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Clean Hydrogen Partnership

Accidental production of hydrogen in an manufactory of electronics products

Event

Event ID
726
Quality
Description

The event occurred at the factory producing multilayer circuit boards by a multistep dip operation. An employee inadvertently mixed 55 gal of 50% hydrogen peroxide into 110 gal of 30 percent formaldehyde. This resulted in a carbon monoxide and hydrogen release. The facility was evacuated and the local fire department and ambulance responded. 14 workers, out of whom three were from temporary employment agencies, were treated for inhalation and released.

The employee did not look carefully at the label on the hydrogen peroxide drum. Both hydrogen peroxide and formaldehyde are in similar black 55 gal poly drums with labels on one side.

Event Initiating system
Classification of the physical effects
Unignited Hydrogen Release
Nature of the consequences
leak no ignition
Macro-region
North America
Country
United States
Date
Component involved
reactor / oven / furnace / test chamber
Failure mode
erroneous release & ignition
Initiating cause
run-away reaction
Root CAUSE analysis

The INITIATING cause was that staff advertently mixed two chemicals which produced and released of carbon monoxide and hydrogen.
The fact that the two products containers were not easily distinguishable hints at a management and/or job factor.

Root causes
Date entry in HIAD
01/01/2020

Facility

Application
Electrical, electronics and micro-electronics industry
Sub-application
circuit boards production
Hydrogen supply chain stage
All components affected

multilayer circuit boards manyfactury, chemicals

Location type
Unknown
Location
unknown
Operational condition

Emergency & Consequences

Number of fatalities
0
Number of injured persons
14
Post-event summary

14 employees were treated for inhalation and released.

Lesson Learnt

Lesson Learnt

It is unknown if the operator adopted corrective actions.
In general, it appears clear that the procedures should be made more effective. The risk of confusing containers with different chemicals should be reduced. At the same time, staff should be better trained and follow operating instructions more carefully.

In-depth data

Release type
gas mixture
Involved substances (% vol)
H2,
CO
Probable IGNITION SOURCE

References

Sources categories
OHSA
Reference & weblink

OSHA Accident Summary Nr: 170620488 - Fourteen Employees Exposed To Carbon Monoxide And Hydrogen
https://www.osha.gov/ords/imis/accidentsearch.accident_detail?id=170620…
(accessed May 2023)