REG NASA-LLIS-4976-2011 Lessons Learned Cryogenic Tank Rupture Mishap.pdf

1、 Public Lessons Learned Entry: 4976 Lesson Info: Lesson Number: 4976 Submitting Organization: KSC Submitted by: Dawn Martin Subject: Cryogenic Tank Rupture Mishap Abstract: A composite overwrapped pressure vessel (COPV) at the Kennedy Space Center ruptured, causing injury to test team personnel. A l

2、ack of adequate independent reviews was the root cause of this mishap. A process for independent reviews of non-routine hazardous test operations and clear Point-of-Contact information pertaining to the necessary disciplines required for review would have triggered the right questions and analyses,

3、thereby avoiding the mishap. Description of Driving Event: On December 23, 2008, a 935-gallon composite overwrapped pressure vessel (COPV) being tested at the Cryogenics Test Laboratory (CTL, or Cryolab) at the Kennedy Space Center ruptured, causing injury to test team personnel in the Cryolab high-

4、bay and damage to the facility and test equipment. IRIS Case Number: S-2008-359-00002 The tank was filled with liquid nitrogen (LN2) and was being pressurized with gaseous nitrogen (GN2) to predetermined pressure levels while the test team monitored strain levels in the tank shell. During testing, t

5、he tank ruptured, the wood and aluminum enclosure did not contain blast resulting in LN2/GN2 flowing into the Cryolab high-bay where 11 members of the test team were located. Personnel were injured by the initial pressure wave. Test team members came in contact with the gaseous and liquid nitrogen a

6、s they evacuated (one person fell, resulting in abrasions, fractured rib, and cryogenic burns). Seven people were transported to the KSC Occupational Health Facility (OHF), (one by ambulance) and all were released for regular duty. One test team member had further complications that required outpati

7、ent medical treatment following his return to his home out of state. Although there were no fatalities associated with this mishap, there was a significant risk of asphyxiation in this event due to the quantity of GN2 that entered the Cryolab high-bay. Lesson(s) Learned: The main lesson is a lack of

8、 adequate independent reviews for the test plan, procedure, and operation. The NASA and contractor test team members did not seek an outside, independent review of a test that was clearly beyond their expertise and experience. An independent review by other disciplines would have likely pointed out

9、important aspects to consider and overcome the group-think and schedule pressure that were factors in many of the decisions made. This mishap would have been avoided had procedures/requirements been followed. When testing a COPV tank above Maximum Expected Operating Pressure (MEOP), and with limited

10、 expertise/knowledge of CPV, an abundance of caution should have been employed. The involvement of Safety and Mission Assurance functions, various NASA discipline consultations, the performance of risk assessments, and the completion of variance documentation, would have triggered the right question

11、s and analyses, thereby avoiding the mishap. Management review and insight for testing and risk analysis was inadequate. Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Figure 1: Location of test personnel Figure 2: Plywood Barrier Recommendation(s):

12、 1. Ensure a process is followed for independent reviews of non-routine hazardous test operations and that the appropriate NASA disciplines evaluate these tests. 2. Establish a Centerwide process to ensure the necessary oversight is provided for hazardous operations at the various laboratories and t

13、est facilities at KSC. 3. Provide the NASA/KSC directorates and contractors with clear Point-of-Contact information pertaining to the necessary NASA disciplines required for review. 4. Ensure adequate internal and external oversight in accordance with contractual requirements. 5. Fulfill the Standar

14、d Operation Procedures (SOP) contractual obligations pertaining to safety, risk management, and pressure vessel system review. 6. NASA Safety should perform periodic reviews to verify contractual obligations pertaining to safety, risk management, and pressure vessel system are met. Evidence of Recur

15、rence Control Effectiveness: A new process KDP-KSC-P-1197, Non-Routine Hazardous Operations Working Group Process was implemented to preclude future occurrence of this situation. Documents Related to Lesson: NPD 8710.5D Policy for Pressure Vessels and Pressurized Systems NPR 8715.3C NASA General Saf

16、ety Program Requirements KDP-P-2755 Contractor Assessment Process KNPR 8715.3 Kennedy NASA Procedural Requirements Mission Directorate(s): Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,- Space Operations Additional Key Phrase(s): Program Management.

17、Role of civil service technical staff versus contractor staff Program Management.Contractor relationships Program Management.Communications between different offices and contractor personnel Program Management. Systems Engineering and Analysis. Additional Categories.Cryogenic Systems Additional Cate

18、gories. Safety and Mission Assurance.Review systems and boards Safety and Mission Assurance.Advanced planning of safety systems Safety and Mission Assurance. Integration and Testing Systems Engineering and Analysis.Planning of requirements verification processes Systems Engineering and Analysis.Engi

19、neering design and project processes and standards Additional Categories.Hazardous/Toxic Waste/Materials Additional Categories.Independent Verification and Validation Additional Categories.Pressure Vessels Additional Categories.Test & Verification Additional Info: Project: N/A Approval Info: Approval Date: 2011-01-14 Approval Name: mbell Approval Organization: HQ Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-