REG NASA-LLIS-0587-1998 Lessons Learned High Pressure Incident.pdf

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1、Lessons Learned Entry: 0587Lesson Info:a71 Lesson Number: 0587a71 Lesson Date: 1998-05-13a71 Submitting Organization: KSCa71 Submitted by: Lisa Grace KestelSubject: High Pressure Incident Description of Driving Event: Recently a “Close Call“ involving the unintentional over-pressurization of a low p

2、ressure system designed to operate at less than 150 p.s.i.g. The system was opened to a pressure of 2300 p.s.i.g. for a fraction of a second until a shop air hose, rated for 300 p.s.i.g., ruptured into two sections. It was fortunate that no one was hurt as the potential for serious injury was very r

3、eal. The sequence of events was started with a work-around that was initiated to replace the shop air (which was out of specification) in the LubeLok spray booth with compressed air from a supplied Manifold K-bottle Rack. The engineer in charge misread the Racks pressure gauge and “assumed“ the outp

4、ut pressure was 160 p.s.i.g. when what he had read off the gauge (see picture) was 160 BAR, approximately the equivalent of 2300 p.s.i.g.Root Causes:1. Failure to pay attention to details because no one involved took the time to correctly observe the high pressure indicated on the gauge. (see pictur

5、e)2. Lack of training and failure to take time to understand the Manifold Racks design which would have revealed that there was no pressure regulator built into the Rack system.3. Failure to develop detailed work authorization documents to perform work on a Safety Reviewed system that processes Flig

6、ht Hardware and which requires “material specifications“.4. No gauge or pressure indication visible from control valve.Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Pressure Gauge on Manifold K-bottle Rack in LubeLok Spray BoothLesson(s) Learned: 1

7、. High pressure systems need to be operated by qualified employees and new high pressure sources evaluated prior being ordered/used.2. Work-arounds create new/unexpected hazards to employees.3. All employees need to have a single and easy to access source of safety information on high pressure syste

8、ms.Recommendation(s): 1. Require all NEW USAGE requests for high pressure gas sources be approved in writing by Safety Dept.2. Require all employees likely to come in contact with or be near compressed gas systems to be trained every three years on high pressure gas hazards and precautions.3. Requir

9、e that all work-arounds and repairs for flight hardware processing systems, beyond the expected routine return to print / configuration , be formally documented on the appropriate approved work authorization procedures (PR, RODS, or FWR). All deviations from approved processes on Safety Reviewed sys

10、tems shall be formally documented and approved by Safety Dept. Particular attention must be applied to work-arounds which have potentially hazardous consequences. These should always be documented with a WAD and approved by Safety.4. Improve existing Safety Procedures to include more information on

11、compressed gas safety requirements such as regulator selection criteria and design requirements.Evidence of Recurrence Control Effectiveness: N/ADocuments Related to Lesson: N/AProvided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Mission Directorate(s): N

12、/AAdditional Key Phrase(s): a71 Configuration Managementa71 Facilitiesa71 Pressure Vesselsa71 Safety & Mission AssuranceAdditional Info: Approval Info: a71 Approval Date: 1998-05-28a71 Approval Name: David Barkera71 Approval Organization: EI-F-Aa71 Approval Phone Number: 407-867-6563Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-