Event
- Event ID
- 592
- Quality
- Description
This incident occurred during the delivery of a hydrogen gas container to a customer site. When a worker turned the protective cap of the container, the valve handle turned together with the container, causing hydrogen gas to leak and ignite, resulting in the worker being burned.
- Event Initiating system
- Classification of the physical effects
- Hydrogen Release and Ignition
- Nature of the consequences
- fire
- Macro-region
- Asia
- Country
- Japan
- Date
- Component involved
- valve (generic)
- Failure mode
- erroneous release & ignition
- Initiating cause
- wrong operation
- Root CAUSE analysis
The INITIATING CAUSE was the accidental (erroneous) opening of the release valve.
The KHK report attributes the ROOT CAUSE to a wrong operation (bad handling). However, this incident should not be made possible by passive safeguards. The fact that it was possible reveal a mistake in the design of the equipment, which did not considered a possible wrong operation.- Root causes
- Date entry in HIAD
- 01/01/2020
Facility
- Application
- Unknown
- Sub-application
- CGH2 cylinders
- Hydrogen supply chain stage
- All components affected
valve, cylinder
- Process temperature range [C]
- ambient temperature (-50°C to +50°C)
- Process pressure range [MPa]
- medium to high pressure (10 to 50 MPa)
- Location type
- Unknown
- Location
- unknown
- Operational condition
Emergency & Consequences
- Number of fatalities
- 0
- Number of injured persons
- 1
- Post-event summary
The worker of the delviery company received burns
Lesson Learnt
- Lesson Learnt
This is a case of release and fire attributed to a wrong operation. However, passive safeguards should made impossible the activation of the release valve while opening the protective cup of a high-pressure cylinder. This is for example obtained by blocking the wheel of the valve by means of a steel cable and a seal.
In-depth data
- Release type
- gas
- Involved substances (% vol)
- H2 100%
- Release temperature [°C]
- 25
- Probable IGNITION SOURCE
References
- Sources categories
- KHK
- Reference & weblink
High Pressure Gas Accident Cases Database of the KHK (High Pressure Gas Safety Association):
https://www.khk.or.jp/public_information/incident_investigation/hpg_inc…
(accessed May 2025)The first entry in HIAD was coming from RISCAD, which is now closed.
