REG NASA-LLIS-0914-2000 Lessons Learned Genesis Canister Lift Incident (2000).pdf

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1、Lessons Learned Entry: 0914Lesson Info:a71 Lesson Number: 0914a71 Lesson Date: 2000-07-20a71 Submitting Organization: JPLa71 Submitted by: Ron Welch/David OberhettingerSubject: Genesis Canister Lift Incident (2000) Abstract: Genesis: In 2000 the Genesis canister detached from a lift fixture fitting

2、just prior to system-level thermal vacuum testing. Fabrication or test organizations should inspect all MGSE for fastener engagement and specified torque prior to delivery for use by a project. Where feasible, threaded components that are to be placed under tension should be designed with a positive

3、 locking device. Flight projects should conduct and document visual and physical inspections of MGSE prior to use. Personnel safety should be addressed, as appropriate, by all procedures. In addition, all test personnel should constantly remain at a safe distance during operations involving suspende

4、d loads.Description of Driving Event: JPL has responsibility for the development, integration, and testing of the payload (including the canister and collector arrays) for the Genesis Project, a mission to collect solar wind particles and return them to Earth. While the Genesis canister was being li

5、fted from the transportation dolly at JPL in preparation for system-level thermal vacuum testing on May 3, 2000, the lift fixture detached at one of the three swivel hoist ring tension fittings.Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-refer to

6、 D descriptionDPrior to mounting on the test chamber door, one corner of the canister fell 5 centimeters (2 inches) back onto the dolly. Nearby personnel cushioned the fall, and there was no damage to the Canister or support equipment, or serious injury to personnel. Post-incident inspection reveale

7、d that the threaded fastener had backed out of the fixture and became detached. Additionally, the fasteners at the other tension fittings, and at the upper hoist point, were found only hand-tight.The lift fixture assembly had been proof tested 8 months earlier. The fixture had been reassembled by th

8、e vendor following the proof test and dye penetrant inspection of the swivel hoist fittings. The fixture had last been used to lift the Canister two days prior to this incident. The fixture was visually inspected prior to the May 3, 2000 lift incident, but the hoist rings were not checked for tightn

9、ess. There is no evidence that the hoist ring fasteners had been properly torqued since the proof test. The procedure governing the canister lift operation (Reference 2) did not require adequate checking of all fasteners prior to attaching the fixture to the hoist.Reference(s):1. Jet Propulsion Labo

10、ratory Problem/Failure Report No. Z69149, May 3, 20002. JPL Assembly and Inspection Data Sheet (AIDS) No. 216421, May 2, 20003. JPL QA Procedure QAP 61.5, “QA Inspections of MGSE Used on JCIs.“Lesson(s) Learned: For mechanical ground support equipment (MGSE), never assume that visual inspections alo

11、ne will assure both flight equipment and personnel safety. Additional Key Words: Nondestructive Inspection, NDI, Crane, Lift Procedure, Quality Assurance, Test Procedures, Mechanical Integration, System Integration and Test, System Safety, Industrial SafetyProvided by IHSNot for ResaleNo reproductio

12、n or networking permitted without license from IHS-,-,-Recommendation(s): 1. The fabrication or test organization should thoroughly inspect all MGSE for fastener engagement and specified torque prior to delivery for use by a project. Where feasible, threaded components that are to be placed under te

13、nsion should be designed with a positive locking device. Otherwise, fastener heads should be spot bonded or torque-striped, as appropriate, to enhance visual inspection of thread engagement.2. Flight projects should also conduct thorough visual and physical inspections of MGSE prior to each individu

14、al use (Reference 3). These inspections should be documented in appropriate procedures, such as JPL Assembly and Inspection Data Sheets (AIDS) for lifting critical hardware.3. Personnel safety should be addressed, as appropriate, by all procedures. In addition, all test personnel should constantly r

15、emain at a safe distance during operations involving suspended loads.Evidence of Recurrence Control Effectiveness: A JPL Corrective Action Notice will be assigned and practices will be modified as appropriate.Documents Related to Lesson: N/AMission Directorate(s): a71 ScienceAdditional Key Phrase(s)

16、: a71 Ground Equipmenta71 Hardwarea71 Lifting Devicesa71 Packaging Handling Storagea71 Safety & Mission Assurancea71 Test FacilityAdditional Info: Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Approval Info: a71 Approval Date: 2000-10-20a71 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-,-,-