REG NASA-LLIS-0257-1994 Lessons Learned - JP-4 Fuel Leak.pdf

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1、Lessons Learned Entry: 0257Lesson Info:a71 Lesson Number: 0257a71 Lesson Date: 1994-01-20a71 Submitting Organization: LERCa71 Submitted by: S. PapellSubject: JP-4 Fuel Leak Description of Driving Event: Operations personnel, in an engine test facility, reported that JP-4 fuel was found leaking in th

2、e basement of the building. Emergency staff responding to the call discovered that the fuel had originated from the engine on the main floor and had leaked onto a power panel in the basement. The spill was located on and around a 480VAC motor control center that contained breakers and contactors to

3、power the pumps, blowers, and fans in the building.The building was evacuated due to a potential explosion hazard. The power was turned off and power to the control center terminated. Absorbent pads were placed around the fuel spill for containment and the area barricaded to prevent access.It was de

4、termined that the fuel spill originated from an open fuel return low point drain valve, recently added to the facility, that was not put on the facility drawings. Operations personnel performing a walk-through inspection of the facility did not observe the added drain and therefore were not aware of

5、 the presence and open valve position of the drain.Lesson(s) Learned: 1. Modifications made to plumbing systems of fuel tanks that are inadvertently left off the facility drawings can lead to unsafe engine operation.2. Fuel system low-point drains should not be placed in close proximity to, or above

6、, critical operating systems.Recommendation(s): 1. Correct facility drawings when modifications are made and notify line management Provided by IHSNot for Resale-,-,-responsible for the facility.2. Design facilities so that fuel drain lines and valves are not in a position to dump fuel on operating

7、electrical equipment.Evidence of Recurrence Control Effectiveness: N/ADocuments Related to Lesson: N/AMission Directorate(s): N/AAdditional Key Phrase(s): a71 Configuration Managementa71 Energetic Materials - Explosive/Propellant/Pyrotechnica71 Facilitiesa71 Hazardous/Toxic Waste/MaterialsAdditional Info: Approval Info: a71 Approval Date: 1994-06-15a71 Approval Name: Maria Havenhilla71 Approval Organization: LERC/EBASa71 Approval Phone Number: 216-977-1483Provided by IHSNot for Resale-,-,-