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.
To prevent a similar flashback, the following measures have been taken:
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…
A tool is provided for removing the cylinder cap that cannot contact the valve.
Several best practices resulted from this incident and will be implemented if similar circumstances present themselves in the future.
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.
All installed and certified safety and emergency systems functioned as designed.
1. The fuel cell turned off immediately after fire detection.
2. The fire suppression system was immediately initiated thereafter.
3. The physical…
Several procedural and design changes should be considered for the future:
The turbine components that caused the vibrations were a retrofit design which had been in service for about two years and were under warranty from the vendor. The root cause analysis of the event determined that the damage was caused by a defect…
Recommendations:
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…
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…
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…
The lessons learned from this incident are:
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…
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…
Key:
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