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Contributing Factors

Situational Awareness

Damage and Injuries

Any

Equipment

Any

Probable Cause

Human Error

Contributing Factors

Situational Awareness

Damage and Injuries

Any

Equipment

Any
Show more

Probable Cause

Human Error

CHECK OUT OUR MOST RELEVANT INCIDENT LISTINGS!

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.

In the future, refining, petrochemical, and chemical industries need to review material verification programs to ensure that the maintenance procedures include sufficient controls and positive material identification (PMI) testing to prevent…

  1. Consider periodic testing of breakaway device.
  2. Consider determining shear force limit of vehicle receptacle adapter fittings.

This occurrence points to the importance of gathering and organizing all applicable administrative controls and other commitments prior to commencing work. It also re-emphasizes the importance of attention to detail, not only by the person…

  • When truck drivers are carrying new trailers, with new load distribution characteristics, they need to exercise caution, especially on hazardous roadways such as the one described in this occurrence. If the trailer stack would have been…

Extra caution should be taken working around elevated pressure or low-temperature fluids and storage. Values should be checked and then verified by a second party, if possible.

  • The fuel cell vehicle that was involved in the accident has been retired. The fuel cell power plant from that vehicle has been removed and is being used in another fuel cell vehicle.
  • The fuel cell vehicle accident reinforced the…

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…

The lessons learned from this incident are:

  1. Verify the gas that you are using.
  2. Avoid using "quick-disconnect" fittings in this type of situation. If they are absolutely needed, there are sets available that ensure that…

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…

Procedures for safe handling of compressed gas cylinders, marking design of gas cylinders and connecting lines, and arrangement of cylinders were reviewed and modified as necessary. The spectrometer was returned to the manufacturer for a careful…

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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