REG NASA-LLIS-0442--1992 Lessons Learned - Pre-Run Checklists.pdf

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1、Lessons Learned Entry: 0442Lesson Info:a71 Lesson Number: 0442a71 Lesson Date: 1992-11-13a71 Submitting Organization: LERCa71 Submitted by: G. MichalsonSubject: Pre-Run Checklists Description of Driving Event: A roof fire occurred in Cell 23 of Building 35. An Accident Review Team concluded that the

2、 cause of the fire was the inoperability of the water quench system used to cool the hot combustion gases exiting the test section. The problem was that the ACROMAG Transmitter was not plugged in and had remained closed. It did not regulate the appropriate amount of quench water for a given hot exha

3、ust temperature.The quench water system had facility alarm and shutdown meters which monitored exhaust gas temperatures downstream of the quench spray station. The high limits for these meters were set too high (800 and 860 degrees F, respectively) and should have been set at 650 degrees F. These me

4、ters were designed to monitor the exhaust gas temperatures and shutdown the fuel system if the limits for the exhaust gas temperatures were exceeded.Lesson(s) Learned: Research and/or operation engineers may overlook important test set-up operations unless they are included and emphasized in the pre

5、-run checklist.Recommendation(s): Include all important test set-up operations in pre-run checklists with special emphasis on instrumentation and meter settings for alarm and shut down.Evidence of Recurrence Control Effectiveness: N/AProvided by IHSNot for ResaleNo reproduction or networking permitt

6、ed without license from IHS-,-,-Documents Related to Lesson: N/AMission Directorate(s): N/AAdditional Key Phrase(s): a71 Facilitiesa71 Fire Protectiona71 Ground Operationsa71 Test FacilityAdditional Info: Approval Info: a71 Approval Date: 1996-09-13a71 Approval Name: Sell Jamesa71 Approval Organization: 501-4a71 Approval Phone Number: 216-433-8618Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-