1、Lessons Learned Entry: 1192Lesson Info:a71 Lesson Number: 1192a71 Lesson Date: 2001-04-21a71 Submitting Organization: GSFCa71 Submitted by: Susan Breon/Catherine BowerSubject: Exposure of Personnel to Electrocution Hazard Description of Driving Event: Early on Saturday, April 21, 2001, a pipe in the
2、 secondary water system failed in the basement of Building 8 at the NASA Goddard Space Flight Center. The primary asset damaged by the resulting flood was the NASA photo archive, located immediately below the location where the pipe failed. It took 2 hours to isolate the secondary water system and s
3、everal more hours for the system to drain through the failed pipe. As a result, much of the basement flooded to a depth of 1-2 inches. Personnel who were working in the building that morning were exposed to an electrocution hazard and had no protective equipment or proper training. No one in the cle
4、an-up or recovery crews was authorized to clear the building. Although floods are identified as a significant hazard/threat in the Goddard Emergency Management Plan, the emergency console had no guidance or preparation for dealing with the hazards presented by this flood.Lesson(s) Learned: The first
5、 lesson learned is that equipment rooms require better markings on valves and fluid lines, as well as diagrams showing location of critical equipment, which would allow the lines to be isolated more quickly.The second lesson learned is that incident control is needed, particularly during off-hours w
6、hen normal incident control personnel are not available. Access to flooded areas should be restricted until it is determined that no electrocution hazard exists.The third lesson learned is that it would be wise to do advanced planning for significant hazards or threats. Current Goddard policy is to
7、allow a specially-trained team to respond at the time of a crisis. Unfortunately, not all crises occur during normal work hours. Even during normal working hours, this team is likely to be in the midst of dealing with the crisis as it unfolds.Provided by IHSNot for ResaleNo reproduction or networkin
8、g permitted without license from IHS-,-,-Recommendation(s): Label valves, fluid lines, and critical equipment in all equipment rooms.Establish an incident command structure that will function at all times, not just during normal working hours.Prepare emergency response plans for identified significa
9、nt hazards or threats prior to the occurrence of such an event.Evidence of Recurrence Control Effectiveness: N/ADocuments Related to Lesson: N/AMission Directorate(s): N/AAdditional Key Phrase(s): a71 Administration/OrganizationAdditional Info: Approval Info: a71 Approval Date: 2002-05-06a71 Approval Name: Jay Liebowitza71 Approval Organization: GSFCa71 Approval Phone Number: 301-286-4467Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-
