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H2Incidents: Hydrogen Incident Reporting and Lessons Learned

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Definitions

Incident
An incident is an event that results in:
  • a lost-time accident and/or injury to personnel
  • damage to project equipment, facilities or property
  • impact to the public or environment
  • an emergency response or should have resulted in an emergency response.
Near-Miss
A near-miss is an event that, under slightly different circumstances, could have become an incident. Examples include:
  • any unintentional hydrogen release that ignites, or is sufficient to sustain a flame if ignited, and does not fit the definition for an incident
  • any hydrogen release which accumulates above 25% of the lower flammability limits within an enclosed space and does not fit the definition of an incident
Non-Event
A non-event is a situation, occurrence, or other outcome relevant to safety that does not involve a particular incident or near miss. For example, a non-event might consist of a failed safety inspection.
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Incident Report

Pressure Reducing Clamp Removal Mishap

Incident Date: 1999

 

Severity:
Incident

Was Hydrogen released?
No

Was there Ignition?
No

Description

On a given day personnel were removing a blind hub that had been used to temporarily isolate a portion of a gaseous hydrogen system. As a result of a sudden release of 2,800 psig gaseous nitrogen, sand and debris kicked up from the concrete pad and caused minor injury to two technicians.

During the investigation, it was found that:


  1. The temporary configuration change to the gaseous hydrogen system was initiated on multiple work orders and by different individuals. There was no single document that documented the temporary system configuration.

  2. The procedure for performing the work was written using a drawing that had not been updated to show the actual system configuration. Verbal field direction was given when it was discovered the system was not configured per the work order.

  3. Incorrect clamp removal techniques were used. Upon pressure release, the clamp, blind hub, and seal ring became projectiles that had the potential to cause significant personnel injury.

Setting

Equipment

Hand Tools

Damage and Injuries

Probable Cause(s)

Contributing Factors

No Characteristics Defined.

The incident was discovered During Maintenance.

Lessons Learned/Suggestions for Avoidance/Mitigation Steps Taken

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 overall work process should be included in one work authorization document.

  2. Re-emphasis to all personnel that current procedures be followed. If the work order is not written to reflect the current system configuration, stop work, revise work order, and have the work order properly reviewed prior to continuing work.

  3. Write a procedure for proper clamp removal and installation and train technicians to the procedure.

    4. Date Added to H2Incidents: 1/17/2007