yee@trident.arc.nasa.gov (Peter E. Yee) (11/14/89)
Ed Campion
Headquarters, Washington, D.C. November 13, 1989
Karl Kristofferson
Kennedy Space Center, Fla.
RELEASE: 89-173
FINDINGS RELEASED ON ORBITER PROCESSING FACILITY WATER MISHAP
An investigation board at NASA's John F. Kennedy Space
Center (KSC), Fla., has determined that human error caused the
release of water from a Firex deluge system in Orbiter Processing
Facility (OPF) bay 2 on Sept. 24 while workers were preparing the
orbiter Columbia for its next mission.
Water damage to the exposed flight hardware and associated
ground support equipment is still being assessed, but appears to
be minimal. The mishap is not expected to impact Columbia's
readiness for the STS-32 mission in December.
The board found that the primary cause of the mishap was the
failure of water technicians to follow procedural instructions
during the repair of a water valve in the deluge system. The
board also cited as a contributing cause the lack of training by
OPF "contingency team" members in the operation of the OPF water
deluge system.
The incident was initiated by a sequence of events that
occurred following the repair of a defective valve in Zone 3 of
the seven-zone OPF water deluge system. Water technicians added
a non-procedural flow test on the Zone 3 system by cycling flow
valves. This allowed water to flow at a reduced rate (20-30
percent of normal flow) into Zone 3 of the deluge system,
resulting in the release of water in the work area of the OPF.
Meanwhile, OPF technicians, who were members of the
facility's "contingency team", had proceeded to the manual
activation station behind OPF bay 2 in an attempt to shut off the
flow, unaware that the Zone 3 water flow had already been
isolated and deactivated.
Believing that the arming and firing valves for the water
zones were in the "on" position rather than the "off" position,
they mistakenly activated Zones 1 through 5 to the "full on"
position, initiating a second and heavier flow of water from
Zones 1, 2, 4 and 5 into the OPF work area. The water flow
subsequently was shut down by water technicians.
The investigation board has recommended that KSC take the
following corrective actions: (1) ensure that personnel with
access to the OPF water deluge system are fully trained and
certified in the operation of the system; (2) develop and
rigorously implement a policy outlining which operations and
activities involving the water deluge system require thorough
pre-task briefings; (3) orient the system's control panels to the
industry norm and label them with specific open and closed
markings; and (4) provide positive control to limit access to the
system's control panels.
The investigation board was chaired by Thomas Utsman, KSC
deputy director. Other board members were Charles Henschel,
Shuttle Operations; Linda Hannett, Safety, Reliability and
Quality Assurance; and Norm Starkey, NASA Headquarters.
Affiliated members were Ronald Gillett, Safety Advisor and
Recorder; Douglas Hendriksen, Legal Advisor; and Dick Young,
Public Affairs Advisor.
Editors Note: A copy of the board's report is available for
review in the newsrooms at NASA Headquarters and the Kennedy
Space Center.