Event
- Event ID
- 1093
- Quality
- Description
- This near-miss occurred at a company producing compressed gas bottles according to customers requests. When preparing a gas mixture containing oxygen and nitrogen, by mistake hydrogen was added, instead of nitrogen. The pipelines did not have clear labelling. The mistake was discovered during analysis, when a small gas sample (less than 5 ml) ignited during flashing.
- Event Initiating system
- Classification of the physical effects
- No Hydrogen Release
- Nature of the consequences
- Macro-region
- Europe
- Country
- Germany
- Date
- Main component involved?
- Cgh2 Cylinder(S)
- How was it involved?
- No Failure
- Initiating cause
- Wrong Operation
- Root causes
- Root CAUSE analysis
- The INITIATING CAUSE was a human error in connecting the wrong pipeline.
A contributing CAUSE was the lack of clear labelling of the pipelines gases.
The root CAUSE could be attributed to management, which did not consider the risk of gas mixing up and did not adopted preventing measures such as different connector for different (incompatible) gases.
Facility
- Application
- Chemical Industry
- Sub-application
- Speciality gas production
- Hydrogen supply chain stage
- Hydrogen Storage (No additional details provided)
- All components affected
- compresed gas mixture bottle
- Location type
- Confined
- Operational condition
Emergency & Consequences
- Number of injured persons
- 0
- Number of fatalities
- 0
- Environmental damage
- 0
- Property loss (onsite)
- 0
- Property loss (offsite)
- 0
- Post-event summary
- The mixed quantities were small: 0.07 kg hydrogen and 0.33 kg oxygen.
Lesson Learnt
- Corrective Measures
The following measures were adopted:
(1) Clear marking of each gas pipeline , visible at working height
(2) Clear labelling of the filling valves with the respective gas type-specific colours and labels
(3) Installation of a protective flap as a mechanical locking of the filling valve
(4) Separate and gas type-specific connections
Event Nature
- Release type
- gas mixture
- Involved substances (% vol)
- H2 (0.07 kg),
O2(0.33 kg) - Released amount
- 0.07 kg hydrogen
033 kg oxygen - Presumed ignition source
- No release
References
- Reference & weblink
Event from German database ZEMA<br />
https://www.infosis.uba.de/index.php/de/site/12981/zema/index/3297.html… />
(accessed December 2023)
JRC assessment
- Sources categories
- ZEMA
