What is Lessons Learned?

What is H2LL?

This database is supported by the U.S. Department of Energy. The safety event records have been contributed by a variety of global sources, including industrial, government and academic facilities.

H2LL is a database-driven website intended to facilitate the sharing of lessons learned and other relevant information gained from actual experiences using and working with hydrogen. The database also serves as a voluntary reporting tool for capturing records of events involving either hydrogen or hydrogen-related technologies.

The focus of the database is on characterization of hydrogen-related incidents and near-misses, and ensuing lessons learned from those events. All identifying information, including names of companies or organizations, locations, and the like, is removed to ensure confidentiality and to encourage the unconstrained future reporting of events as they occur.

The intended audience for this website is anyone who is involved in any aspect of hydrogen use. The existing safety event records are mainly focused on laboratory settings that offer valuable insights into the safe use of hydrogen in energy applications and R&D. It is hoped that users will come to this website both to learn valuable lessons from the experiences of others as well as to share information from their own experiences. Improved safety awareness benefits all.

Development of the database has been primarily supported by the U.S. Department of Energy. While every effort is made to verify the accuracy of information contained herein, no guarantee is expressed or implied with respect to the completeness, causal attribution, or suggested remedial measures for avoiding future events of a similar nature. The contents of this database are presented for informational purposes only. Design of any energy system should always be developed in close consultation with safety experts familiar with the particulars of the specific application.

We encourage you to browse through the safety event records on the website and send us your comments and suggestions. We will continue to add new records as they become available.

How does H2LL work?

If you have an incident you would like to include in the H2LL database, please click the "Submit an Incident" button at the top of the page. You will be asked for a wide range of information on your incident. Please enter as much of the information as possible. In order to protect your and your employer's identities, information that may distinguish an incident (your contact information, your company's name, the location of the incident, etc.) will not be displayed in the incident reports on H2LL.

Lessons Learned Corner

Visit the Lessons Learned Corner Archives.

Key themes from the H2Incidents database will be presented in the Lessons Learned Corner. Safety event records will be highlighted to illustrate the relevant lessons learned. Please let us know what you think and what themes you would like to see highlighted in this safety knowledge corner. You can find all the previous topics in the archives.

Overview: A pipe end containing fuel oil corroded at the outlet of a heat exchanger on the outlet side of a desulfurization reactor. The corroded pipe end leaked hydrogen gas, which exploded, causing oil to leak from the heat exchanger. The leaking oil developed into an oil fire, and the damage spread. The causes of the pipe end corrosion include the following:

There was a high concentration of corrosive substances in the process injection water.
The concentration of corrosive substances increased due to re-molding the heat exchangers.
The shape of the pipe cap was dead end piping.

Incident: During normal operations at a fuel oil refinery, a pipe end in a desulfurization unit developed a hydrogen leak, which led to an explosion. The pipe end was located on view more

Overview

The catalyst in a dehydrogenation reactor, which was usually operated under a hydrogen atmosphere, was changed while the reactor was isolated from the peripheral equipment by closing a 20-inch remotely controlled valve. The hydrogen pressure in the peripheral equipment was set at 20 KPaG, and the reactor was opened to the atmosphere. Anticipating some hydrogen leakage, suction from the piping was accomplished with a vacuum device and, nitrogen sealing was performed. When the piping connections were restored after changing the catalyst, flames spouted from the flange clearance and two workers were burned. One cause of the fire was poor management of the catalyst replacement process.

Incident Synopsis

A catalyst exchange was carried out in a dehydrogenation view more

Overview

Hydrogen leaked from the outlet piping of a hydrogen heating furnace at a fuel oil desulfurization cracking unit during normal refinery operation. The leaking hydrogen caused a localized fire. Dilution water for cleaning polythionic acid collected in the drain nozzle after a turnaround shutdown. The chlorine concentration in this dilution water was high because its concentration in the industrial water was originally high. The chlorine in the industrial water was concentrated by the high temperature, after the plant was restarted, and stress corrosion cracking occurred. Hydrogen leaked and was ignited by static electricity or heat.

Incident 

A fire occurred at the fuel oil desulfurization cracking unit of a refinery 257 hours after startup of the plant, view more

The bulkhead between a liquid hydrogen tank and a liquid oxygen tank failed due to a series of events. Air services to the building were shut down for repairs and the facility had switched to an emergency nitrogen supply. Failure to switch back to service air when it became available, led to the mishap.

