REG NASA-LLIS-1779-2007 Lessons Learned - Power Outage.pdf

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1、Lessons Learned Entry: 1779Lesson Info:a71 Lesson Number: 1779a71 Lesson Date: 2007-5-8a71 Submitting Organization: KSCa71 Submitted by: Michael Bella71 POC Name: Wayne Keea71 POC Email: Wayne.M.Keenasa.gova71 POC Phone: 321-867-8723Subject: Power Outage Abstract: A total loss of power at Orsino Sub

2、station occurred at 12:06 pm on Friday March 2, 2007. The power loss affected all facilities south of Schwartz Road at Kennedy Space Center, except the Assembly and Refurbishment Facility (ARF). The cause of the power loss was a failure of Florida Power & Light (FPL) 115KV line feeding the Orsino Su

3、bstation. FPL arrived at 1:08 pm and rerouted the power and restored service to the Orsino Substation at 1:36 pm. All infrastructure systems came online as expected with no anomalies. Personnel affected by the power outage were released on Administrative leave. Description of Driving Event: The caus

4、e of the power loss was a failure of Florida Power & Light (FPL) 115KV line feeding the Orsino Substation. Lesson(s) Learned: 1.Employees were not familiar with the long-standing policy and procedure for evacuating employees with disabilities as described in the Consolidated Comprehensive Emergency

5、Management Plan (CCEMP), JDP-KSC-P-3001. 2. Practical usage of National Incident Management System (NIMS) is needed above training curriculum. Also, the command and control structure changes from the Center Director to the Incident Commander. Provided by IHSNot for ResaleNo reproduction or networkin

6、g permitted without license from IHS-,-,-3. Personnel should be placed on administrative leave when there is an uncertainty of loss of power duration. 4. Policies are needed that determine when an unscheduled power outage becomes an emergency. 5. Identify facilities that have internal battery operat

7、ed fire alarm paging systems and utilize these systems to make announcements in the affected areas. 6. Page and Area Warning System (PAWS) should have battery back-up power. 7. Efficient emergency lighting systems (with backup) are needed in all hallways and stairwells to accomplish timely evacuatio

8、n.Recommendation(s): 1. The policy and procedure will be re-emphasized again in the monthly Emergency Preparedness (EP) Bulletin, through the Disability Awareness & Action Working Group (DAAWG), and managers and supervisors must also educate their employees on emergency procedures at least annually.

9、 Fire Services will continue to exercise these procedures during annual facility evacuation drills. The identification of employees who need assistance is mandatory. Supervisors are responsible for ensuring personnel meet this requirement. Self Service Maintenance Tool (SSMT) and Form 7-625 will be

10、used for this purpose. Additional Stair chairs shall be purchased for Fire Services to aid egress to personnel who need assistance. 2.NIMS Training will continually be emphasized to our emergency responders at all levels. Follow the National Incident Management System (NIMS) adopted in the CCEMP. 3.

11、 Personnel should be placed on administrative leave when there is an uncertainty of loss of power duration. Contributing factors to personnel dismissal: Emergency lighting (only lasting 60-90 minutes during power loss), total darkness in facilities and loss of air conditioning without any backup. 4.

12、 Define in the policy when the unscheduled power outage becomes an emergency. Update the Loss of Utilities documented procedure, JDP-KSC-P-3012, to include the policy how & when an unscheduled power outage becomes an emergency. 5. Protective Services will include in their response plans a list of al

13、l facilities that have paging systems at the fire panels and make this a checklist item for emergency responders. 6. Supply PAWS with battery back-up. 7. Adverse weather conditions must be written into appropriate policy especially when personnel are egressing facilities during emergencies. 8. Assur

14、e appropriate emergency lighting sources in stairwells and hallways are available with backup.Evidence of Recurrence Control Effectiveness: N/ADocuments Related to Lesson: Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-KSC Lessons Learned Industrial

15、 Area Power Outage, Tech Doc # 07_04_04_S_LLPOWER Consolidated Comprehensive Emergency Management Plan, (CCEMP) JHB 2000, Rev D Warning, Alerting and Evacuation, JDP-KSC-P-3001 Fire Response, JDP-KSC-P-3003 Loss of Utilities, JDP-KSC-P-3012Mission Directorate(s): a71 Space OperationsAdditional Key P

16、hrase(s): a71 Additional Categories.Emergency Preparednessa71 Additional Categories.Facilitiesa71 Additional Categories.Fire ProtectionAdditional Info: a71 Project: Emergency Preparedness ProgamApproval Info: a71 Approval Date: 2007-07-26a71 Approval Name: ghendersona71 Approval Organization: HQProvided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-