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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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Navigation

The left navigation on the H2Incidents website is two-fold.

  1. Links
    By clicking on the links in the left navigation, you can view all incident reports matching that lone selection. For example, clicking on "Minor Injury" within the "Damages and Injuries" category will return a list of all incident reports that included "Minor Injury."
  2. Checkboxes
    Selecting checkboxes next to navigation items—then clicking the "Update Criteria" button—will provide a restrictive search on the criteria selected. Each selected checkbox will restrict the results to only incident reports that include that criteria. For example, selecting the checkbox next to "Minor Injury" in the "Damages and Injuries" category and selecting the checkbox next to "Decision Making" in the "Factors" category will return a list of all incident reports that included both "Minor Injury" and "Decision Making."
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Incident Report

Invisible Hydrogen Fire Injures Technician

No Incident Date defined.

 

Severity:
Incident

Was Hydrogen released?
Yes

Was there Ignition?
Yes

No Ignition Source Defined.

Description

Incident Synopsis
A technician was welding a cable suspended over a stainless steel H2 instrument line. During the welding process, two holes were accidentally burned through the hydrogen tubing. The operator heard a hissing sound and closed the valve, but the hydrogen had already ignited and it burned his hand while he was feeling for a leak.

Cause
A short during welding caused the pinholes in the tubing containing the gaseous H2.

Setting

Equipment

Electrical Equipment

Hand Tools

Piping/Fittings/Valves

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

Because of the near invisibility of a hydrogen flame in daylight and hydrogen's extremely low ignition coefficient, if a known leak is present (e.g., an audible hissing), ignition should always be presumed. The primary cause of this incident derives from the technician improperly performing hot work in the vicinity of a charged flammable gas line. Given the location of the flammable gas line, an alternative to performing hot work or relocating the hot work should have been considered. If such work was necessary at this location, it should have been performed only after the gas supply was verified closed (along with a lock and tag). Also, if this latter option was chosen, then the system should be checked for leaks prior to turning the gas back on.

Date Added to H2Incidents: 1/29/2007