Incident Reporting: Learning from Experience Steven C. Weiner, Bruce Kinzey, Jesse Dean, Pat Davis and Antonio Ruiz presented to the International Conference on Hydrogen Safety San Sebastian, Spain September 13, 2 International Conference on Hydrogen Safety Any system to receive, process, record, analyze and act on a safety event requires a great deal of information sharing as openly and thoroughly as possible, some degree of confidentiality to deter punishment of personnel and a commitment to creating higher learning value. Pisa 2005 3 4 DOE hopes that the hydrogen community will consider using this resource as a place to share safety related experiences so that we all may learn from our individual experiences. May 2006 H2Incidents.org 5 Safety Planning Incidents and Near-Misses A good safety plan should describe the following elements in the event that an incident occurs The reporting procedure within an organization The method and procedure used to investigate events How corrective measures will be implemented How lessons learned from incidents and near-misses are documented and disseminated 6 Definitions Incidents and Near-Misses An incident is an event that results in a lost-time accident and/or injury to personnel, damage to project equipment, facilities or property, impact to the public or environment, an emergency response or should have resulted in an emergency response. A near-miss is an event that under slightly different circumstances could have become an incident. Examples include: any unintentional hydrogen release that ignites, or is sufficient to sustain a flame if ignited, and does not fit the definition for an incident any hydrogen release which accumulates above 25% of the lower flammability limits within an enclosed space and does not fit the definition of an incident 7 Submitting and Characterizing Safety Event Information TitleHydrogen characteristics SeverityHydrogen release? SettingIgnition? Types of equipmentProbable causes DescriptionContributing factors Damages and injuriesLessons learned Contact information requested of a submitter is only used by the database administrator in the case of questions or the need for clarification. This information is specifically excluded from the published safety event record. 8 Equipment-Related Factors for Hydrogen Incidents Hydrogen storage Burst disk failures Pressure relief valve or pressure transducer failures Over-pressurization of hydrogen storage tanks by operators Oxygen/air infiltration of hydrogen-containing vessels Piping/Fittings Improperly sized and installed Improperly labeled leading to operational errors Leaks due to inadequate inspection/maintenance 9 Human Error-Related Factors for Hydrogen Incidents Lack of personnel training on specific equipment, systems and operating scenarios Personnel inadequately trained on hydrogen properties and potential consequences of their actions Inattentive and complacent actions by personnel operating hydrogen and related equipment Personnel not following written procedures 10 Lessons Learned Equipment maintenance and sensor calibration Management of change at any scale of operation Training, training and training! DRAFT 12 Thoughts on Next Steps Improvements will enhance utility and value graphical features to display trends Allow users to submit comments by safety event record/page Other hydrogen incident collection and reporting efforts link and integrate these initiatives across the global hydrogen community 13 14 Acknowledging.Acknowledging. U.S. Department of Energys Hydrogen, Fuel Cells and Infrastructure Technologies Program Office and JoAnn Milliken, Program Manager My co-authors International Conference on Hydrogen Safety