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.
1. Management must ensure that operating decisions are not based primarily on cost and production. Performance goals and operating risks must be effectively communicated to all employees. Facility management must set safe, achievable operating…
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…
The primary lesson learned was that the active hydrogen facility and existing operating procedure, at the time of the accident, were sound. While this now has been determined, the previous form(s) of this system, associated documentation, and…
Batteries stored on a charger can explode during use if overcharged.
Recommendations
The use of inerting gas or other means of separation should be employed when conducting mechanical work where hydrogen gas could be present. More importantly, per CGA S1.3, the vessel should be equipped with a dual relief system that can isolate…
All valves and connectors should be clearly labeled to minimize chances for mis-connection. All technicians must be trained on proper procedures for both taking systems offline and bringing them back online.
Valves for compressed hydrogen…
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 charging characteristics of a battery vary with the condition of the battery and are proportional to the ampere-hour capacity of the battery. During charging, when a battery is close to being fully charged, hydrogen and oxygen both offgas in…
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 visiting intern had several years of experience in research projects and tasks that were similar to those in progress at this laboratory. This led to the incorrect assumption that formal introductory training for this laboratory was…
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…
Several procedural and design changes should be considered for the future:
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:
We are the leaders in the building industries and factories. We're word wide. We never give up on the challenges.
