen furnaces in the plant. The apparent cause was an inadvertent valve closing, which was contrary to the written procedure.
A preventative maintenance activity was being conducted on the hydrogen gas system. Shortly after starting that work, various hydrogen gas users notified the emergency response personnel that the hydrogen supply safety alarms sounded, indicating an interruption of the hydrogen gas supply. As a result, the hydrogen furnaces shut down. This shut down is an automated process which injects an inert gas (nitrogen or argon) to prevent the introduction of oxygen and its mixing with any hydrogen gas. All shut downs functioned as designed. As a precautionary measure, fire protection view more
A laboratory research technician entered a lab to begin preparing samples that were to ultimately be purged in an anaerobic chamber (glove box) located in that room. As the technician walked into the lab, she looked at the chamber to see if it was adequately inflated. This chamber is equipped with a gas concentration meter, capable of simultaneously displaying the oxygen and hydrogen concentrations of the chamber atmosphere. Under normal operating conditions, the atmosphere inside the chamber is comprised of 0% oxygen (as intended/desired for an anaerobic atmosphere), approximately 2-3% hydrogen, and with the remaining balance being nitrogen (approximately 98-97%). Under such normal operating conditions, the hydrogen concentration inside the chamber is less than the lower explosive view more
A health physics technician (HPT) discovered that a scaler in an analytical laboratory was out of P-10 gas (90%Ar and 10% CH4). The HPT went to the building where auxiliary gas cylinders are stored. He located a P-10 gas cylinder and turned to search for a hand-cart. There were no hand-carts present, and the technician had to get one from another room. When he returned to the cylinder storage area, he loaded the wrong cylinder. It contained hydrogen gas instead, however, the two cylinders were next to each other and they were basically identical. The empty cylinder was then replaced by the full one and the scaler was purged for several minutes before it was used. The alpha channel worked well, however, the beta channel did not respond. An instrument technician was contacted to identify view more
A liquid hydrogen neutron moderator developed a leak between the canister that contains liquid hydrogen and the insulating vacuum jacket.
The moderator assembly consists of an exterior metal vacuum jacket with an interior metal transfer line and canister that contain liquid hydrogen. The moderator canister is constructed of aluminum and is approximately five inches wide, five inches high, and two inches deep. The liquid hydrogen supply lines to the moderator canister are constructed of stainless steel. The operating temperature of the moderator varies from -420 degrees Fahrenheit to a possible 300 degrees Fahrenheit. Mechanical operators discovered a leak following a cleaning operation on the moderator. The cleaning operation was performed to remove impurities that could freeze view more
During a facility walk-through, it was noted that a combustible gas (hydrogen) monitoring system installed in a furnace room was inoperable (the system had been unplugged). This system is used to detect and warn facility employees of an explosive or flammable environment. An explosive or flammable environment can only occur if there is a leak in the system, which would not be expected to occur during normal operations. When the system was reactivated, no leaks were indicated.
The incident had the following three causes:
A procedure describing administrative controls necessary to ensure safe operations in the area should have been developed and implemented prior to disabling the hydrogen monitoring system.
The hydrogen monitor was not hard-wired, which allowed it 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
A routine security patrol reported a strong odor of sulfur coming from a battery charging facility. The battery charging facility is used for charging the various forklift batteries for the shipping and receiving operation. The building is approximately 450 sq. ft. and has four charging stations. Emergency response was initiated and the incident commander responded to the scene. Initial air monitoring indicated readings above the Lower Explosive Limit (LEL) for hydrogen gas. The local fire department responded and setup for the situation. Facilities personnel responded and turned power off to the building. The building was ventilated and verified to be safe by the fire department. There were no injuries or damage.
The exhaust fan for the building failed, allowing hydrogen gas to view more
A process area alarm activated. The alarm was caused by an instrument channel located above a reaction vessel off-gas system final HEPA filter canister, which indicated 25% of the lower explosive limit (LEL) for hydrogen. Since the only source of hydrogen is from the reaction vessel during the reaction of sodium with concentrated sodium hydroxide, the immediate actions were to shutdown the reaction process and place the facility in a safe condition.
The root cause was inadequate or defective design. Had the pre-filter drains been vented to outside the building, no hydrogen could accumulate in the process area. The corrective action for this is to complete an Engineering Task Authorization (ETA) to install a sample/drain collection system with loop seals to prevent any release of view more
A temperature excursion occurred in a sealed environmental chamber during a 0°C ambient temperature test. An elevated temperature in the chamber resulted in a small fire that was confined to the environmental chamber. Visual observation indicated no damage to nearby equipment, including nearby computer cables.
A committee was assembled with the task of identifying the cause of the incident. The committee concluded that the fire was caused by failure of the heater control system for the environmental chamber. The failure of the heater control system caused the chamber temperature to eventually exceed 200°C. As the chamber temperature increased, plastic materials and electrical insulation present in the chamber started to decompose. A battery scheduled for testing was also located view more