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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

Combustible Gas Monitoring System in Furnace Room Found Inoperable

Incident Date: 1996

 

Severity:
Near-Miss

Was Hydrogen released?
Uncertain

Was there Ignition?
No

Description

During a facility walk-through, it was noted that a combustible gas (hydrogen) monitoring system installed in a furnace room was inoperable (the system had been unplugged). This system is used to detect and warn facility employees of an explosive or flammable environment. An explosive or flammable environment can only occur if there is a leak in the system, which would not be expected to occur during normal operations. When the system was reactivated, no leaks were indicated.

The incident had the following three causes:

  1. A procedure describing administrative controls necessary to ensure safe operations in the area should have been developed and implemented prior to disabling the hydrogen monitoring system.
  2. The hydrogen monitor was not hard-wired, which allowed it to be unplugged and rendered inoperable.
  3. The hydrogen monitors were disabled and the status of the monitors was not communicated to personnel that work in the area.

Setting

Equipment

Safety Systems

Damage and Injuries

Probable Cause(s)

Contributing Factors

No Characteristics Defined.

The incident was discovered During Inspection.

Lessons Learned/Suggestions for Avoidance/Mitigation Steps Taken

Work preplanning 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 must be communicated to affected personnel. SOPs and OPs must be fully implemented and the implementation should be verified during facility and organizational assessments.

Date Added to H2Incidents: 6/26/2006