REG NASA-LLIS-0051-1991 Lessons Learned - Dry Well Transducer Installations are Susceptible to Inadvertent Removal Disposal of Contaminated Waste.pdf

1、Lessons Learned Entry: 0051Lesson Info:a71 Lesson Number: 0051a71 Lesson Date: 1991-12-27a71 Submitting Organization: KSCa71 Submitted by: David PenningtonSubject: Dry Well Transducer Installations are Susceptible to Inadvertent Removal; Disposal of Contaminated Waste Description of Driving Event: A

2、 hypergol technician erred in the removal of a temperature transducer from a 3-inch hypergol line at the “Pad A“ fuel farm, resulting in a major fuel spill and hypergol burns to himself. The installation design of the dry well and temperature transducer provides a means to remove the transducer from

3、 the system for replacement or calibration without having to “open“ the fluid volume. The dry well installation design is inadequate to preclude an untrained technician or a careless technician from inadvertently removing the dry well from the hypergol propellant line by mistake.Lesson(s) Learned: 1

4、. Adequate physical safeguards do not exist to prevent the inadvertent removal of dry wells/transducer installations from hazardous systems.2. Failure to test for hazardous levels of MMH within the sump tank, resulted in the release of contaminated waste water to the environment.Recommendation(s): 1

5、. Design of dry well/transducer installations should be modified to preclude the inadvertent removal of dry wells from hazardous systems.2. SPC-wide publicity should be given to the requirements for proper hazardous waste disposal and testing as contained in SPI SO-O37(4)KV.Evidence of Recurrence Co

6、ntrol Effectiveness: N/AProvided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Documents Related to Lesson: N/AMission Directorate(s): N/AAdditional Key Phrase(s): a71 Energetic Materials - Explosive/Propellant/Pyrotechnica71 Ground Operationsa71 Ground Equ

7、ipmenta71 Hazardous/Toxic Waste/Materialsa71 Human Factorsa71 Industrial Operationsa71 Packaging Handling Storagea71 Safety & Mission AssuranceAdditional 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-,-,-