scope:

Description of Driving Event:

A Hypergol technician erred in the removal of a temperature transducer from a 3-inch Hypergol line at the pad "A" fuel farm, resulting in a major fuel spill. The installation design of the dry well and temperature transducer provide a means to remove the transducer from the system for replacement or calibration without having to open the fluid volume. The dry well installation design is inadequate to preclude an untrained or careless technician from inadvertently removing the dry well from the Hypergol propellant line by mistake.

Additional Comments:

OMI V2196 Titled: "Hyper Fuel System Validation Storage Area-Local Control/LPS" has been updated to include the following warning: "Removing transducers from dry wells may be hazardous. A restaining retainer is designed to prevent removal of dry well while secured in place by set screws. As transducers are being removed from dry wells, PMTG shall visually verify that dry wells are not turning. Wear face shield, apron and rubber gloves and use extreme care to avoid inadvertent loosening of any temperature XDCR dry well, which could release MMH liquid. If A78633 TEMP XDCR dry well is loosened the entire storage tank contents could be released."