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Gas Cylinder Inadvertently Replaced with Hydrogen Gas Cylinder for Use in AL Proportional Counter

Severity
Incident
Was Hydrogen Released?
Yes
Was There Ignition?
No
Incident Date
Incident Attributes
Setting
Equipment
Damage and Injuries
Contributing Factors
When Incident Was Discovered
Describe the incident, including corrective steps taken and their result.

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 any possible electronic failures in the instrument and he discovered that the gas was hydrogen rather than the P-10 gas. The hydrogen cylinder was shut off, disconnected and removed. The correct P-10 cylinder was located and connected to the scaler.

Lessons Learned

All chemicals, including gases, should be clearly labeled and expiration dates (if applicable) identified. Incidents are more common when incompatible chemicals are mixed or when chemicals are stored/transferred using incompatible equipment. Personnel should ensure that labels are read and understood prior to mixing, dispensing, or transferring chemicals.

Key:

  • = No Ignition
  • = Explosion
  • = Fire
Hydrogen Incident Summaries by Equipment and Primary Cause/Issue
Equipment / CauseEquipment Design or SelectionComponent FailureOperational ErrorInstallation or MaintenanceInadequate Gas or Flame DetectionEmergency Shutdown ResponseOther or Unknown
Hydrogen Gas Metal Cylinder or Regulator 3/31/2012
4/30/1995
2/6/2013
4/26/201012/31/1969  3/17/1999
11/1/2001
12/23/2003
Piping/Valves4/4/2002
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
2/7/20091/24/1999
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
1/1/19829/30/2004
10/7/2005
 10/7/2005 
Compressor 10/5/2009
6/10/2007
8/21/2008
1/15/2019
  10/5/20098/21/2008 
Liquid Hydrogen Tank or Delivery Truck4/27/198912/19/2004
1/19/2009
8/6/200412/31/1969 1/1/197412/17/2004
Pressure Relief Device7/25/2013
5/4/2012
1/15/2002
1/08/2007
12/31/1969    
Instrument1/15/20193/17/1999
12/31/1969
2/6/2013
  11/13/73  
Hydrogen Generation Equipment7/27/1999  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
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