REG NASA-LLIS-0049-1991 Lessons Learned - Firex Deluge Valve Configurations.pdf

1、Lessons Learned Entry: 0049Lesson Info:a71 Lesson Number: 0049a71 Lesson Date: 1991-12-23a71 Submitting Organization: KSCa71 Submitted by: David PenningtonSubject: Firex Deluge Valve Configurations Description of Driving Event: The remote manual arming and firing valves are in the “on“ position when

2、 perpendicular to the water lines, which is not the industry norm for hydraulic systems. This contributed to the OPF GSE technicians believing they were closing the valves by positioning them perpendicular to the water line when, in fact, they were opening the valves. This misinterpretation resulted

3、 in the activation of zones 1,2,3,4, and 5 of the bay 2 Firex deluge system.Lesson(s) Learned: The OPF Firex deluge remote manual arming and firing valves do not conform to industry norms, allowing for misinterpretation of their configuration.Recommendation(s): All Firex deluge system valves should

4、be in accordance with industry norms and provided with specific open and closed position markings.Evidence of Recurrence Control Effectiveness: N/ADocuments Related to Lesson: N/AProvided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Mission Directorate(s):

5、 a71 Space Operationsa71 Exploration SystemsAdditional Key Phrase(s): a71 Configuration Managementa71 Fire Protectiona71 Ground Operationsa71 Ground Equipmenta71 Hardwarea71 Industrial OperationsAdditional Info: Approval Info: a71 Approval Date: 1994-06-01a71 Approval Name: James G. Klinea71 Approval Organization: KSC/HEIa71 Approval Phone Number: 407-867-7614Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-