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PNNL-SA-82561 Paper 139. Lessons Learned from Safety Events “H2Incidents.org”. Steven C. Weiner and Linda L. Fassbender presented to the International Conference on Hydrogen Safety San Francisco, CA September 14, 2011. From Pisa to San Francisco.

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lessons learned from safety events h2incidents org


Paper 139

Lessons Learned from Safety Events“H2Incidents.org”

Steven C. Weiner and Linda L. Fassbender

presented to the

International Conference on Hydrogen Safety

San Francisco, CA

September 14, 2011

from pisa to san francisco
From Pisa to San Francisco
  • Presentations and discussions at first ICHS (2005) set the context for developing “H2Incidents.org” as a voluntary, publicly-accessible database
  • Hydrogen Safety Panel emphasized
    • Importance of reporting and analyzing incidents and near-misses as part of an organization’s safety culture
    • Sharing lessons learned will benefit and encourage others, particularly “incident owners”
  • International collaboration has become integral to creating value in “H2Incidents.org”
  • The “Lessons Learned Corner” highlights one means for additional knowledge sharing around sets of safety events.
what is h2incidents org
What is H2Incidents.org?
  • Database-driven website launched in 2006 to store information and analysis of hydrogen-related safety events
  • “H2Incidents.org” facilitates sharing of lessons learned from actual experiences with hydrogen in order to prevent similar events from happening in the future.
  • Targeted website users are those who work with or around hydrogen
  • PNNL sends e-mail notifications to an international distribution list when new safety event records are posted on the website.
capturing safety event information
Capturing Safety Event Information

Each safety event record contains:

  • Description
  • Severity (Was hydrogen released? Was there ignition?)
  • Setting
  • Equipment
  • Characteristics (High pressure? Low temperature?)
  • Damage and Injuries
  • Probable Cause(s)
  • Contributing Factors
  • Lessons Learned/Suggestions for Avoidance/Mitigation Steps Taken
  • Some records include photos

Tube Trailer Rollover

Gas Chromatograph Piping

Leak and Explosion

developing new incident and near miss records
Developing New Incident and Near-Miss Records
  • An easy-to-use, online form is provided for self-submittal of records.
  • Self-submittal is encouraged, but only ~10% of the records have been self-submitted.
  • Multiple approaches are used to seek out new safety records.
  • Working with incident owners and other submitters is an important aspect of this work.
    • Discuss, encourage and reach agreement for the submittal of a safety event record.
    • Discuss, clarify and edit the description, information and lessons learned.
    • Obtain organizational approval for posting.
expanding knowledge sharing the lessons learned corner
Expanding Knowledge SharingThe Lessons Learned Corner
  • Helps focus attention on key safety themes and what has been learned utilizing safety event records
  • Published quarterly
  • Themes covered to date:
      • Management of Change
      • Working with Reactive Metal Hydrides in the Laboratory
      • The Importance of Purging Hydrogen Piping and Equipment
      • Hydrogen Use in Anaerobic Chambers
      • Adequate Ventilation of Battery Charging Facilities
      • Learning from Burst Disk Failures
lessons learned corner management of change
Lessons Learned CornerManagement of Change
  • MOC is the process used to review all proposed changes to materials, technology, equipment, procedures, personnel, and facility operation to determine their potential effects on safety vulnerabilities.
  • At least 25 records in “H2Incidents.org” refer to MOC.
  • Hydrogen Safety Panel suggests that MOC principles should be applied more systematically to elevate the importance of safety in the research environment.
  • MOC usually applies to permanent changes, but temporary changes (e.g., deviations from standard operating conditions, untrained personnel filling in during an absence) have also contributed to catastrophic events.
lessons learned corner working with reactive metal hydrides
Lessons Learned CornerWorking with Reactive Metal Hydrides
  • Scientists and engineers are trying to develop safe and cost-effective energy storage systems using metal hydrides.
  • At least 10 records in “H2Incidents.org” deal with metal hydrides.
  • Materials must quickly and efficiently absorb hydrogen during fueling process and release it during duty cycle.
  • Metal hydrides are very reactive and must be handled in a robust inert gas environment (i.e., laboratory glove box) to protect personnel and equipment.
  • Lessons learned relate to handling, storing, and shipping metal hydrides, as well as laboratory procedures and equipment issues.
getting feedback from users
Getting Feedback from Users
  • An insurance company reprinted an incident record for use in their customer intranet.
  • A power plant engineer used incident information for a slide presentation on safety.
  • The U.S. Nuclear Regulatory Commission used some incident records and photos for their power plant engineering training course to communicate lessons learned in working with hydrogen.
  • An international company duplicated our HTML structure and interface to create a lessons learned database for global oil and gas services.
  • The International Association of Fire Chiefs used some photos for their new online training course for first responders.
  • A student used the content of one incident record for a school paper on hydrogen production.
  • The National Institute of Standards and Technology added a link to “H2Incidents.org” from their Weights and Measures website.
international collaborations enhance h2incidents org
International Collaborations Enhance “H2Incidents.org”
  • Conducted a one-day workshop at DNV (Hoevik, Norway) in 2008 to discuss current efforts on “H2Incidents.org” and the HySafe Hydrogen Incident and Accident Database (HIAD)
  • An initiative captures safety event records and learnings from members of the IEA Hydrogen Implementing Agreement Task 19 (Canada, France, Germany, Greece, Italy, Japan, Netherlands, Norway, Switzerland, U.K., U.S.)
  • Collaboration with HIAD, JRC, IA HySafe integrated with work plan for new IEA HIA Task 31.
  • Safety event records have been exchanged with HIAD.
concluding thoughts
Concluding Thoughts
  • Safety knowledge tools such as “H2Incidents.org” provide a powerful resource for conveying data, information and knowledge as a means to share, discuss and learn from the experience of others.
  • The issues associated with sharing safety information and data in a publicly-accessed database are understood and solvable.
  • Such information from hydrogen fuel cell R&D, demonstration and deployment projects and commercial operation can serve as a rich resource if systematically collected, analyzed and used for several purposes:
    • To identify lessons learned from safety events
    • To develop quantitative risk assessment methodologies and models
    • To identify gaps in applicable codes and standards that can be addressed by R&D and further analysis
  • Progress is being made but there is more to be done!
  • U.S. Department of Energy
    • Fuel Cell Technologies Program (Sunita Satyapal, Program Manger; Antonio Ruiz, Safety, Codes and Standards lead)
  • Colleagues at PNNL, the Hydrogen Safety Panel, other collaborators and “incident owners”
  • You, the audience and the ICHS

“I believe your site is an invaluable safety reference resource for a range of people experimenting and working in the alternative energy sector. Providing information about and scrutiny of hydrogen accidents and mishaps in the way your site does is a great idea!”

--- A website user from Australia