REG NASA-LLIS-0501-1994 Lessons Learned - Adequate Procedures and Safeguards.pdf

1、Lessons Learned Entry: 0501Lesson Info:a71 Lesson Number: 0501a71 Lesson Date: 1994-07-08a71 Submitting Organization: LARCa71 Submitted by: Bernard LewisSubject: Adequate Procedures and Safeguards Description of Driving Event: On or about January, 1993, the LOX/LN2System (an Oxygen Clean Environment

2、) of the LaRC 7“ High Temperature TUNNEL Was leak checked using K-Bottle nitrogen. At Langley Research Center, only personnel from the Fluid Systems Section of the Operations Support Division are authorized to work on oxygen clean systems. Personnel doing the leak testing were not from the Fluid Sys

3、tems Office.When Fluid Systems Section personnel became aware of the leak testing, they questioned the use of K-Bottle nitrogen from the standpoint of system contamination. While the LN2furnished for use in K-Bottles is over 99% pure, the K-Bottle itself, unless specifically tested and posted with a

4、ppropriate paperwork attesting to that fact, is assumed to be contaminated with rust, hydrocarbons, and/or various other contamination-causing particles.Langley Handbook 1740.5 governs working with oxygen clean systems.Lesson(s) Learned: Adequate procedures and safeguards must be in place to assure

5、that all foreseeable risks to people, facilities, equipment, or missions are identified and mitigated.Recommendation(s): Specifically, the unauthorized leak testing was stopped. In general, Langley Handbook 1740.5, governing procedures for working with oxygen clean systems, is in production.Provided

6、 by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Evidence of Recurrence Control Effectiveness: N/ADocuments Related to Lesson: N/AMission Directorate(s): N/AAdditional Key Phrase(s): a71 Facilitiesa71 Industrial Operationsa71 Test FacilityAdditional Info: Approval Info: a71 Approval Date: 1997-04-02a71 Approval Name: Elijah C. Kenta71 Approval Organization: 421a71 Approval Phone Number: 757-864-3345Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-