REG NASA-LLIS-1260-2002 Lessons Learned - Discipline Rigor in Routine Processes.pdf

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1、Lessons Learned Entry: 1260Lesson Info:a71 Lesson Number: 1260a71 Lesson Date: 2002-07-09a71 Submitting Organization: JSCa71 Submitted by: Randy Willhite/ Ronald A. MontagueSubject: Discipline Rigor in Routine Processes Description of Driving Event: On 24 April 2002, 7:35 a.m. (CST) two employees, w

2、orking in a Clean Room configured for glass inspection and assembly, were rotating a Flight Cupola Trapezoidal Debris Pane as part of a planned event to setup for the final glass inspection prior to assembling the pane into the frame. During the rotation, the glass made contact with the aluminum tab

3、le which caused a shatter mark internal to the glass, approximately .300“ X .500“ at the edge. The incident was reported to the Quality Assurance and S&MA managers and all glass handling activities in the shop was suspended pending a detailed investigation and corrective action. DCMA was en route to

4、 the inspection room when the incident occurred. Non-Conformance #17817 was also initiated to document the incident. Lesson Foundation/Root Cause: The following were determined to be the root causes of the glass damage incident and suggested areas for improvements: a71 The glass teetered on the foam

5、 blocks used to support the glass during rotation causing the corner of the cupola glass Trapezoidal debris pane to impact the table. Improvements to the foam blocks used for the rotation and other glass shop aids need to be implemented.a71 The impact of the glass on the anodized aluminum table surf

6、ace caused the glass damage. Softer materials for the glass work surfaces need to be evaluated.a71 There was a miscommunication between the 2 technicians handling the glass and what to do with the corner blocks. Improved methods of communication between the glass handlers and the task leaders need t

7、o be evaluated.Lesson(s) Learned: Simple processes involving costly flight equipment still require sufficient process control discipline to preclude loss Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Recommendation(s): The following recommendations

8、 and corrective actions were established as a result of this incident: 1. Permanently affix fluorescent light fixture to inspection table.2. Remove micrometer guide rails from inspection table.3. Use six (6) foam blocks for both round and trapezoidal shaped glass. Space blocks evenly around round pa

9、ne. For trapezoidal glass, one block at each corner and one block at the center of top (short side) and bottom (long side) edges.4. Use improved rotation aid and continue to pursue improved tools and shop aids for all operations.5. Implement improved black, corrugated, polypropylene surface on the i

10、nspection table to provide a surface that wont damage the glass on impact.6. Rotate glass certified inspectors after every 2 or 3 glass pane inspections (dependent on complexity of inspections).7. Provide an overhead support system that allows attachment of “black light“. Attachment of light to supp

11、ort system should be away from glass area.8. Provide means to transfer light directly over glass. Support should allow the inspector to let go of light and not impact glass.Evidence of Recurrence Control Effectiveness: N/ADocuments Related to Lesson: N/AMission Directorate(s): a71 Exploration System

12、sa71 Sciencea71 Space Operationsa71 Aeronautics ResearchAdditional Key Phrase(s): a71 Configuration Managementa71 Flight Equipmenta71 Flight Operationsa71 Ground Equipmenta71 Ground OperationsProvided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-a71 Hardwa

13、rea71 Industrial Operationsa71 Parts Materials & Processesa71 Risk Management/Assessmenta71 Test & VerificationAdditional Info: Approval Info: a71 Approval Date: 2002-07-15a71 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-,-,-