scope:

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 policies. Also recommended was increased training of personnel to include these improvements.