REG NASA-LLIS-0495-1983 Lessons Learned - Systems Engineering System Safety and R&QA Program Integration Operational Safety and Performance Risk Management and Facility Safety Insp.pdf

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1、Lessons Learned Entry: 0495Lesson Info:a71 Lesson Number: 0495a71 Lesson Date: 1983-02-28a71 Submitting Organization: ARCa71 Submitted by: Ken ZanderSubject: Systems Engineering, System Safety and R&QA Program Integration, Operational Safety and Performance, Risk Management, and Facility Safety Insp

2、ections Description of Driving Event: December 9, 1982, the 80 x 120 foot wind tunnel at the Ames Research Center was undergoing commissioning/shakedown testing when Vane Set 5 collapsed destroying the vane set, the fan blades of all six drive motors, and damaging the tunnel itself.Lesson(s) Learned

3、 1. Procedures for effective systems engineering on safety issues are lacking.2. System safety and R&QA omitted for project design decisions results in design deficiencies and possibly manufacturing defects affecting safety.3. The user/operator community does not understand the design constraints o

4、n the system imposed by issues of safety and risk management.4. Cost control does influence performance, safety and reliability.5. Modifications to facility design contained specific configurations that serve to abate previous safety inspection hazards.Recommendation(s): 1. Define procedures to ensu

5、re effective systems engineering.2. Assign review and approval authority to system safety and R&QA on project design decisions.3. Involve the user/operator community in the design decision process regarding safety and operational safety issues.4. Institute cost control systems for safety and reliabi

6、lity.5. Check all aspects of facility design construction and operation against modification.Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Evidence of Recurrence Control Effectiveness: N/ADocuments Related to Lesson: N/AMission Directorate(s): N/AA

7、dditional Key Phrase(s): a71 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-,-,-