1、Public Lessons Learned Entry: 5936 Lesson Info: Lesson Number: 5936 Lesson Date: 2011-6-27 Submitting Organization: KSC Submitted by: Amber Porter Subject: Fire Protection System (FPS) Failure at the Launch Control Center (LCC) Abstract: At approximately 9:00 p.m., on 28 January 2010, a six-inch dia
2、meter fire suppression (Firex) main supply pipe coupling separated from a pipe elbow releasing approximately 29,000 gallons of water into the Kennedy Space Center (KSC) Launch Control Center (LCC), Building K6-900, I.R.I.S. case number S-2010-029-00002. The water was released into the fourth-floor R
3、 stairwell, cascading down to all floors below. Much of the facility was flooded with the dirty, brackish water. System reviews should be conducted after major contract changes to ensure all required inspection and maintenance activities are scheduled in accordance with NASA, NFPA and manufacturer r
4、equirements. Description of Driving Event: During a weekly fire pump run for the 3 diesel fire pumps located in the VAB Utility Annex one of the low side pressure reducing valves failed to regulate the pressure from 330 psig to 140 10 psig. The LCC fire suppression water supply loop and all the subs
5、equent wt pipe suppression systems directly connected to the building supply loop were over pressurized in excess of 300 psig. The over pressurization of the entire LCC fire suppression system caused numerous mechanical couplings to partially fail. 28 January 2010, six-inch fire suppression supply p
6、ipe coupling separated from elbow at coupling joint in LCC Stairwell 4R99C. Smaller leaks were in LCC firing rooms, hallways, and offices. 300-500 gallons of water released in VAB Low Bay from ruptured sight glass. Immediately prior to the pipe coupling separation, smaller leaks were observed in the
7、 LCC launch control firing rooms, as well as in the nearby Vehicle Assembly Building (VAB), Building K6-848. Although no critical electronic launch equipment was damaged, facility damages were estimated at over $706,000, and this does not include repair of LCC Firex system as it was a pre-existing c
8、ondition, failure was imminent. Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Figure 1: LCC R Stairwell, Separated Pipe, Damage to wall during separation Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-
9、Figure 2 Pressure Reducing Valves in VAB Utility Annex Mezzanine Lesson(s) Learned: All systems need to be properly maintained and inspected to make sure that everything functions properly so that mishaps such as this can be prevented. Recommendation(s): Require system reviews be conducted after
10、 major contract changes to ensure all required inspection and maintenance activities are scheduled in accordance with NASA, NFPA and manufacturer requirements. Create a process to periodically review contractor compliance with NASA, NFPA, and manufacturer requirements for inspection and maintenance
11、of critical fire suppression system components. Create a process to periodically review monitoring requirements of the Firex system and pumps. Contractor personnel monitor PRV discharge pressure when pumps are operating. Install an alarm system in the VAB Utility Annex to warn diesel pump operators
12、of an over-pressure condition. Monitor Firex system pressure in the LCC with an alarm on the KCCS water console. If the alarm activates, personnel can direct diesel-driven pump operators to shut the pumps down and isolate the LCC from the VAB Firex supply loop. Require pump operators to be in direct
13、 communication with SPOC personnel on the KCCS water console while operating the pumps. For future fire suppression system installations, at the beginning of the construction project, contractors should be briefed on the importance of following contract requirements for installation of the fire supp
14、ression systems, including manufacturers recommendations. The entire VAB / LCC fire suppression system should be reviewed to identify single failure points in all stages of operation. Evidence of Recurrence Control Effectiveness: N/A Documents Related to Lesson: Click to view mishap report Provided
15、by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Mission Directorate(s): N/A Additional Key Phrase(s): Safety and Mission Assurance.Maintenance Additional Categories.Accident Investigation Additional Categories.Facilities Additional Categories.Fire Protection Additional Info: Project: N/A Approval Info: Approval Date: 2011-10-03 Approval Name: mbell Approval Organization: HQ Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-
