REG NASA-LLIS-1517--2005 Lessons Learned - Test Stand E-1 Mishap.pdf

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1、Lessons Learned Entry: 1517Lesson Info:a71 Lesson Number: 1517a71 Lesson Date: 2005-02-17a71 Submitting Organization: SSCa71 Submitted by: Cecile SaltzmanSubject: Test Stand E-1 Mishap Abstract: During welding operations at the E-Complex in support of the Full-Volume RP Construction Project at Stenn

2、is Space Center, a fire occurred as a result of welding/cutting operations being performed on Level 5 of the E-1 Test Stand. The Mishap Investigation Team concluded that the proximate cause of this Type C incident was hot welding slag igniting combustible material under and near the vicinity of the

3、welding/cutting operation. Contractor failure to follow procedures associated with hot work permits due to schedule pressure contributed to the incident, as well as lack of training and overburdened supervisory personnel.Description of Driving Event: During welding operations at the E-Complex in sup

4、port of the Full-Volume RP Construction Project at Stennis Space Center, a fire occurred as a result of welding/cutting operations being performed on Level 5 of the E-1 Test Stand. The Mishap Investigation Team concluded that the proximate cause of this Type C incident was hot welding slag igniting

5、combustible material under and near the vicinity of the welding/cutting operation. Contractor failure to follow procedures associated with hot work permits due to schedule pressure contributed to the incident, as well as lack of training and overburdened supervisory personnel.Lesson(s) Learned: a71

6、If not managed appropriately, schedule pressures will result in the degradation of formal work processes and safe engineering practices as well as erode the execution of proper supervision.a71 Failure to verify proper training and apply thorough supervision will lead to safety incidents.a71 The diff

7、erence between work conditions in the presence and absence of water dictates the need for separate policies governing hot activity in each environment.Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-a71 Synergy between the status of fire suppression

8、systems and the Fire Department is critical to maximum protection of human life and agency assets.a71 Greater consideration to fire safety support is required during the facility design review process. Recommendation(s): 1. Ensure that all personnel associated with hot work are aware of the hot work

9、 permit process and associated requirements. Clearly identify responsibilities including who verifies that precautions have been taken. Ensure a system is in place that will continually verify requirements are being met. (This system should extend to all safety related areas).2. Ensure all personnel

10、 are trained to the proper procedure and that they are following procedures.3. a) When water is not available, implement a system that ensures safe hot work operations. b) Improve the notification process to assure that the Fire Department is aware anytime that a fire suppression system is taken out

11、-of-service and that the Fire Department is provided a date when service will be restored.4. a) Ensure all personnel, including supervisory personnel, understand their authority, responsibilities, and limits and that they are trained and have adequate time to perform their jobs. As part of implement

12、ing this recommendation the MIT would like the implementer to consider utilization of a transition plan for new supervisors. This would help ensure that all aspects of the position and especially the safety aspects are fully understood. b) Analyze workloads of supervisory personnel (and others as ap

13、propriate) to ensure adequate time is available to perform safety aspects of their jobs, including time to become thoroughly knowledgeable of job requirements and procedures, frequently visit work sites, supervise work crews, review hazardous operations with employees, ensure personnel are properly

14、trained, and be aware of physical and mental health of employees which could affect safe job performance.5. a) An obvious distinction needs to be made between facility fire alarm system pull boxes and all other pull boxes. Also, evaluate the adequacy of existing fire alarm system. b) Evaluate the de

15、sign/design review process to ensure the adequacy of the process, that sufficient time is allocated for review, and that the correct disciplines are involved in the review including human factors.6. a) Temporary configurations need to be reviewed by the appropriate engineering disciplines Provided b

16、y IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-to ensure safe engineering practices, policies and procedure are followed. b) Immediately stop using tarps in locations where hot work operations are taking place unless they are approved for hot work (flame reta

17、rdant).7. Ensure the implementation of all safety related procedures. Any deviations must get adequate review and approval. Furthermore, all emphasis on schedule must be accompanied with an even greater emphasis on safety. If the contractor is penalized for missing schedule because of safety concern

18、s, NASA must be aware of the message being sent. Evidence of Recurrence Control Effectiveness: N/ADocuments Related to Lesson: The lesson does not relate to a rules based document but does digest an official mishap report entitled “Test Stand E-1 Mishap.“Mission Directorate(s): a71 Exploration Syste

19、msa71 Space Operationsa71 Aeronautics ResearchAdditional Key Phrase(s): a71 Accident Investigationa71 Emergency Preparednessa71 Energetic Materials - Explosive/Propellant/Pyrotechnica71 Fire Protectiona71 Human Factorsa71 Policy & Planninga71 Risk Management/Assessmenta71 Safety & Mission Assurancea

20、71 Test FacilityAdditional Info: Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Approval Info: a71 Approval Date: 2005-04-14a71 Approval Name: Cecile Saltzmana71 Approval Organization: SSCa71 Approval Phone Number: 228-688-3945Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-