REG NASA-LLIS-1198-1990 Lessons Learned Payload Hazardous Servicing Facility (PHSF) Water Deluge System Close Call Investigation Final Report.pdf

1、Lessons Learned Entry: 1198Lesson Info:a71 Lesson Number: 1198a71 Lesson Date: 1990-07-26a71 Submitting Organization: KSCa71 Submitted by: Robert Luken/ Eric RaynorSubject: Payload Hazardous Servicing Facility (PHSF) Water Deluge System Close Call Investigation Final Report Description of Driving Ev

2、ent: On July 26, 1990, 14:06 EDT, a Payload Hazardous Servicing Facility (PHSF) fire alarm indication was received at the Protective Services Control Center (PSCC) in the Launch Control Center (LCC). Fire services responded and found no alarm indications at the facility. Initial troubleshooting by E

3、G telephone and handset communication are not recorded. There seemed to be no distinction in trouble-shooting methods employed for critical vs. non-critical circuits.Water Deluge System: 1. Drawings: The system schematics of the Water Deluge System at the PHSF did not reflect Provided by IHSNot for

4、ResaleNo reproduction or networking permitted without license from IHS-,-,-that the control lines between the Control Building (M7-1357) and the Service Building (M7-1354) were routed through comm. system Frames. They incorrectly showed direct dedicated lines between the buildings2. Separation: The

5、“ARM it is accessible for work or troubleshooting by people with no knowledge of the presence of criticality of the Water Deluge circuitry.4. Monitoring: The Water Deluge control logic is designed and implemented such that there is no monitoring or traceability of which panel and/or pushbutton was a

6、ctuated. Therefore it is impossible to tell if the system was actuated by a malfunction of by a switch actuation.5. Other Facilities: There are at least 15 other facilities with the Water Deluge Systems utilizing remote control panels. There is a high probability that these systems are implemented t

7、hat same as the PHSF system.Contractor Interface: Fragmentation of the fire Protection systems prevent the individual contractors and their NASA counterparts from understanding the overall system and how their part of the system may affect the whole. Recommendation(s): Communication System: 1. Frame

8、 Control: The existing Frames Status Indicators should be utilized for Frame access control in all facilities that have critical or hazardous systems in operation. Frame Access control should be coordinated with Facility Management and potentially affected systems should be safed prior to Frame acce

9、ss.2. Critical Functions: All critical or hazardous functions routed through the Comm. system should be appropriately identified and protected.3. Documentation: Formal documentation of troubleshooting procedures should be required when work involves critical or hazardous systems or is accomplished i

10、n the vicinity of them.Water Deluge System: Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-1. Documentation: Systems drawings should be updated and audited to verify accuracy and completeness.2. Control lines: Control functions which require an OPEN

11、/CLOSED path between two wires should be designed and implemented such that exposed terminals are non-adjacent and are adequately protected. If possible separate wires should be utilized, not a twisted pair.3. Routing: control lines for “ARM & ACTIVATE“ values and other critical functions should not

12、 be routed through uncontrolled TDs and Frames along with other miscellaneous systems4. Monitoring: Control logic should be designed such that traceability is provided to indicate how the system was activated. (i.e. which pushbutton).5. Verification: Examine all Water Deluge Systems and identify tho

13、se with conditions similar to the PHSF system so that appropriate action can be taken.6. Oversight: Establish a fire protection systems committee consisting of representatives from Codes SI, CM, TE, DE, RT & CCAFS to provide oversight and integration of the contractors involved.Evidence of Recurrenc

14、e Control Effectiveness: N/ADocuments Related to Lesson: N/AMission Directorate(s): a71 Space Operationsa71 Exploration SystemsAdditional Key Phrase(s): a71 Communication Systemsa71 Computersa71 Configuration Managementa71 Emergency Preparednessa71 Facilitiesa71 Fire Protectiona71 Flight Equipmenta7

15、1 Flight Operationsa71 Ground Equipmenta71 Ground Operationsa71 Industrial Operationsa71 Mishap ReportingProvided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-a71 PayloadsMishap Report References: Payload Hazardous Servicing Facility (PHSF) Water Deluge System Close Call Investigation Final ReportAdditional Info: Approval Info: a71 Approval Date: 2002-05-06a71 Approval Name: Gena Bakera71 Approval Organization: KSCa71 Approval Phone Number: 321-867-4261Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-