1、Lessons Learned Entry: 0450Lesson Info:a71 Lesson Number: 0450a71 Lesson Date: 1991-04-04a71 Submitting Organization: JSCa71 Submitted by: L. UnderwoodSubject: Emergency Procedure Training for Critical Operations/Areas Description of Driving Event: While installing electrical cables into a conduit i
2、n 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 sufficient lubrication on the cables being pulled through
3、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 emergency plan that did not include water leaks, and (2)
4、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 allowable work policies. Also recommended was increase
5、d training of personnel to include these improvements.Lesson(s) Learned: Personnel working in critical equipment areas with no training in emergency procedures resulted in a delayed response causing additional damage.Recommendation(s): Train personnel working on critical systems in emergency procedu
6、res to reduce the response time for emergencies.Evidence of Recurrence Control Effectiveness: N/AProvided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Documents Related to Lesson: N/AMission Directorate(s): N/AAdditional Key Phrase(s): a71 Emergency Preparednessa71 FacilitiesAdditional Info: Approval Info: a71 Approval Date: 1996-09-30a71 Approval Name: Ron Montaguea71 Approval Organization: JSC/NA3a71 Approval Phone Number: 281-483-8576Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-
