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.
This occurrence underscores the importance of appropriate design, equipment selection, and design review; the potential drawbacks of sharing utilities with other facilities; and the need to simplify [in this case, glove box atmosphere…
The risk of a serious fire occurring inside the chemistry laboratory hood from use of hydrogen gas and/or presence of a small quantity of hydrazine-hydrate was underestimated. Additional control measures were required to reduce the risk of fire…
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…
Work pre-planning is essential whenever maintenance or work activities may have an adverse impact on everyday operations. When there are changes to the operational status of any critical system, especially a safety critical system, those changes…
Hazard assessment is critical during the design, fabrication, and installation of system modifications to ensure hazards and potential hazards are addressed prior to system start-up and operation.
A hydrogen release of this type is a significant event. The event highlighted a number of procedural contributing factors that will influence the manner in which these fuel cell systems will be serviced in the future. A complicating factor in…
The incident was the result of a combination of factors leading to exceptional temperature conditions that were not taken into account in the mechanical design of the reactor. Corrective actions that were implemented by the plant management…
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