Vehicle Assembly Building Fire Mishap Investigation Report. Volume I of V.

摘要

On January 13, 2005, at approximately 1355, smoke was noticed on the 4th floor of D Tower in the Vehicle Assembly Building (VAB). Subsequently, a 911 call was made, a fire alarm pull station was activated, and the VAB was evacuated. The source of the smoke was determined to be a fire on the Low Bay M/N section roof near the Launch Control Center (LCC) Crossover. Due to the high visibility of the mishap, the KSC Center Director appointed a Mishap Investigation Board. Damage to government property was limited to the roof and a small number of ceiling tiles that were damaged by the fire fighters during the response. At the time of the mishap, there were hazardous commodities in the VAB including Solid Rocket Motors (SRMs) with open grain due to Solid Rocket Booster (SRB) igniter inspections. The Board agrees with the SGS Fire Services' theory that large amounts of smoke concentrated in the VAB D Tower and moved downward into the cable tunnel. The Board determined the proximate cause of this incident to be torching. HRI was installing a torch applied roof membrane which resulted in the ignition of combustible materials under the membrane near a wooden roof expansion joint. The torch applied roofing method is a universally accepted safe industry practice when applied to non-combustible surfaces. The combination of an open flame torch and combustible materiaLs presents an increased level of risk even with skilled applicators. The addition of high winds to this combination results in a risk the Board thinks can not be adequately mitigated. An appropriate risk assessment and analysis must be performed on the proposed roofing method to be used on high visibility facilities which represent unique national assets even when using common industry practices for repair and modification. The Board identified three root causes which contributed to or created the proximate cause and, if eliminated or modified, would have prevented the mishap: 1. Combustible materials in existing roof system 2. Wind speed and direction 3. Inadequate fire watch technique. Two contributing factors were identified which may have contributed to the occurrence but, if eliminated or modified, would not have prevented the occurrence: 1. HRI rushed to dry in and seal the roof on January 13 because heavy rain was predicted for the next day 2. No guidance on torching in windy conditions A total of 17 significant observations were noted during this investigation, which could lead to another mishap, or increase the severity of a mishap, but were not contributing factors in this mishap.