REG NASA-LLIS-1186--1992 Lessons Learned - Railroad Maintenance Contractor Boom Crane Mishap Investigation Team Report of April 9 1992.pdf

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1、Lessons Learned Entry: 1186Lesson Info:a71 Lesson Number: 1186a71 Lesson Date: 1992-04-09a71 Submitting Organization: KSCa71 Submitted by: W.A. Holden/Eric RaynorSubject: Railroad Maintenance Contractor Boom Crane Mishap Investigation Team Report of April 9, 1992 Description of Driving Event: On Feb

2、ruary 25, 1992, at approximately 0930 hours, two NASA contractor employees had been instructed by their foreman to proceed to the Locomotive Maintenance Facility, K6-1844, area to pick up four railroad switch plate kits and take them to the Wilson comer area. The two employees proceeded to load the

3、kits, which were in palletized crates, using a National N-45 articulating boom crane mounted on the rear of a 1978 Ford truck. One of the employees operated the crane from the operator position atop the crane mast. This same employee loaded one crate into the forward area of the truck bed and while

4、loading the second crate, the crane broke at the welded interface between the rotating turret and upright mast. Upon failing, the crane boom fell, throwing the operator to the ground. As the operator was thrown to the ground and away from the crane, he/she landed on his/her right leg causing it to b

5、reak.When the mishap occurred, the other, uninjured employee ran to the Maintenance Facility Office area and asked personnel inside to call for help. He/she then returned to assist the injured employee. Emergency personnel stabilized the injured employee and transported him/her to the hospital.Lesso

6、n(s) Learned: It is the opinion of this mishap investigation team that the primary cause of this mishap was structural failure of the crane at the turret/mast interface, most probably due to fatigue cracking of the welded area in question. This area had cracked at some previous time and there is evi

7、dence of continued crack generation resulting in diminished load lifting capability of the crane. When the switch plate kits were loaded, their weight would not normally have exceeded the lifting capacity of the unit but did exceed its diminished capability. The result was a catastrophic failure lea

8、ding to personnel injury and equipment damage.Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Contributing to the failure cause was possible momentary overloading of the crane. No data was discovered that indicated the crane had been overloaded and i

9、n fact, the design of the hydraulic system precludes that from happening. No evidence was found, however, of operator training beyond on-the-job experience and that lack of proper training could have resulted in poor operating technique imparting momentary loads well in excess of crane capability, s

10、etting up a progressive fatigue cracking mechanism. The weld area in question had cracked at some time prior to this failure and there was evidence of attempts to repair cracks. The workmanship of this repair was extremely poor and failed to correct the problem. The fatigue cracking continued to pro

11、gress to the point of failure.Also noted during this investigation were deficiencies in meeting contractual and OSHA/ANSI requirements. No evidence was found of daily, weekly, or monthly safety inspections of the equipment or contractually required safety reports. No evidence was found of an annual

12、inspection for safety and operability. No evidence was found that the operators had received any training beyond on-the-job instruction on operation of the unit. The injured employee was to be transported to the hospital by a NASA helicopter but this wasnt done due to a lack of proper transport capa

13、bility of the helicopter.Recommendation(s): 1. Insure all operators of lifting equipment are properly trained to applicable standards.2. Insure all weld repairs on lifting equipment are accomplished per applicable standards by certified welders.3. This equipment and other lifting equipment should un

14、dergo regularly scheduled inspections and maintenance to insure safe operation.4. Ensure that the director of Safety, Reliability, and Quality Assurance is made aware of all contracts and contractors on KSC property so the appropriate safety surveillance can be exercised.5. The contract manager and

15、contracting officer should insure that all safety related reports and plans be delivered per contract.6. Insure that all helicopters are properly outfitted to transport patients.Evidence of Recurrence Control Effectiveness: N/ADocuments Related to Lesson: N/AMission Directorate(s): Provided by IHSNo

16、t for ResaleNo reproduction or networking permitted without license from IHS-,-,-a71 Space Operationsa71 Exploration SystemsAdditional Key Phrase(s): a71 Emergency Preparednessa71 Facilitiesa71 Ground Equipmenta71 Ground Operationsa71 Hardwarea71 Human Factorsa71 Human Resources & Educationa71 Indus

17、trial Operationsa71 Lifting Devicesa71 Medicala71 Mishap Reportinga71 Packaging Handling Storagea71 Procurement Small Business & Industrial Relationsa71 Training Equipmenta71 TransportationMishap Report References: Railroad Maintenance Contractor Boom Crane Mishap Investigation Team Report of April 9, 1992Additional Info: Approval Info: a71 Approval Date: 2002-05-06a71 Approval Name: Gena Bakera71 Approval Organization: KSCa71 Approval Phone Number: 321-867-4261Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-