1、Lessons Learned Entry: 0003Lesson Info:a71 Lesson Number: 0003a71 Lesson Date: 1991-04-01a71 Submitting Organization: JSCa71 Submitted by: L. UnderwoodSubject: Hazard Potentials Associated With Maintenance in High Valued, Mission Critical Areas (Mission Control at JSC) Description of Driving Event:
2、While installing electrical cables into a conduit in the Johnson Space Center Mission Control Room, the conduit was displaced from its mounting, and then contacted and broke a chilled water line. A portion of the room was flooded. The installation procedures did not include details for using suffici
3、ent lubrication on the cables being pulled through the conduit. Also, no cautions or warnings were provided to alert the electricians to take additional precautions to prevent accidents in a high value, mission essential area. Other factors that increased the extent of damage included; (1) an emerge
4、ncy plan that did not include water leaks, and (2) no information was available to the maintenance or operations personnel on the location of or access to shutoff systems. The investigation board recommended correcting the deficiencies in the work procedures, emergency plans, and mission control all
5、owable workLesson(s) Learned: Additional preparedness and precautions are necessary to preclude damaging incidents during installation or maintenance operations performed in high value and mission critical areas.Recommendation(s): The investigation board recommended correcting deficiencies in the wo
6、rk procedures, emergency plans, and mission control allowable work policies; and training of personnel for these changes.Evidence of Recurrence Control Effectiveness: N/AProvided by IHSNot for Resale-,-,-Documents Related to Lesson: N/AMission Directorate(s): a71 Exploration Systemsa71 Sciencea71 Sp
7、ace Operationsa71 Aeronautics ResearchAdditional Key Phrase(s): a71 Configuration Managementa71 Emergency Preparednessa71 Facilitiesa71 Ground Equipmenta71 Industrial OperationsAdditional Info: Approval Info: a71 Approval Date: 1993-09-09a71 Approval Name: Ron Montaguea71 Approval Organization: JSC/NS3a71 Approval Phone Number: 281-483-8576Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS
