REG NASA-LLIS-1227-1999 Lessons Learned - Adequacy of multiple checkpoints to ensure correct installation.pdf

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1、Lessons Learned Entry: 1227Lesson Info:a71 Lesson Number: 1227a71 Lesson Date: 1999-06-03a71 Submitting Organization: JSCa71 Submitted by: Kate Rupley/ Ronald A. MontagueSubject: Adequacy of multiple checkpoints to ensure correct installation Description of Driving Event: A manufacturing engineer fo

2、und that sixteen fasteners were not installed on Flight Wing 1 (Solar Array Assembly) two (2) days prior to shipment. Investigation revealed deficiencies and/or breakdowns in several discrete process.Root cause: 1. Engineering design error; fastener was too short.2. Failure to adhere to manufacturin

3、g control processes: a. Fasteners were not installed and informal notification of fastener size error was done in lieu of formal discrepancy report (DR) documenting incorrect fastener size and lack of fastener installation.b. Inspection/Manufacturing failure to verify completion of operation at docu

4、mentation buyoff (Inspection buyoff indicated bolts were installed, but bolts were not actually installed). Operation had Operator the design change adoption process was not followed. When an engineering change initiated to correct the fastener size was processed, planner did not flow the change dow

5、n to the initial assembly, only subsequent assemblies.5. Subsequent Engineering/Manufacturing/Quality Assurance hardware reviews (“shakes“) failed to identify missing bolts: “Shakedown“ verification process inadequate.Provided by IHSNot for ResaleNo reproduction or networking permitted without licen

6、se from IHS-,-,-Lesson(s) Learned: All multiple controls in the design, manufacture, and inspect sequence must be effective to ensure the acceptability of end productsRecommendation(s): An all hands meeting was conducted with planning staff, technicians, and inspectors. 1. Adherence to process/proce

7、dures was re-emphasized;2. Implemented a weekly documentation review for process compliance;3. Improved “shakedown“ inspection process and checklist was developed and implemented;4. Product Assurance performed a procedure review, clarification, and personnel training to ensure process compliance;5.

8、Conducted thorough process review of engineering change implementation to ensure process is adequate;6. Added requirement for a dry-fit check where critical thermal interfaces depend on a specific level of clamping force;7. Reviewed drawing standards with personnel to address the proper use of redli

9、ne drawings.8. Confirmed that during the fabrication, assembly and test operations, processes are in place to identify defects and/or deficiencies that are identified by non-conformance reports. These are evaluated and dispositions determined by Engineering, processed through the Material Review Boa

10、rd (MRB), and finally sold off to inspection during assembly.Evidence of Recurrence Control Effectiveness: N/ADocuments Related to Lesson: N/AMission Directorate(s): N/AAdditional Key Phrase(s): a71 Computer-Aided Design/Manufacturing/Engineeringa71 Configuration Managementa71 Flight EquipmentProvid

11、ed by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-a71 Ground Equipmenta71 Hardwarea71 Parts Materials & Processesa71 Policy & Planninga71 Procurement Small Business & Industrial Relationsa71 Risk Management/Assessmenta71 Safety & Mission Assurancea71 Softwarea71 Test & VerificationAdditional Info: Approval Info: a71 Approval Date: 2002-06-27a71 Approval Name: Ronald A. Montaguea71 Approval Organization: JSCa71 Approval Phone Number: 281-483-8576Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-