The emergency supply became depleted and two valves in the normal nitrogen purge system failed in the open position, releasing the high-pressure nitrogen gas from the manifold into the liquid hydrogen tank. The gas flow raised the liquid hydrogen tank pressure to 4.5 psig. That was sufficient to rupture the bulkhead wall.

Overview
A solution of potassium carbonate was being drawn off to an inventory tank for a turnaround/shutdown maintenance activity at a refinery's hydrogen production unit. On the day of the incident, the solution level in the tower wasn't checked as it should have been, which resulted in hydrogen gas flowing back into the tank until the increased pressure caused the tank to explode. The direct cause of the incident was the workers neglecting to check the solution level in the tower. It is not known whether the potential for backflow of hydrogen gas into the inventory tank was understood beforehand or not.

Incident Synopsis
An explosion occurred due to unexpected backflow of hydrogen gas while a solution of potassium carbonate was being drawn off to an view more

A laboratory technician died and three others were injured when hydrogen gas being used in experiments leaked and ignited a flash fire.

The incident occurred in a 5,700-square-foot, single-story building of unprotected non-combustible construction. The building was not equipped with automatic gas detection or fire suppression systems.

Employees in the laboratory were conducting high-pressure, high-temperature experiments with animal and vegetable oils in a catalytic cracker under a gas blanket. They were using a liquefied petroleum gas burner to supply heat in the process.

Investigators believe that a large volume of hydrogen leaked into the room through a pump seal or a pipe union, spread throughout the laboratory, and ignited after coming into contact with the view more

An employee at a soap manufacturing plant died in a flash fire outside the facility's hydrogenation building. Responding personnel encountered a fire at the base of the plant's hydrogen storage towers, and they found the victim, who was burned over 90 percent of his body, some 50 feet away.

Officials determined that a pipe connection failed and that hydrogen, pressurized at 1,800 psi, ignited when it was released into the atmosphere, killing the plant operator.

According to reports, the pipe connection failure stemmed from pressures higher than design tolerance, which in turn were the result of over tightening that occurred during routine maintenance replacement. The new bolts were stronger than those they replaced, and the threads of the nuts had been partially view more

SummaryA fire occurred in a battery manufacturing plant that was about to cease operations for the night. The fire caused an estimated $2.4 million in property damage when an electrical source ignited combustible hydrogen vapors.BackgroundThe incident occurred in the forming room, where wet cell batteries were stored for charging on metal racks. The facility had a wet-pipe sprinkler system, but no automatic hydrogen detection equipment.Incident SynopsisAt 11:52 pm, a security guard on patrol noticed a free burning fire in the forming room and notified the fire department. It took fire fighters almost three hours to bring the fire under control.Although the facility was equipped with a wet-pipe sprinkler system, the forming room's branch had been disconnected 10 to 15 years before view more

Summary
A hydrogen explosion occurred at a plant, damaging a wall adjacent to the hydrogen storage assembly. The investigation revealed that the explosion was the consequence of deficiencies in components integral to the hydrogen storage assembly, and that this assembly belonged to a supplier contracted to provide hydrogen to the plant. The analysis revealed that had the supplier properly installed and maintained this equipment, this incident would have been prevented. By receiving assurance, on an ongoing basis, that the supplier was properly maintaining this equipment, the company could have also reduced the chance of occurrence of this incident.

Background
A hydrogen supplier was awarded a contract in 1990 to supply the plant with hydrogen as well as to provide view more

Overview
During operation of a succinic acid plant, hydrogen leaked from a mounting joint on a safety valve at the upper part of a reactor, which generated a hydrogen flame. Prior to the incident, the safety valve was removed and reattached during an inspection at a turnaround shutdown. An incorrectly sized, smaller gasket was installed on the joint, and the tightening force on the bolts was inadequate. Therefore, a gap was generated as time went by and un-reacted hydrogen leaked.

Background
In the case of many leak tests after construction, a leak is checked by a soap test after pressurizing piping and facilities for the test. (A soap test is conducted by pouring soap suds at the place to be checked (mainly a joint part) after pressurizing. If bubbles are found, view more