REG NASA-LLIS-0873-2000 Lessons Learned Use of Detailed Procedures on Critical Equipment.pdf

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1、Lessons Learned Entry: 0873Lesson Info:a71 Lesson Number: 0873a71 Lesson Date: 2000-02-29a71 Submitting Organization: JSCa71 Submitted by: Larry GreggSubject: Use of Detailed Procedures on Critical Equipment Description of Driving Event: On May 16, 1994, an AMDAHL 5995M mainframe computer overheated

2、 at approximately 8:20 AM in the Software Production Facility (SPF) in Building 30 at JSC. Physical damage to the computer due to this overheat was estimated at $669,000. This overheat occurred due to an inadvertent miswiring of a circuit breaker after a routine power outage and maintenance of the b

3、reaker. The quality inspection failed to check for the proper rewiring of the circuit breaker. The miswiring caused a phase rotation of the power, which in turn caused fans cooling the AMDAHL 2550 to turn backwards. Power isolation and monitoring equipment that could have prevented any impact from t

4、he phase rotation was not properly utilized. This led to insufficient cooling of the AMDAHL 2550 which resulted in the overheat and subsequent damage.Lesson(s) Learned: All work on critical equipment and its supporting interfaces (e.g., power, cooling) should follow clearly written, detailed procedu

5、res that are understood by all personnel who operate or work with that equipment.Recommendation(s): Detailed procedures should be developed and used; and operations and maintenance personnel should be trained in power-up and power-down procedures.Evidence of Recurrence Control Effectiveness: N/AProv

6、ided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Documents Related to Lesson: N/AMission Directorate(s): a71 Exploration Systemsa71 Sciencea71 Space Operationsa71 Aeronautics ResearchAdditional Key Phrase(s): a71 Communication Systemsa71 Computersa71 Conf

7、iguration Managementa71 Environmenta71 Energya71 Facilitiesa71 Ground Operationsa71 Ground Equipmenta71 Hardwarea71 Industrial Operationsa71 Information Technology/Systemsa71 Parts Materials & Processesa71 Spacecrafta71 Test Articlea71 Test Facilitya71 Test & VerificationAdditional Info: Approval Info: a71 Approval Date: 2000-04-11a71 Approval Name: Eric Raynora71 Approval Organization: QSa71 Approval Phone Number: 202-358-4738Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-