Event
- Event ID
- 220
- Quality
- Description
During functional tests of the system, a major quantity of hydrogen-containing gas was released from an adsorber, followed by its ignition.
After the alarm was released the feed of the adsorber was closed, while the sprinkling system was activated by the high temperatures arising from the fire.
The cause of this event was an assembly error, which caused the failure of a gasket (comb-shaped) at the head flange of the adsorber.- Event Initiating system
- Classification of the physical effects
- Hydrogen Release and Ignition
- Nature of the consequences
- fire
- Macro-region
- Europe
- Country
- Germany
- Date
- Component involved
- flange (gasket)
- Failure mode
- leak & ignition
- Initiating cause
- wrong installation
- Root CAUSE analysis
The INITIATING CAUSE was an assembly error, which Caused the failure of a gasket It was due to human error during repair works.
ROOT CAUSE was reported as installation procedure. As in many of these cases, inadequate instructions or procedures could have been a contributing factor.
- Root causes
- Date entry in HIAD
- 28/02/2009
Facility
- Application
- Chemical industry
- Sub-application
- industrial gases production
- Hydrogen supply chain stage
- All components affected
adsorber, gasket, head-flange of adsorber
- Location type
- Unknown
- Location
- industrial area
- Operational condition
- Pre-event occurrences
The event occurred during the execution of complex functional tests.
Emergency & Consequences
- Number of fatalities
- 0
- Number of injured persons
- 1
- Post-event summary
Material damage for ca. 25 000 EURO and one person who suffered minor injuries.
- Emergency action
After the alarm was released, the gas feed to the adsorber was closed, and the sprinkling system was activated by the high temperatures arising from the fire.
Lesson Learnt
- Corrective Measures
The plant operator modified the sealing system (cantering).
Although the reports do not tackle the aspect of the human error, the measure akin was probably adopted to avoid any further assembly error.
In-depth data
- Release type
- gas
- Involved substances (% vol)
- H2 100%
- Probable IGNITION SOURCE
- Flame type
References
- Sources categories
- eMARS
- Reference & weblink
Event description in European database eMARS
https://emars.jrc.ec.europa.eu/en/eMARS/accident/view/abc44c21-1088-a3c…
(accessed September 2020)Event no. 19490 in French database ARIA
https://www.aria.developpement-durable.gouv.fr/accident/19490/
(accessed September 2020)Event from German database ZEMA
https://www.infosis.uba.de/index.php/de/site/12981/zema/index/3015.html
(accessed December 2023)