REG NASA-LLIS-2196-2009 Lessons Learned - Hypergolic Propellant Related Spills and Fires.pdf

1、Lessons Learned Entry: 2196Lesson Info:a71 Lesson Number: 2196a71 Lesson Date: 2009-06-1a71 Submitting Organization: KSCa71 Submitted by: Michael Bella71 POC Name: Brian Nufera71 POC Email: brian.nufernasa.gova71 POC Phone: 321-861-7311Subject: Hypergolic Propellant Related Spills and Fires Abstract

2、: The attached report is a compilation of all credible, unintentional hypergolic fluid related spills, fires, and explosions from the Apollo Program, the Space Shuttle Program, Titan Program, and a few other programs. Spill sites include the following government facilities: KSC, JSC, WSTF, VAFB, CCA

3、FS, EAFB, Little Rock AFB, and McConnell AFB. The root causes and consequences of the incidents contained in this document vary drastically; however, certain themes can be deduced and utilized for future hypergolic propellant handling. Some of those common themes are summarized below: 1. Improper co

4、nfiguration control and complacency can lead to being falsely comfortable with a system Communication breakdown can escalate an incident to a level where injuries occur and/or hardware is damaged. 2. Improper propulsion system and ground support system designs can destine a system for failure. 3. Im

5、proper training of technicians, engineers, and safety personnel can put lives in danger. 4. Improper PPE, spill protection, and staging of fire extinguishing equipment can result in unnecessary injuries or hardware damage if an incident occurs. 5. Improper procedural oversight, development, and adhe

6、rence to the procedure can be Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-detrimental and quickly lead to an undesirable incident. 6. Improper local cleanliness or compatibility can result in fires or explosions.The items listed above are only a

7、short list of the issues that should be recognized prior to handling of hypergolic fluids or processing of vehicles containing hypergolic propellants. The summary of incidents in this report is intended to cover many more issues than those listed above that have been found during nearly the entire s

8、pectrum of hypergolic propellant and/or vehicle processing. Description of Driving Event: Hypergolic rocket propellants have proven to be a highly reliable asset in manned and unmanned space flight; however, their maintenance on the ground has proven to be relatively difficult. Do the operational ri

9、sks from possibly catastrophic incidents, human errors, or hardware failures outweigh the usefulness of hypergols even though they have been used for the last 50 years of manned and unmanned spaceflight? One would have to say no, since hypergols are so widely used in the space industry currently and

10、 are being proposed to be used on many vehicles in the future. Therefore, ground operations on hypergol systems have become increasingly scrutinized for possible unknowns and rightfully so. This document is not an example of why we should not be using hypergolic propellants on spacecraft and launch

11、vehicles, but rather what we can and should do to mitigate possible unforeseen ground operation and/or design problems. Some type of human error can be traced to nearly every incident discussed in this document as a root cause, whether it be an error in the design phase or an error prior to or durin

12、g operational use of hardware containing hypergols. Humans are most definitely not perfect and even when the most knowledgeable personnel are intimately involved in the design phase (vehicle or GSE) or during an operation, mistakes can be made and items can be overlooked. One can deduce, however, th

13、at most incidents happen during some sort of operation, i.e. when the system is not static. Hypergols tend to be very stable in a static configuration (as long as the compatibility characteristics have been well addressed).Lesson(s) Learned: Some common lessons learned deduced from the various root

14、causes are shown in the attached document.Recommendation(s): Finding/Observation Procedure was reviewed and alternative purge processes were discussed in house by NASA/USA engineering system experts. Recommendation Evaluate and develop alternative methods to reduce risk of liquid release. Evaluate p

15、rocess for independent review of complex hazardous tasks using the First Article Review Process. Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Finding/Observation Failure to develop contingency plans in the event of unexpected liquid release. Recom

16、mendation Include Emergency Procedures for unexpected liquid release. Finding/Observation Personnel reported smell of oxidizer in SCAPE suit and reported to the test team. Each member of the test team directed the potentially exposed employee to leave the work area. Employee egressed after the third

17、 request to leave the test cell. An employee in the relief SCAPE crew stated later that he smelled oxidizer in his SCAPE suit, but failed to report it to the test team. Recommendation Brief individuals involved in the SCAPE operation on the proper response to possible hypergolic contamination inside

18、 the SCAPE suit. Reemphasize training in removing individual from contaminate area, (squat and squeeze), report anomaly, depart area, perform individual change out, and maintain the buddy system. Finding/Observation Mulitple occurrences of SCAPE discipline breakdown; breathing air was not maintained

19、 either by air bottle or hardline and communication between SCAPE personnel and test team was not maintained. Recommendation Management to brief individuals involved in the SCAPE operation on the importance of maintaining positive breathing air and communications at all times. Finding/Observation Sp

20、ill Protection did not adequately contain quantity of defined credible spill and failed to protect adjacent hardware from oxidizer release. Recommendation Evaluate Spill protection process and develop desk instructions to ensure proper level of spill protection corresponds to reasonable risk of rele

21、ase.Evidence of Recurrence Control Effectiveness: N/ADocuments Related to Lesson: Click here to download document. Mission Directorate(s): N/AAdditional Key Phrase(s): a71 Additional Categories.Ground Operationsa71 Additional Categories.Energetic Materials - Explosive/Propellant/Pyrotechnica71 Addit

22、ional Categories.Hazardous/Toxic Waste/Materialsa71 Additional Categories.Packaging, Handling, Storagea71 Additional Categories.Industrial OperationsProvided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-a71 Hypergolic Fuel SystemsAdditional Info: Approval Info: a71 Approval Date: 2010-01-15a71 Approval Name: mbella71 Approval Organization: HQProvided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-