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Overview

author

BakerRisk Marketing

published on

April 2026

Timeline of Events

OPERATION

The Hawaii Natural Energy Institute (HNEI) had been conducting research on renewable energy integration into the grid using knallgas bacteria, which generates energy through reactions between hydrogen (H2 ) and oxygen (O2 ). As part of this work, varying mixtures of H2, O2, and carbon dioxide (CO2) were stored in a supply tank at pressures between 37 and 117 psig. Staff held weekly experiment reviews and considered the process safe, as operating pressures remained below the tank’s maximum rating of 140 psig.

WARNING SIGNS AND THE INCIDENT

On March 15, 2016, the postdoctoral researcher reported a “cracking sound” on an incubation vessel when pressing the On/Off button of the pressure gauge attached. Upon inspection, the petri dishes inside the incubation vessel were found to be scorched and cracked due to uneven mixing leading to deflagrating reaction.

On March 16, 2016, after filling a gas supply tank, the researcher attempted to reconnect it to the bioreactor. When she turned on the pressure gauge, the supply tank exploded causing severe injuries to the researcher, destroyed equipment, and damaged adjacent labs and hallways.

IMMEDIATE RESPONSE AND POST-INCIDENT INVESTIGATION

Investigation by the university safety officials and laboratory personnel suggested that the detonation was likely caused by electrostatic charge accumulation due to a lack of grounding. When the installed digital pressure gauge was switched On/Off, it created a corona or brush discharge, igniting the explosive gas mixture.

 

 

Important Notes

Process Safety Gaps

The investigation revealed lapses in safety, including:

  • Inadequate explosion protection measures such as safety barricade and PRV on bioreactor.
  • Failure to properly account for engineering requirements when designing containers, equipment, and gauges for hydrogen and hydrogen/oxygen mixtures.
  • Presence of potential ignition sources without effective mitigation or engineering control (no electrical grounding and bonding).
  • Experimental design is often based on peer‑reviewed publications in the field, which typically do not address or communicate potential hazards.

 

 

Lessons Learned

 

ENSURE REGULAR AND THOROUGH EQUIPMENT INSPECTIONS:

Minor internal rust went unnoticed, and critical components like digital gauges were not evaluated. All pressure systems require routine, documented inspections beyond visual checks.

 

UPDATE SAFETY INSPECTIONS TO REFLECT PROCESS HAZARDS:

Standard lab safety checklists missed hazards associated with gas mixing and pressurized vessels. Inspections must be tailored to lab-specific operations and updated as processes evolve. A formal Process Hazard Analysis (PHA) must be conducted, and documented, every time SOPs change, regardless of process size.

 

MITIGATE IGNITION SOURCES WITH ENGINEERING AND ADMINISTRATIVE CONTROLS:

The likely ignition source was a digital pressure gauge. All ignition risks must be identified and mitigated through grounding, bonding, intrinsic safety design, and documented procedures for equipment selection and use.

 

INHERENTLY SAFER DESIGN FOR INTERNAL EXPLOSION CONTAINMENT:

The tank met typical operational pressure ratings but failed due to internal detonation. Equipment design specifications must consider explosion risks, mixture behavior/interactions, and consequences of flammable material confinement, not just structural compliance.

 

APPLY PROPER HAZARDOUS AREA CLASSIFICATION (HAC) AND EXPLOSION PROTECTION:

The lab lacked explosion-rated equipment despite housing flammable gas mixtures at significant pressures and concentrations. Accurate hazardous area classification must guide the design of control systems, selection of electrical and instrumentation equipment, and facility zoning.

 

 

BakerRisk’s team of dedicated risk management consultants has conducted risk analyses for more than 20 global biofuel sites and is currently supporting clients’ transition to biofuels. Our experts serve on numerous NFPA (68/69, 652, 654) and API (752/753/756) committees, and we are a member of the RNG Coalition. Coupled with decades of experience in risk management, we are uniquely qualified to support the biofuel production and distribution industry.