REG NASA-LLIS-4236-2010 Lessons Learned - Facility Building B1201 Roof Repair Mishap.pdf

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1、 Public Lessons Learned Entry: 4236Lesson Info:a71 Lesson Number: 4236 a71 Lesson Date: 2010-10-22 a71 Submitting Organization: SSC a71 Submitted by: Robert Traill Subject: Facility Building B1201 Roof Repair Mishap Abstract: During weekend work conducted February 3 and 4, 2007, contract workers rem

2、oved the existing B1201 roof material, which uncovered an old drain (drain 1). This drain 1 had been abandoned in place, the drain pipe had been cut, and vertical section removed below the roof deck. During the same activity the roofers broke the PVC bowl of a nearby active drain (drain 2). The work

3、ers, believing that drain 1 was viable, proceeded to unblock the drain pipe and finished the drain location to the completed roof. As part of the same operation, the workers did not repair the drain 2 damage, instead they covered over this drain. Over one (1) inch of rain fell at the Stennis Space C

4、enter during the night of February 12th and the morning of the 13th. Rain entered B1201 through drain 1; the rain fell on and damaged several pieces of IT equipment. In a separate location another drain pipe connection to an internal drain also failed, allowing water to flood an adjacent hallway. Th

5、is incident was classified a Type B Mishap according to NPR 8621.1B - NASA Procedural Requirements for Mishap Reporting, Investigation, and Recordkeeping. The proximate causes leading to the mishap are listed below. 1. The abandoned drain (drain 1) opened at roof level. 2. The opened, abandoned drai

6、n (drain 1) pipe ended above IT equipment. Description of Driving Event: NASA/SSC Facility Operating Services Contractor (FOSC) contracted with the roofing contractor to repair through replacement Hurricane Katrina damage to B 1201 roof. The prime contractor then subcontracted the work to a sub-tier

7、 contractor, notifying the FOSC of his action. The sub-tier contractor further subcontracted the work to a third-tier subcontractor; FOSC was not notified of this last action. FOSC was not aware of a third-tier contractor on site as the workers information for access badges was provided as though th

8、ey were the second-tier contractors labor force. Contractual and notification information that normally flows to sub-tier contractors did not reach the third-tier contractor. The third-tier contractor did not know to notify FOSC of the anomalous condition at the roof site. Lesson(s) Learned: 1. Invo

9、lve the Facility Manager at design reviews to ensure that knowledge of any prior and undocumented facility modifications is captured. 2. Make a thorough sweep of all Engineering Modification Instructions (EMI) packages and shop work orders for the facility undergoing modification. 3. Require prime c

10、ontractors to disclose all sub-tier contractors that are required in the performance of the work. 4. All contractors - prime and sub - shall participate in pre-construction meetings. Recommendation(s): 1. Include standard questions on field changes in weekly Facility Operating Services (FOS) constru

11、ction notes. 2. Test all drains per existing specifications to ensure they are functional. 3. Evaluate drains, close and remove inactive ones. 4. Conduct thorough inspection of all roof drains per specifications, including areas covered by drop ceiling tiles when drain pipes are internal to the buil

12、ding. Evidence of Recurrence Control Effectiveness: N/A Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Documents Related to Lesson: Investigation of the SSC Building 1201 Roof Failure Type B Mishap. IRIS number 2007-045-00001 Mission Directorate(s):

13、 N/A Additional Key Phrase(s): a71 Maintenance a71 International partner coordination a71 Contractor relationships a71 Communications between different offices and contractor personnel a71 Acquisition / procurement strategy and planning a71 Facilities a71 Ground processing and manifesting a71 Review systems and boards Additional Info: a71 Project: N/A Approval Info: a71 Approval Date: 2010-11-18 a71 Approval Name: mbell a71 Approval Organization: HQ Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-