REG NASA-LLIS-2040-2008 Lessons Learned NASA HQ 2H32 Exposure Lost-time Case (Type C Mishap).pdf

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1、Lessons Learned Entry: 2040Lesson Info:a71 Lesson Number: 2040a71 Lesson Date: 2008-11-18a71 Submitting Organization: HQa71 Submitted by: Angela Stowesa71 POC Name: Cherie Zieschanga71 POC Email: cherie.zieschang-1nasa.gova71 POC Phone: 202-358-1569Subject: NASA HQ 2H32 Exposure/Lost-time Case (Type

2、 C Mishap) Abstract: This mishap involved three office workers in a high-rise office building who lost time from work between January 26 and March 27, 2007. The subsequent investigation identified causes including problems with the performance and operation of the buildings HVAC system, operation of

3、 the garage exhaust ventilation system, the lack of maintenance personnel training on the HVAC and energy management systems, the lack of written mishap preparedness and contingency plans, and employees lack of knowledge and understanding of the process to follow when reporting health and safety haz

4、ard and concerns. Lessons learned from this mishap are provided to prevent recurrences of similar events.Description of Driving Event: Illness of employees resulting from an undetected orderLesson(s) Learned: 1. Building Management must use a process to verify, document, and monitor the energy manag

5、ement system/building automation system for correct settings and proper operation, especially after system upgrades or updates. 2. Building engineers must be properly trained and have working knowledge and experience handling problems with the buildings HVAC system. 3. Building Management must assur

6、e that the building receives the appropriate amount of outdoor Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-(fresh) air, per ASHRAE standard 62.1, Ventilation for Acceptable Indoor Air Quality. 4. Space modifications plans and drawings should be r

7、eviewed and concurred by facility managers in consultation with Building Management, and the safety and occupational health personnel. 5. Before moving employees into reconfigured space, facilities managers must inspect and verify that the space is configured per design, and receiving the proper ven

8、tilation per ASHRAE standards 62.1, Ventilation for Acceptable Indoor Air Quality. 6. The garage ventilation system should be operated based on carbon monoxide levels detected instead of specific time periods during the day. 7. Custodial closets need to be secured and housekeeping chemicals properly

9、 handled. 8. Building occupants need periodic reminders and/or training on how to report safety and health hazards, including environmental health emergencies. 9. Headquarters needs to develop and implement a written mishap preparedness and contingency plan. Recommendation(s): Intermediate cause 1 f

10、or all lost-time events: Operating cycles of parking garage fans Recommendation IC1: Operate the garage fans during all hours of the work day or install carbon monoxide sensors that activate the fans when an established level of carbon monoxide is detected. Recommendation IC2: Ensure that building o

11、ccupants are properly trained on the use of the Facility Help Line for reporting environmental health concerns. Recommendation IC3: Develop and implement a written mishap preparedness and contingency plan. On the basis of the E&CF analysis, the following root causes and recommendations for the CS1,

12、CS2, and Cl lost-time events were identified: Root Cause 1: The HVAC system was not performing to design specifications or American Society of Heating, Refrigeration and Air Conditioning Engineers (ASHRAE) recommendations (ref 1). Recommendation RC1: Install a variable-air-volume system. Because of

13、the floor design and layout of the suites and cubicles, a variable-air-volume system would be more compatible with the HVAC system installed in the building. This system would allow for individual areas to be adjusted for comfort rather than trying to control and maintain an entire floor at a comfor

14、table level for everyone. Recommendation RC2: Reduce the number of full floor-to-ceiling walls. There is a high cost associated with the installation of a variable-air-volume HVAC system. An alternative recommendation is to increase the number of cubicles on each floor. This would reduce the number

15、of full floor-to-ceiling walls on each floor and would allow for air circulation that is more compatible with the HVAC system currently installed. Root cause 2: Facility maintenance has difficulty controlling and managing an unfamiliar system. Recommendation RC3: Inspect and ensure that offices are

16、getting the required 20 cubic feet per minute (CFM) per person. Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Recommendation RC4: Modernize the energy management system known as the building automation system (BAS). Recommendation RC5: Conduct a co

17、mplete examination of the buildings environmental controls and subsystems. Validate and verify that all HVAC permanent ducts operate as designed and that airflow valves are in the proper locations and positions. The buildings environmental monitoring and control system should also be reviewed and up

18、dated as needed. Recommendation RC 6: Ensure that maintenance personnel have been provided adequate training on this buildings HVAC system and its operating parameters Evidence of Recurrence Control Effectiveness: N/ADocuments Related to Lesson: Click here to download document. Mission Directorate(s

19、): N/AAdditional Key Phrase(s): a71 Engineering Design (Phase C/D).a71 Safety and Mission Assurance.Additional Info: a71 Project: NAApproval Info: a71 Approval Date: 2009-04-24a71 Approval Name: mbella71 Approval Organization: HQProvided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-