REG NASA-LLIS-0494-1989 Lessons Learned - Verification of Baseline Configuration before Modification Upkeep of Maintenance and Operational Logs Operation Condition Effects Upkeep D.pdf

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1、Lessons Learned Entry: 0494Lesson Info:a71 Lesson Number: 0494a71 Lesson Date: 1989-05-05a71 Submitting Organization: ARCa71 Submitted by: Mike Shovlin, Ken ZanderSubject: Verification of Baseline Configuration before Modification, Upkeep of Maintenance and Operational Logs, Operation Condition Effe

2、cts, Upkeep Documentation, Safety System Checks Description of Driving Event: On January 25, 1984, the National Geotechnical Centrifuge, located at NASA Ames Research Center, experienced a catastrophic failure of the 18,000 horsepower drive motor thrust bearing. The failure permitted the 100 ton dri

3、ve motor armature to drop, the centrifuge to stop, and resulted in extensive electrical and mechanical damage. Repairs may take one year, and cost estimated at $550,000.Lesson(s) Learned: 1. Configuration must be baselined and accepted before modification to understand design, identify all necessary

4、 changes, assess effects on whole.2. Incomplete data recording and maintenance of operational logs resulted in incomplete determination of effects.3. Abnormal operating conditions producing effects that are unanticipated or can not be explained should be investigated prior to continuing testing.4. R

5、eview of documentation found errors or deficiencies on operational and maintenance logs.5. Safety equipment should be used prior to any test or review for safety of operation, adequate warning, and/or understanding of operation.Recommendation(s): 1. Ensure that the configuration is defined and verif

6、ied before modifying.2. Document adherence to operating procedures with defined procedures for data recording of maintenance and operational logs.3. Test for abnormal operating conditions and determine rational for results before proceeding.Provided by IHSNot for ResaleNo reproduction or networking

7、permitted without license from IHS-,-,-4. Define procedures for keeping reference documentation current, and complete.5. Investigate procedures: Check performance of safety equipment prior to installation (note procedures for Safe Operation, Shut Down, and Alarm).Evidence of Recurrence Control Effec

8、tiveness: N/ADocuments Related to Lesson: N/AMission Directorate(s): N/AAdditional Key Phrase(s): a71 Configuration Managementa71 Logisticsa71 Safety & Mission Assurancea71 Test FacilityAdditional Info: Approval Info: a71 Approval Date: 1997-03-10a71 Approval Name: Anthony Bricenoa71 Approval Organization: N244-30a71 Approval Phone Number: 415-604-1012Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-