REG NASA-LLIS-0866-2000 Lessons Learned High Altitude Missions Branch Fatal Mishap.pdf

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1、Lessons Learned Entry: 0866Lesson Info:a71 Lesson Number: 0866a71 Lesson Date: 2000-05-22a71 Submitting Organization: ARCa71 Submitted by: Anthony BricenoSubject: High Altitude Missions Branch Fatal Mishap Description of Driving Event: A personal equipment technician employed by a California Company

2、 in support of the operations of the High Altitude Missions Branch, was fatally injured by inhalation of nitrogen while conducting a periodic inspection on a pressure helmet.It is presumed that the technician donned the helmet in the course of his inspection; he then closed and secured the face seal

3、. The helmet was connected to a source of nitrogen, the gas used in the facility for bench-testing and maintenance of this equipment. The technician lost consciousness within 20-35 seconds after beginning to breathe nitrogen; he was found by a coworker at 3:15 p.m., deeply cyanotic and unresponsive.

4、Cardiopulmonary resuscitation efforts were unsuccessful; the technician was pronounced dead at the hospital upon arrival there by ambulance. A post-mortem examination was conducted by the Office of the Coroner-Medical Examiner, County of Santa Clara. The cause of death was stated to be asphyxia due

5、to inhalation of nitrogen gas.Lesson(s) Learned: 1. Government and industry need to increase their efforts to educate and heighten the awareness of users regarding the lethality of nitrogen and other inert gases and the rapid onset of asphyxia when these gases are inspired.2. New safety provision an

6、d requirements should be documented in existing organizational safety plans required by AHB 1700-1. It is the responsibility of management to insure awareness of these plans with periodic safety review staff meetings for both Government and contract personnel.3. Consideration should be given to ampl

7、ification of management responsibility for dealing with Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-emergencies and mishaps, and to dissemination of this information by means of an appropriate memorandum to all management at reasonable intervals.

8、4. NASA should require training and/or certification procedures for personnel working with inert gases under circumstances such that they can become asphyxiants.5. Thorough training and checkout should be given to all new personal equipment technicians in the High Altitude Missions Branch notwithsta

9、nding their previous knowledge of and experience with the equipment.6. The nitrogen regulator and outlet to the portable testing kit in the personal equipment maintenance room should be placarded.7. A warning placard near or over any testing console or workbench utilizing nitrogen or other inert gas

10、 should make reference to the hazards of asphyxia.8. Consideration should be given to the use of breathing air instead of nitrogen as the gas supply for personal equipment testing in this facility.9. A number of contractor and/or NASA personnel in the High Altitude Missions Branch should receive car

11、diopulmonary resuscitation training. At this time, the nearest CPR-trained staff members are in Building 240A, too far away to be of much help in the event of a serious problem in Building 240.Recommendation(s): See Lesson(s) Learned.Evidence of Recurrence Control Effectiveness: N/ADocuments Related

12、 to Lesson: N/AMission Directorate(s): a71 Exploration Systemsa71 Aeronautics ResearchAdditional Key Phrase(s): a71 Administration/Organizationa71 Aircrafta71 Flight Equipmenta71 Hardwarea71 Hazardous/Toxic Waste/MaterialsProvided by IHSNot for ResaleNo reproduction or networking permitted without l

13、icense from IHS-,-,-a71 Policy & Planninga71 Test Facilitya71 Test & VerificationAdditional Info: Approval Info: a71 Approval Date: 2000-06-6a71 Approval Name: Eric Raynora71 Approval Organization: QSa71 Approval Phone Number: 202-358-4738Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-