1. Revise fire protection operations surveillance tests to include a maximum of 110% of the agent net weight to prevent over-filled cylinders from being placed in service.
2. Identify cylinders currently in service that exceed the 110…

• The fuel cell vehicle that was involved in the accident has been retired. The fuel cell power plant from that vehicle has been removed and is being used in another fuel cell vehicle.
• The fuel cell vehicle accident reinforced the…

Proper installation of check valves and other equipment should be visually inspected prior to pressurization.

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…

A new best practice resulted resulted from this incident. It states that before any work is started, a third party should verify with a visual inspection that the actual equipment to be used matches the planned equipment list/protocol.

1. Place signs on all liquid hydrogen tanks indicating that no water is to be put on the vent stack.
2. An additional secondary backup vent stack was added to liquid hydrogen tanks. This secondary stack is designed to be used only if…

Several procedural and design changes should be considered for the future:

1. Replace the use of pure hydrogen with a 95:5 mixture of nitrogen and hydrogen to reduce the possibility of an explosive atmosphere occurring. Laboratory…

The lessons learned from this incident are:

1. Verify the gas that you are using.
2. Avoid using "quick-disconnect" fittings in this type of situation. If they are absolutely needed, there are sets available that ensure that…

1. Follow the rules (e.g., using a torque-amplifying device requires supervisor approval).
2. Some valves are susceptible to disassembly, with potentially significant consequences, if excessive torque is applied to the handwheel.…

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…

Process changes have been implemented for development and review of safety basis documents that focus on a collaborative effort between the preparer and reviewers in order to provide a more in-depth review. This change is anticipated to provide…

It appears that this was an isolated event caused by human error. The lessons learned are: (1) to caution workers to maintain their focus during fuel cell stack assembly, (2) to require verification that all tools and spare parts are accounted…

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…

Procedures for safe handling of compressed gas cylinders, marking design of gas cylinders and connecting lines, and arrangement of cylinders were reviewed and modified as necessary. The spectrometer was returned to the manufacturer for a careful…

Personnel were focused on the AGES system test and results, not the compatibility of the test equipment. The manual valve was needed to successfully test the system, however the fact that this particular valve could not accommodate the full…