REG NASA-LLIS-0588-1998 Lessons Learned Solid Rocket Booster (SRB) Holddown Post Incident.pdf

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1、Lessons Learned Entry: 0588Lesson Info:a71 Lesson Number: 0588a71 Lesson Date: 1998-05-13a71 Submitting Organization: KSCa71 Submitted by: Lisa Grace KestelSubject: Solid Rocket Booster (SRB) Holddown Post Incident Description of Driving Event: On October 8, 1997, a 7,000-pound Solid Rocket Booster

2、Holddown Post (HDP) slid off a forklift while it was being moved up a slight ramp into the low bay of building M7-505 at the Launch Equipment Test Facility (LETF). Neither damage to the holddown post nor injuries to personnel occurred during this near miss.Root Causes:1. Design: The less than optima

3、l design of the shipping/handling pallet and the load restraint configuration of the HDP provided a minimal margin for stability (see figure 1).2. Procedure: The forklift operators lack of attention to the HDP configuration and good forklift operating practices contributed to the unstable conditions

4、.3. Environment: Storage of equipment in the rollup door area hindered the forklifts approach and contributed to the improperly angled entry into the area.Lesson(s) Learned: 1. OSHA standards are inadequate for space operations. Organizations that move very large, heavy, critical, or high-value hard

5、ware/equipment need to review training requirements and adjust certification criteria where appropriate. A standardized set of minimum certification requirements for all KSC operators would be helpful in ensuring a uniform proficiency level.2. Housekeeping requires continuous vigilance. Obstacles ca

6、n cause abnormal maneuvering and/or load shifts that affect stability. The entire path of movement needs to be clear.Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Original Pallet/Handling Configuration for Solid Rocket Booster (SRB) Hold Down Post

7、(HDP)Figure 1. Original Pallet/Handling Configuration Redesigned Pallet/Handling Configuration for Solid Rocket Booster (SRB) Hold Down Post (HDP)Figure 2. Redesigned Pallet Recommendation(s): 1. Shipping/handling pallets and containers for large/bulky items should be designed to provide adequate re

8、straint of a load during movement (see figure 2).2. Adequate procedures/training should be developed for handling critical and high-value ground support equipment and other equipment.3. Operators must maintain situational awareness of the task to be performed, load management factors, and the enviro

9、nment (obstacles, weather, terrain, etc.).4. Supervisors should exercise judgment when assigning tasks. If tasks are hazardous, critical, high value, or new/infrequent, supervisors should assign the task by experience or should provide experienced trainers.5. Organizations that move very large, heav

10、y, critical, or high-value hardware/equipment need to review training requirements and adjust certification criteria where appropriate.6. A standardized set of minimum certification requirements for all KSC operators would be helpful in ensuring a uniform proficiency level.7. Obstacles can cause abn

11、ormal maneuvering and/or load shifts that affect stability. The entire path of movement needs to be clear.Evidence of Recurrence Control Effectiveness: N/ADocuments Related to Lesson: N/AMission Directorate(s): N/AProvided by IHSNot for ResaleNo reproduction or networking permitted without license f

12、rom IHS-,-,-Additional Key Phrase(s): a71 Industrial Operationsa71 Packaging Handling Storagea71 TransportationAdditional Info: Approval Info: a71 Approval Date: 1998-05-28a71 Approval Name: David Barkera71 Approval Organization: EI-F-Aa71 Approval Phone Number: 407-867-6563Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-