REG NASA-LLIS-0923-2000 Lessons Learned - Quick Release Pin Causes Shuttle Launch Scrub.pdf

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1、Lessons Learned Entry: 0923Lesson Info:a71 Lesson Number: 0923a71 Lesson Date: 2000-11-28a71 Submitting Organization: KSCa71 Submitted by: Charles G. StevensonSubject: Quick Release Pin Causes Shuttle Launch Scrub Description of Driving Event: On 10 October 2000, during the STS-92 launch countdown T

2、-3 hour Final Inspection, a 4-inch long and 3/16-inch diameter “T-handle“ Quick Release Pin (QRP) and tether were discovered laying between the External Tank (ET) LO2 Feedline and the in-board Feedline Support Bracket.Provided by IHSNot for ResaleNo reproduction or networking permitted without licen

3、se from IHS-,-,-Quick Release Pin (QRP) with tether laying between ET LO2 Feedline and In-board Feedline Support BracketPhoto 1 - Quick Release Pin found on inboard side of the ET LO2 Feedline support bracketThe inspection team was unable to retrieve the QRP. The launch team was notified and launch

4、was scrubbed at T-20 minutes. Removal of the QRP and tether was completed at 0226 hours on 11 Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-October 2000. The QRP had only caused minor damage to the LO2 Feedline Support Bracket foam insulation. STS-

5、92, the 100th Space Shuttle Mission, was launched successfully at 1917 hours on 11 October 2000.During a follow-up investigative walkdowns of the Vehicle Assembly Building (VAB) and Pad A, a VAB High Bay (HB) 3 “B Roof“ kickplate attachment for platform F-9 was discovered to be missing a 3/16-inch d

6、iameter QRP. The F-9 platform is located 73.6 feet directly above the found QRPs resting location on the LO2 Feedline Support Bracket.Removed QRP w/tether evidenceProvided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Photo 2 - 2VAB HB-3 Integration Cell Pl

7、atform configuration in relation to pin locationThe kickplate was routed to the Malfunction Lab on 16 October 2000 and the Lab confirmed a match between the paint over spray found on the QRPs T-handle and the paint on the kickplate.The Investigative Board concluded that the QRP most likely fell just

8、 prior to or during the “B Roof“ Level F-9 platform retraction, which occurred approximately 3 hours after the pre-rollout inspection of the D-2 Level platform. The parallel task sequencing, of the platform inspections and retractions, was not constrained by current procedures.Lesson(s) Learned: 1.

9、Maintenance practices, for the proper use, stowage, inspection and repair of QRPs and tethers, were not conveyed, monitored, or reinforced.2. Previously assigned QRP and tether corrective actions were not implemented.3. The VAB HB-3 “B Roof“ F-9 platform modifications final acceptance inspection fai

10、led to detect the kickplates tether was not installed per the drawing, nor did the inspection identify the incorrect swage on the end of the tether.4. The approved procedural task sequencing for inspections and platform retractions set up the conditions that permitted the QRP to fall and remain unde

11、tected in the VAB.Recommendation(s): 1. Standardize QRP and tether maintenance procedures across processing facilities.2. Add “maintenance practices“ (in general) and QRPs and tethers (specifically) to first line managements Site Safety Observation Checklists, to ensure QRPs are stowed correctly, as

12、 well as to ensure maintenance inspection and repair tasks are effectively completed.3. Charter a cross-functional team to assess the current status of the facility maintenance program and identify areas of improvement needed to enhance maintenance effectiveness.4. Develop an Internet Based training

13、 course that emphasizes the expectations for achieving a “Level of Excellence“ for maintenance practices. As a minimum, course content should address the proper use, stowage, inspection, maintenance and repair of QRPs and tethers.5. Corrective Action Engineering should review, and correct as needed,

14、 their in-house recurrence control identification process.6. Revise and standardize final inspection acceptance criteria sheets, to verify the as-built configuration matches the released engineering design.7. Eliminate/minimize the handling risk associated with the current design of the F-9 kickplat

15、e. Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Modify the F-9 kickplate, as needed, in order to attach it permanently to the F-9 flip platform. Identify any other kickplates being used in the processing facilities that present a similar handling

16、risk.8. Revise the pre-VAB rollout inspection. Procedure should constrain task sequencing to ensure upper level platforms are verified retracted, prior to performing lower level platform inspections.9. Revise the External Tank Pre-Launch inspection to add more detailed inspection criteria.For more d

17、etailed information refer to the Formal Accident Investigation Board Report: Quick Release Pin - Launch Delay STS-92/OV-103/PAD A.Evidence of Recurrence Control Effectiveness: N/ADocuments Related to Lesson: N/AMission Directorate(s): a71 Exploration Systemsa71 Sciencea71 Space Operationsa71 Aeronau

18、tics ResearchAdditional Key Phrase(s): a71 Aircrafta71 Configuration Managementa71 Facilitiesa71 Flight Operationsa71 Flight Equipmenta71 Ground Operationsa71 Ground Equipmenta71 Hardwarea71 Human Factorsa71 Industrial Operationsa71 Launch Processa71 Launch Vehiclea71 Lifting Devicesa71 LogisticsPro

19、vided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-a71 Packaging Handling Storagea71 Parts Materials & Processesa71 Payloadsa71 Research & Developmenta71 Risk Management/Assessmenta71 Safety & Mission Assurancea71 Spacecrafta71 Test Facilitya71 Training EquipmentAdditional Info: Approval Info: a71 Approval Date: 2001-01-10a71 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-,-,-