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.
Personnel should be properly supervised, and supervisors should be aware of the activities of their personnel. Personnel must be motivated to adhere to established policies and procedures. All personnel associated with potentially hazardous work…
Because of the near invisibility of a hydrogen flame in daylight and hydrogen's extremely low ignition coefficient, if a known leak is present (e.g., an audible hissing), ignition should always be presumed. The primary cause of this incident…
The tube was 403 stainless steel, which is subject to hydrogen embrittlement. It is requested that all gauges that have bourdon tubes be replaced with 303 stainless steel.
A web-based resource developed by Sandia National Laboratories to…
Management should ensure that a complete and thorough review of the previous work activities identified in the work package is performed at the pre-job briefing for the planned work. Work activities should be discontinued if any confusion exists…
In this case, failure to recognize a run of tubing still maintaining pressure could have been avoided if such information was provided in a safety briefing. Knowledge of any job is the utmost importance in promoting and maintaining a safe working…
Installation
When performing maintenance evolutions, proper work control processes must be in place to insure that process systems are adequately prepared, remain in a safe energy state during the maintenance evolution, and are properly restored afterwards.…
Although most of the hydrogen fluoride piping system was open to the atmosphere before the elbow was cut, the lines were not purged. Two plugs of residual material on either side of the elbow remained in place, thus allowing hydrogen to be…
This incident illustrates how difficult it is to completely purge hydrogen out of a large, complex piece of equipment. Uniform mixing and dilution is unlikely in all the partially enclosed spaces, crevices, etc. If a hazardous operation such as…
In addition to the probable causes listed above, the lack of a standard operating procedure for hydrogen leak detection was one of the probable causes of this incident. Additional contributing factors included the following:
- Severe pipe…
The following actions were proposed as a result of this incident:
Key:
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