REG NASA-LLIS-5456-2011 Lessons Learned Building 1100 3rd Floor Fire.pdf

1、Public Lessons Learned Entry: 5456 Lesson Info: Lesson Number: 5456 Submitting Organization: SSC Submitted by: Robert Traill Subject: Building 1100 3rd Floor Fire Abstract: A fire at NASA John C. Stennis Space Center occurred in an area that was undergoing asbestos abatement. The direct cost of dama

2、ge from this mishap has been estimated at $376,000 and was classified as a Type B Mishap, IRIS Safety Incident #2008-075-00002. An Events and Causal Factors (E&CF) Tree was generated and the primary proximate cause was determined to be an undersized extension cord that was improperly routed and ener

3、gized, in the presence of fuel sources and adequate oxygen. Three Root Causes and two Contributing Factors were identified, resulting in three Recommended Corrective Actions. Description of Driving Event: On March 14, 2008, at NASA John C. Stennis Space Center (SSC), at approximately 1750 Central St

4、andard Time (CST), a fire occurred in Building 1100, 3rd floor, in an area that was undergoing asbestos abatement. There were no injuries associated with this mishap. The fire occurred in an unoccupied construction area following the end of a normal workday (0800-1630 hours). The SSC Fire Department

5、 (FD) serves as first responders for fire, emergency and emergency medical services (EMS) for the center and was on scene within six minutes of the first alarm. The center section of the 3rd floor was engulfed with heavy smoke upon FD arrival. The FD laid two fire hoses, one from a water hydrant loc

6、ated near the northeast corner of Building 1100 and one from a standpipe on the 2nd floor to the fire on the 3rd floor. The fire was brought under control within 15 minutes of the initial attack by the FD. The direct cost of damage from this mishap has been estimated at $376,000 and was classified a

7、s a Type B Mishap, IRIS Safety Incident #2008-075-00002. The proximate causes leading to the mishap are listed below. For the fire to occur, one Event and two Conditions had to be met and were identified as the three Proximate Causes: an ignition event, available fuel, and an adequate oxygen supply.

8、 Available fuel and oxygen supply were eliminated as ignition sources. A Fault Tree was developed to identify the most likely ignition source based on potential ignition sources present in the fire area. This process identified undersized and improperly routed extension cords as the most likely igni

9、tion source. These results were fed into the Events and Causal Factors (E&CF) tool for additional assessment. An E&CF Tree was generated based on the three Proximate Causes (see Figure 1, Events and Causal Factors Tree). Each Proximate Cause was developed to examine all reasonable or possible hypoth

10、eses for how the mishap might have occurred, and to systematically rule out as many alternatives as the evidence allowed. The E&CF analysis resulted in three Root Causes and two Contributing Factors. The primary proximate cause was an undersized extension cord that was improperly routed and energize

11、d, in the presence of fuels sources and adequate oxygen. Based on evidence at the scene, the fire originated in an asbestos decontamination station, which was a wood-framed enclosure covered with 6 mil plastic. The station was not in use on the day of the mishap. All elements required for a fire wer

12、e present in the area: oxygen at normal levels, combustibles, and potential ignition sources that included task lighting, equipment and extension cords. Utilizing the investigative approach above, the source of ignition for the fire was determined to be undersized and improperly routed extension cor

13、ds. Three Root Causes and two Contributing Factors were identified, resulting in three Recommended Corrective Actions. Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Lesson(s) Learned: Provided by IHSNot for ResaleNo reproduction or networking permi

14、tted without license from IHS-,-,-LL1: Smoke and Fire Alarm System deactivated for construction: The alarm systems were deactivated for the construction activities in the 3rd floor area. This is a normal approach to construction activities at SSC. LL2: SSC did not execute the established Incident Re

15、sponse Team (IRT) processes: The emergency response by the fire department was executed extremely well to this mishap, but the required IRT process was never implemented. Without the guidelines of the IRT process, the impounding and security of the mishap area was potentially jeopardized. Recommenda

16、tion(s): RCA 1.2: NASA/SSC SMA should require contractors to implement site-specific safety inspection checklists for construction projects that identify unique requirements based on the contract Statement of Work. RCA 2.1: NASA/SSC SMA should develop site-specific safety inspection checklists for c

17、onstruction projects that identify unique requirements based on the contract Statement of Work. RCA 3.2: NASA/SSC SMA should implement a verifiable contract requirement for construction contractor safety inspection documentation. Evidence of Recurrence Control Effectiveness: N/A Documents Related to Lesson: N/A Mission Directorate(s): N/A Additional Key Phrase(s): Facilities Additional Info: Project: NA Approval Info: Approval Date: 2011-03-09 Approval Name: mbell Approval Organization: HQ Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-