1、Lessons Learned Entry: 1375Lesson Info:a71 Lesson Number: 1375a71 Lesson Date: 2002-08-29a71 Submitting Organization: JSCa71 Submitted by: Ronald A. MontagueSubject: Demand and Ensure High-Quality Safety Performance from all Contractors Abstract: The companys failure to implement and enforce their c
2、ompany safety program, as defined in their Safety & Health plan submitted to NASA, resulted in a lax safety culture. This lax safety culture supported the deceased, a journeyman electrician, in feeling comfortable working on an energized electrical circuit without the proper PPE (personal protective
3、 equipment), which he ultimately contacted resulting in his electrocution. Specifically, procedures were not followed when the deceased and his apprentice did not stop work and isolate the circuit or seek a “hot work permit“ upon discovering the circuit was still energized.The subsequent investigati
4、on revealed three central themes involved in the mishap: 1. Implementation and Verification of Lockout / Tagout Procedures,2. Accurate Drawings of Facility Systems as a Prerequisite to Project Implementation, and3. Demand and Ensure High-Quality Safety Performance from all Contractors (the subject o
5、f this lesson).Each theme is published as a separate lesson. (A fourth lesson underscores the successful implementation of the preliminary investigation, which was critical to performing a successful, formal mishap investigation.) Description of Driving Event: Following is an excerpt from the Mishap
6、 investigation report: Finding A: Construction contractors are treated as “transient“ employees for the purpose of meeting safety requirements. Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-1. They are not required to participate in the NASA Close
7、Call system.2. They are not required to provide safety metrics.3. They are not required to participate in training required for onsite, permanent employees, e.g., Safety Through Everyones Participation (STEP), Hazards Communication, etc.4. There is no “closed loop“ tracking of observed safety defici
8、encies. Specifically,(4a) There is no provision for “real time“ feedback to contractor management of safety violations. (4b) Formal written evaluation of firm fixed price construction contractors is only provided at job completion.Finding B: NASA and NASA-delegated oversight and “quality and safety“
9、 inspection processes lack rigor to assure contract provisions are being adhered to. The following evidence supports this finding: 1. Contractors failure to submit required submittals did not stop the job.2. NASA/JSC did not conduct or require the contractor to conduct mandatory safety inspection po
10、ints to assure through independent verification that systems had been de-energized.3. Insufficient number of NASA/JSC delegated safety inspectors performing random inspections to assure contractor compliance with contract provisions.4. No “task readiness review“, outlining work to be performed, was
11、conducted.5. NASA/JSC did not take adverse action against this contractor even though they had a history of violating non-electrical safety policies and procedures (procedures for adverse action are in the contract).Lesson(s) Learned: Construction contractors (and any type of non-resident contractor
12、) doing work at NASA centers should be held to the same standard as on site support services contractors with respect to safety training, tracking of issues/violations, and regular feedback on safety and quality of work.Recommendation(s): 1. Immediate feedback should be provided by NASA to contracto
13、r senior management for all safety violations.2. 3. NASA should establish a “closed loop“ tracking and reporting system for safety violations to assure and document that contractor management has been notified.4. Construction contractors should be made “part of the NASA team“, not treated as transie
14、nts. They should be required to participate in the NASA Close Call system, included in trending data, etc.5. NASA should implement a rigorous randon safety inspection process to assure contractors are complying with their approved Safety & Health Plans.6. Adverse action provisions in contracts shoul
15、d be enforced for gross or repeated safety Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-violations, including warnings when appropriate.7. NASA/JSC should assess the on-site inspection responsibilities and determine if changes are necessary to mak
16、e the process more robust.8. If changes are deemed necessary, augmented duties should be clarified to all safety and quality inspectors.9. NASA should institute Mandatory Safety Inspection Points (MSIP) prior to work on electrical circuits and other energized systems to assure, by independent verifi
17、cation, that they have been properly de-energized. A contractor or the Government could conduct the independent confirmation of systems de-energized status.10. NASA should require Pre-Project Safety Reviews prior to construction start. (This should be more comprehensive than pre-construction meeting
18、s with a format analogous to an Operational Readiness Inspection (ORI), Test Readiness Review (TRR), etc.)Evidence of Recurrence Control Effectiveness: PendingDocuments Related to Lesson: JPG 1700.1, “JSC Safety and Health Handbook,“ Chapter 11.2, Safety and health requirements for services or const
19、ruction contractsMission Directorate(s): a71 Exploration Systemsa71 Sciencea71 Space Operationsa71 Aeronautics ResearchAdditional Key Phrase(s): a71 Configuration Managementa71 Energya71 External Relationsa71 Facilitiesa71 Human Factorsa71 Human Resources & Educationa71 Industrial Operationsa71 Pers
20、onal Protective Equipmenta71 Policy & Planninga71 Procurement Small Business & Industrial Relationsa71 Program and Project ManagementProvided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-a71 Risk Management/Assessmenta71 Safety & Mission Assurancea71 Test & VerificationAdditional Info: Approval Info: a71 Approval Date: 2004-01-08a71 Approval Name: Ron Montaguea71 Approval Organization: JSCa71 Approval Phone Number: 281-483-8576Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-
