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. The trailer involved in the incident used a frangible burst disk based upon the proprietary metal compound designated as Inconel #600. Random sampling of similar pressure relief devices from the same trailer showed that all of them failed at…
The uncontrolled release of hydrogen occurred as a result of the rupture of the No. 6 hydrogen storage tube’s burst disc. This disc failed in response to being overloaded by mechanical stresses developed as water expanded and formed ice while in…
Recommendation 1 - Overhaul and replace the diaphragms on all cells showing low-purity results. Check on a routine basis the individual cell purity levels to monitor the deterioration of performance of individual cells. Certain…
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…
Hydrogen distribution lines should be designed and carefully inspected to ensure process equipment in the area is correctly and safely installed. Equipment subject to vibration should not be placed in contact with hydrogen lines or with other…
All safety devices worked as designed thereby protecting the environment and laboratory personnel. Researchers involved in the experiment acted properly and with the parameters set forth in operational procedures.
Follow up: Stops have…
This occurrence demonstrated the use of data by engineering to evaluate equipment problems. As the data changed, highlighting a problem with one-half inch PVC ball valves, the facility redesigned the valve extension and valve handle to prevent…
Facilities should review their process systems to determine if they have valves installed that may be subject to this hazard. If so, facilities should conduct a detailed hazard analysis to determine the risk of valve failure. Detailed internal…
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…
The simplicity of this situation has made us aware that increased consideration must be given to all aspects of the workplace when preparing preliminary hazard assessments. Some hazardous situations appear so trivial that they can be easily…
Designs for high-tech systems/components evolve based on operating experience. The design changes should resolve identified deficiencies and are part of a continuous improvement process to increase reliability and productivity.
The lessons of this event fall into five categories: (1) proper in-plant communications during events, (2) proper valve application for use with hydrogen, (3) excess flow check valve set point, (4) heating and ventilation and air conditioning (…
These events show the importance of preventing combustible gas mixtures from accumulating in piping. In both of the above described events, hydrogen and oxygen gases apparently accumulated to a combustible level which then catastrophically failed…
Immediate Corrective Actions
The site needs to implement a good Operational and Readiness Inspection procedure. System inspection deficiencies need to be identified, and (if possible) reviewed by a second party before future tests are conducted. This inspection could include…
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