1、Public Lessons Learned Entry: 5396 Lesson Info: Lesson Number: 5396 Submitting Organization: KSC Submitted by: Dawn Martin Subject: Cryogenic Tank Rupture/Close Call Abstract: A composite pressure vessel at the Kennedy Space Center ruptured, causing injury to test team personnel. A lack of adequate
2、independent reviews was the root cause of this mishap. A process for independent reviews of non-routine hazardous test operations and clear Point-of-Contact information pertaining to the necessary disciplines required for review would have triggered the right questions and analyses, thereby avoiding
3、 the mishap. Description of Driving Event: On December 23, 2008, a 935-gallon composite pressure vessel being tested at the Cryogenics Test Laboratory (CTL, or Cryolab) at the Kennedy Space Center ruptured, causing injury to test team personnel in the Cryolab high-bay and damage to the facility and
4、test equipment. IRIS Case Number: S-2008-359-00002 The tank was filled with liquid nitrogen (LN2) and was being pressurized with gaseous nitrogen (GN2) to predetermined pressure levels while the test team monitored strain levels in the tank shell. During testing, the tank ruptured and the wood and a
5、luminum enclosure did not contain the blast, resulting in LN2/GN2 flowing into the Cryolab high-bay where 11 members of the test team were located. Personnel were injured by the initial pressure wave. Test team members came in contact with the gaseous and liquid nitrogen as they evacuated (one perso
6、n fell, resulting in abrasions, fractured rib, and cryogenic burns). Seven people were transported to the KSC Occupational Health Facility (OHF) (one by ambulance), and all were released for regular duty. One test team member had further complications that required outpatient medical treatment follo
7、wing his return to his home out of state. Although there were no fatalities associated with this mishap, there was a significant risk of asphyxiation in this event due to the quantity of GN2 that entered the Cryolab high-bay. Lesson(s) Learned: The main lesson is a lack of adequate independent revie
8、ws for the test plan, procedure, and operation. The NASA and contractor test team members did not seek an outside, independent review of a test that was clearly beyond their expertise and experience. An independent review by other disciplines would have likely pointed out important aspects to consid
9、er and overcome the group-think and schedule pressure that were factors in many of the decisions made. This mishap would have been avoided had procedures/requirements been followed. When testing a Composite Pressure Vessel (CPV) tank above Maximum Expected Operating Pressure (MEOP), and with limited
10、 expertise/knowledge of CPV, an abundance of caution should have been employed. The involvement of Safety and Mission Assurance functions, various NASA discipline consultations, the performance of risk assessments, and the completion of variance documentation, would have triggered the right question
11、s and analyses, thereby avoiding the mishap. Management review and insight for testing and risk analysis was inadequate. Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Figure 1: Location of test personnel Figure 2: Plywood Barrier Recommendation(s):
12、 1. Ensure a process is followed for independent reviews of non-routine hazardous test operations and that the appropriate NASA disciplines evaluate these tests. 2. Establish a Center-wide process to ensure the necessary oversight is provided for hazardous operations at the various laboratories and
13、test facilities at KSC. 3. Provide the NASA/KSC directorates and contractors with clear Point-of-Contact information pertaining to the necessary NASA disciplines required for review. 4. Ensure adequate internal and external oversight in accordance with contractual requirements. 5. Fulfill the Standa
14、rd Operation Procedures (SOP) contractual obligations pertaining to safety, risk management, and PV/S review. 6. NASA Safety should perform periodic reviews to verify contractual obligations pertaining to safety, risk management, and pressure vessels and systems are met. Evidence of Recurrence Contr
15、ol Effectiveness: N/A Documents Related to Lesson: N/A Mission Directorate(s): Space Operations Additional Key Phrase(s): Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Safety and Mission Assurance.Advanced planning of safety systems Safety and Miss
16、ion Assurance.Review systems and boards Additional Categories. Safety and Mission Assurance. Integration and Testing Systems Engineering and Analysis.Planning of requirements verification processes Systems Engineering and Analysis.Engineering design and project processes and standards Systems Engine
17、ering and Analysis. Program Management.Role of civil service technical staff versus contractor staff Program Management.Contractor relationships Program Management.Communications between different offices and contractor personnel Program Management. Additional Categories.Cryogenic Systems Additional
18、 Categories.Test & Verification Additional Categories.Pressure Vessels Additional Categories.Independent Verification and Validation Additional Categories.Hazardous/Toxic Waste/Materials Additional Info: Project: N/A Approval Info: Approval Date: 2011-02-22 Approval Name: mbell Approval Organization: HQ Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-
