REG NASA-LLIS-1757--2006 Lessons Learned Electrical conduit mistaken for pneumatic tube.pdf

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1、Lessons Learned Entry: 1757Lesson Info:a71 Lesson Number: 1757a71 Lesson Date: 2006-7-24a71 Submitting Organization: JSCa71 Submitted by: Ron MontagueSubject: Electrical conduit mistaken for pneumatic tube Abstract: During facility refurbishment, an electrical conduit was misidentified as being a pn

2、eumatic tube and shorted during a cutting operationDescription of Driving Event: Workers were in the process of renovating an area when they uncovered a 4 metal pipe which went through the ceiling of the room. There was no identification on the pipe and there was no indication of pipe on as-built dr

3、awings. The facility manager told the employees that it was a pneumatic tube pipe that had been part of the pneumatic dispatch system that was no longer used as he had been told by other facilities users. There were other personnel in the building that told the foreman the same thing. The workers to

4、ok the facility managers word and started to cut through the pipe using a electrical band saw while on a 12 A frame ladder. When the bandsaw had cut through approximately three-quarters of an inch deep, there was a loud boom and sparks. There were 3 cables inside the pipe (conduit) with electrical p

5、ower. The blade on the bandsaw was broke and a breaker had been tripped. There was no other damage. The breaker did not feed any equipment. The power had been terminated from its original equipment but not from the transformer & breaker. The employee was not hurt as he was on a fiberglass ladder.Les

6、son(s) Learned: Direct testing of piping or conduit for live or energized contents shall take priority over any verbal input as to contents regardless of unanimity of consensus by multiple parties.Recommendation(s): Provided by IHSNot for ResaleNo reproduction or networking permitted without license

7、 from IHS-,-,-Require that any unidentified piping, conduit, etc., be tested for contents before proceeding to cut or otherwise work on the pipe/conduit. Crafts will work on tasks that are identified as being part of their area of responsibility only. Do not take verbal confirmation without objectiv

8、e proof such as a drawing or testing of material.Evidence of Recurrence Control Effectiveness: It is now standard operating procedure that all piping, conduit, or carrying vessel that is not positively identifiable from labels or drawings will be tested and verified prior to any cutting, disconnecti

9、on, or demolition operations.Documents Related to Lesson: N/AMission Directorate(s): a71 Space Operationsa71 Sciencea71 Exploration Systemsa71 Aeronautics ResearchAdditional Key Phrase(s): a71 Program Management.a71 Program Management.Communications between different offices and contractor personnel

10、a71 Program Management.Configuration and data managementa71 Program Management.Contractor relationshipsa71 Program Management.Risk managementa71 Missions and Systems Requirements Definition.a71 Missions and Systems Requirements Definition.Configuration control and data managementa71 Systems Engineer

11、ing and Analysis.a71 Systems Engineering and Analysis.Planning of requirements verification processesa71 Safety and Mission Assurance.a71 Safety and Mission Assurance.Configuration Change Controla71 Additional Categories.a71 Additional Categories.Configuration Managementa71 Additional Categories.Ene

12、rgya71 Additional Categories.Facilitiesa71 Additional Categories.Ground Operationsa71 Additional Categories.Industrial Operationsa71 Additional Categories.Personal Protective EquipmentProvided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-a71 Additional Cat

13、egories.Program and Project Managementa71 Additional Categories.Risk Management/AssessmentAdditional Info: a71 Project: Institutional Facilities and SystemsApproval Info: a71 Approval Date: 2006-12-06a71 Approval Name: ghendersona71 Approval Organization: HQProvided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-