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|
Attributes | |
ACN | 391246 |
Time | |
Date | 199712 |
Day | Sat |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | atc facility : dca |
State Reference | DC |
Person 1 | |
Affiliation | government : faa |
Function | other personnel other |
Qualification | other |
ASRS Report | 391246 |
Person 2 | |
Affiliation | government : faa |
Function | oversight : supervisor |
Qualification | other |
Events | |
Anomaly | non adherence : published procedure other anomaly other |
Independent Detector | other other : unspecified |
Resolutory Action | none taken : unable |
Consequence | Other |
Supplementary | |
Air Traffic Incident | other |
Narrative:
On dec/xx/97, the dca AFSS fire alarm sounded in response to smoke described as 'like thick fog' by several employees, and noxious, choking fumes in the operations greater area. Management response was in violation of dcaa order 3900.2A (dated nov/xx/93) 5A (1 through 5) and/or 5B (4, 5). With sight and smell evidence of smoke, the alarm was first silenced, no evacuate/evacuation was made of personnel, and no calls were made by management to the fire department or other institutions as mandated. Multiple instances of similar actions (12/X-Z/97) have established an informal modus operandi of action in violation of dcaa 3900.2A, shaped and reinforced by consistent expressions by both atm and aatm informally authorizing the above actions. Supervisors, with evident fire and/or smoke, are instructed to determine the proximal suspected or likely cause of the fire alarm activation (although not trained in fire detection) -- using a 'common sense, good judgement' approach -- and further to terminate the incident based on their judgement of hazard without evacing personnel or summoning the fire department for a full building check as mandated by dcaa 3900.2A. Proposed solution: dcaa 3900.2A should be adhered to fully, formally and informally, with the primary, overriding and sole directive, when smoke and/or fire are evident, to both employees and management to evacuate/evacuation the building and call the fire department for a full building check by trained fire fighters (in addition to other mandated actions in dcaa 3900.2A). Alarms must not be silenced by facility personnel with evidence of smoke and/or fire. Both the atm and the aatm need to clearly express to management and employees their authority/authorized of only those actions delineated in dcaa 3900.2A, explicitly reversing their (current) expressed variance from dcaa 3900.2A. Only this consistent step will change the informal 'corporate culture' which now prioritizes continued operation above failsafe, automatic measures to protect employees.
Original NASA ASRS Text
Title: A FLT SVC STATION SPECIALIST COMPLAINS ABOUT SUPERVISORY PERSONNEL NOT EVACING THE FSS BUILDING WHEN THE FIRE ALARM SOUNDED DUE TO SMOKE AND FUMES.
Narrative: ON DEC/XX/97, THE DCA AFSS FIRE ALARM SOUNDED IN RESPONSE TO SMOKE DESCRIBED AS 'LIKE THICK FOG' BY SEVERAL EMPLOYEES, AND NOXIOUS, CHOKING FUMES IN THE OPS GREATER AREA. MGMNT RESPONSE WAS IN VIOLATION OF DCAA ORDER 3900.2A (DATED NOV/XX/93) 5A (1 THROUGH 5) AND/OR 5B (4, 5). WITH SIGHT AND SMELL EVIDENCE OF SMOKE, THE ALARM WAS FIRST SILENCED, NO EVAC WAS MADE OF PERSONNEL, AND NO CALLS WERE MADE BY MGMNT TO THE FIRE DEPT OR OTHER INSTITUTIONS AS MANDATED. MULTIPLE INSTANCES OF SIMILAR ACTIONS (12/X-Z/97) HAVE ESTABLISHED AN INFORMAL MODUS OPERANDI OF ACTION IN VIOLATION OF DCAA 3900.2A, SHAPED AND REINFORCED BY CONSISTENT EXPRESSIONS BY BOTH ATM AND AATM INFORMALLY AUTHORIZING THE ABOVE ACTIONS. SUPVRS, WITH EVIDENT FIRE AND/OR SMOKE, ARE INSTRUCTED TO DETERMINE THE PROXIMAL SUSPECTED OR LIKELY CAUSE OF THE FIRE ALARM ACTIVATION (ALTHOUGH NOT TRAINED IN FIRE DETECTION) -- USING A 'COMMON SENSE, GOOD JUDGEMENT' APCH -- AND FURTHER TO TERMINATE THE INCIDENT BASED ON THEIR JUDGEMENT OF HAZARD WITHOUT EVACING PERSONNEL OR SUMMONING THE FIRE DEPT FOR A FULL BUILDING CHK AS MANDATED BY DCAA 3900.2A. PROPOSED SOLUTION: DCAA 3900.2A SHOULD BE ADHERED TO FULLY, FORMALLY AND INFORMALLY, WITH THE PRIMARY, OVERRIDING AND SOLE DIRECTIVE, WHEN SMOKE AND/OR FIRE ARE EVIDENT, TO BOTH EMPLOYEES AND MGMNT TO EVAC THE BUILDING AND CALL THE FIRE DEPT FOR A FULL BUILDING CHK BY TRAINED FIRE FIGHTERS (IN ADDITION TO OTHER MANDATED ACTIONS IN DCAA 3900.2A). ALARMS MUST NOT BE SILENCED BY FACILITY PERSONNEL WITH EVIDENCE OF SMOKE AND/OR FIRE. BOTH THE ATM AND THE AATM NEED TO CLEARLY EXPRESS TO MGMNT AND EMPLOYEES THEIR AUTH OF ONLY THOSE ACTIONS DELINEATED IN DCAA 3900.2A, EXPLICITLY REVERSING THEIR (CURRENT) EXPRESSED VARIANCE FROM DCAA 3900.2A. ONLY THIS CONSISTENT STEP WILL CHANGE THE INFORMAL 'CORPORATE CULTURE' WHICH NOW PRIORITIZES CONTINUED OP ABOVE FAILSAFE, AUTOMATIC MEASURES TO PROTECT EMPLOYEES.
Data retrieved from NASA's ASRS site as of July 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.