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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 percent 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 (No additional details provided)
Macro-region
North America
Country
United States
Date
Root causes
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.

Facility

Application
Electronics And Micro-Electronics
Sub-application
reactor
Hydrogen supply chain stage
All components affected
multilayer circuit boards manyfactury, chemicals
Location type
Unknown
Operational condition

Emergency & Consequences

Number of injured persons
14
Number of fatalities
0
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.

Event Nature

Release type
gas mixture
Involved substances (% vol)
H2,
CO
Presumed ignition source
No ignition

References

Reference & weblink

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

JRC assessment