Type: Lessons Learned
Publisher: National Aeronautics and Space Administration, Kennedy Space Center, Cape Canaveral FL
Published As: Public
The immediate investigation was able to determine that a conduit housing both water pipes and three potentially lethal energized 480V AC electrical conductors was breached by the drill bit. Consequently, work was stopped, the job site secured, and measures were taken to safely complete the job.
Lessons Learned: Using out of date or unintelligible building drawings to guide potentially hazardous work is comparable to not consulting any drawings at all. This practice actually increases the risk of exposing personnel to hazards since the work is unjustifiably considered to be safe or controlled. Consequently: a. A hazard analysis should be performed when a standard control is compromised or suspect. Critical safety requirements and processes may be undermined and overlooked if they are placed in the appendices of a document, they do not provide sufficient implementation details, or if they reference non-existent documents. Halting a penetration operation and investigating it when there is a change in backpressure or ejection of an unexpected material is a good practice that can prevent a serious injury.
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