Do not interconnect hydrogen drain trap lines with other drain lines

Thoroughly inspect equipment installation to manufacturer’s installation instructions

Warn against unauthorized field modifications

Consult the…

1. Evaluate any change in normal procedures or conditions for storage of aluminum hydride products. In this case, the aluminum hydride material was typically stored at -35°C in the glove box freezer. However, due to a change in glove boxes, this…

1. Inadequate Safeguards - The system was designed with low-point drains to facilitate water removal, however, these were found to be inadequate in both location and size. The fact that the mixed feed pre-heat coil was not self-draining was…

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…

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…

In the future, this mesoporous carbon material and ammonia borane:mesoporous carbon material will be handled under anaerobic conditions (glove box) to prevent further incidents.

This occurrence underscores the importance of completing a hazard analysis for each different process. Non-safety-related systems or equipment may be used for purposes other than their primary purpose so long as potential hazards are identified…

1. Provide additional retraining of operators. Curriculum should emphasize the proper response to high oxygen in the hydrogen gas.
2. Evaluate current knowledge of operators. Operators should know…

Mechanical pressure gauges tend to be imprecise if only used in a narrow portion of the full scale. Digital transducers, although slightly more expensive, offer much more precision. The event happened because the set pressure was only 10% of full…

Metallurgical examination of the two failed disks by light optical microscopy (LOM), scanning electron microscopy (SEM), and energy-dispersive x-ray spectroscopic analysis (EDS) found them to be fabricated from pure nickel with evidence of…

The possible outcomes from new maintenance scenarios can be predicted by using an accurate simulation. The proposed filter change-out maintenance was studied to identify conditions to which the catalyst might be exposed and a mock-up of the…

Installation

1. Fittings need to be visually inspected to insure ferules are in place and correctly positioned prior to swageing.
2. Research staff are responsible for communicating system specifications [gas type,…

After this accident, a safety inspection team was organized. An investigation of this incident and an inspection of all other experimental equipment was conducted by the team. As a result of this inspection, the heaters are now hard-wired to the…

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…

An important lesson to be derived from this incident is the need to carefully engineer and test all repairs and modifications to high-pressure process equipment.

The above described events are an indication of a potential licensee/vendor interface problem. Based on the information received, the vendor was not completely informed via the purchase specifications regarding the service condition to which the…

The investigative report noted that the explosion could have been prevented by (among other things) a continuous gas analyzer test of oxygen and hydrogen product purity. The continuous analyzer should be interlocked to shut the electrolyzer down…

Work documentation (work orders and baseline drawings) should reflect the current system configuration.

Recommendations

1. Develop procedures for temporary change configuration control of high-pressure systems. The…

In addition to resealing the glove box window, a positive pressure of argon gas was maintained inside the glove box while the course of action was planned. Subsequently, the glove box was cleaned up by specialized hazardous materials personnel…