1、Lessons Learned Entry: 0054Lesson Info:a71 Lesson Number: 0054a71 Lesson Date: 1992-01-20a71 Submitting Organization: KSCa71 Submitted by: David PenningtonSubject: Excessive Release of Nitrogen Tetroxide (N2O4); Public Address Statements; Pinhole Leaks in SCAPE Suits Description of Driving Event: Th
2、e nitrogen tetroxide (N2O4) vapor release, which occurred during a storage tank relief valve changeout, greatly exceeded the “one gallon quantity“ specified in the task OMI V2197, sequence 03-014. Also, sequence 03-074 states, “total amount of commodity involved: 1 gallon.“ Post incident calculation
3、s estimated the total release to have been 28 gallons. The vapor cloud of N2O4 far exceeded the 700-foot clear area called out in the OMI. Unless the magnitude of the release is accurately predicted, the downwind clear area cannot be properly established and personnel may be endangered.Lesson(s) Lea
4、rned: 1. Failure of an OMI to require calculation of quantities of N2O4 to be released could result in loss of life or personnel injury.2. During hazardous operations (OMI V2197) public address statements were out of sequence with events and did not accurately depict conditions which were to occur.3
5、 Maintenance for SCAPE Suits does not include checking for pinhole leaks, allowing SCAPE suit deterioration to go unnoticed, endangering personnel.Recommendation(s): 1. Revise OMIs to address the need for calculating estimated vapor release quantities and use those values in establishing an area cl
6、earing.2. Hazardous operations public address announcements should be tailored to specific hazardous operations.3. Establish a test program to accurately determine the integrity of protective suits after the Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IH
7、S-,-,-normal maintenance recycle following each use.Evidence of Recurrence Control Effectiveness: N/ADocuments Related to Lesson: N/AMission Directorate(s): N/AAdditional Key Phrase(s): a71 Communication Systemsa71 Emergency Preparednessa71 Energetic Materials - Explosive/Propellant/Pyrotechnica71 F
8、acilitiesa71 Hazardous/Toxic Waste/Materialsa71 Industrial Operationsa71 Personal Protective Equipmenta71 Safety & Mission AssuranceAdditional Info: Approval Info: a71 Approval Date: 1994-06-01a71 Approval Name: James G. Klinea71 Approval Organization: KSC/HEIa71 Approval Phone Number: 407-867-7614Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-
