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NASA-LLIS-0003
Lessons Learned - Hazard Potentials Associated With Maintenance in High Valued, Mission Critical Areas (Mission Control at JSC)
Year: 1991
Abstract: Description of Driving Event:
While installing electrical cables into a conduit in 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 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) 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.
While installing electrical cables into a conduit in 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 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) 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.
Subject: Configuration Management
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| contributor author | NASA - National Aeronautics and Space Administration (NASA) | |
| date accessioned | 2017-09-04T16:21:11Z | |
| date available | 2017-09-04T16:21:11Z | |
| date copyright | 04/01/1991 | |
| date issued | 1991 | |
| identifier other | TMYCQCAAAAAAAAAA.pdf | |
| identifier uri | https://yse.yabesh.ir/std/handle/yse/84681 | |
| description abstract | Description of Driving Event: While installing electrical cables into a conduit in 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 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) 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. | |
| language | English | |
| title | NASA-LLIS-0003 | num |
| title | Lessons Learned - Hazard Potentials Associated With Maintenance in High Valued, Mission Critical Areas (Mission Control at JSC) | en |
| type | standard | |
| page | 2 | |
| status | Active | |
| tree | NASA - National Aeronautics and Space Administration (NASA):;1991 | |
| contenttype | fulltext | |
| subject keywords | Configuration Management | |
| subject keywords | Emergency Preparedness | |
| subject keywords | Facilities | |
| subject keywords | Ground Equipment | |
| subject keywords | Industrial Operations |