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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.
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…
It is characteristic of silver/zinc batteries to outgas both hydrogen and oxygen for several hours after discharge. Also, in the future, the battery should be properly secured inside the container.
Lessons Learned The site initiated the establishment of a field patrol and strengthened their onsite monitoring of mechanical equipment during a plant-wide temperature rise.
The lesson to pass on is that ventilation is critical in UPS battery rooms. Great care should be taken to ensure that the ventilation system is operational and brings in enough outdoor air to properly ventilate the enclosure.
Electrical…
Hazard analysis should consider potential leak locations, potential ignition sources in the vicinity, and the potential for accumulating flammable gases in that area.
Users should leak-check all cylinders upon installation. This event…
Implementing and enforcing the laboratory's stop work and restart policy and procedures in conjunction with peer reviews for new processes and experiments should help prevent future accidents due to a lack of recognition of potential reactions…
Several procedural and design changes should be considered for the future:
Key:
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