REG NASA-LLIS-1338--2002 Lessons Learned - Stennis Space Center Near-Miss Ground Support Equipment.pdf

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1、Lessons Learned Entry: 1338Lesson Info:a71 Lesson Number: 1338a71 Lesson Date: 2002-04-15a71 Submitting Organization: SSCa71 Submitted by: Michael E. McDaniel, Boeing-SSC Manager S&MASubject: Stennis Space Center Near-Miss/Ground Support Equipment Description of Driving Event: On Monday, April 15, 2

2、002 at approximately 5:45 PM the following incident occurred on the Stennis Space Center A1 test stand, level 5 upper engine work deck.Subsequent to the removal and replacement of a High Pressure Fuel Pump the upper engine deck extension piece was rolled away from the main upper engine deck with the

3、 pump lifting/handling device still on the upper engine deck extension piece. The pump lifting device fell off the upper engine deck pinning a quality inspector between it and the upper engine deck handrail. The arm of the pump lifting/handling device was moved enough for the employee to be moved aw

4、ay and the deck was cleared. The device was secured in the as-rested position and the deck was cordoned off. The employee was able to walk on his own to inside the test stand. The employee was transported to a local hospital for an examination as a precaution. Photographs were taken of the area and

5、equipment involved (contact Michael McDaniel, 228-688-2233).An investigation/preventive action team was formed by management on the morning of Tuesday, April 16, 2002 to investigate, find the root cause, and make corrective action recommendations.The A1 test stand had been recently reconfigured from

6、 a previous test program to a different test program after a 5 year period. The test team had moved from the A2 test stand to the A1 test stand. The test team did not feel this was a factor due to the similarities between the two test stands. The normal configuration for all pump removals is to use

7、a roll-around work deck extension piece secured to the main work deck via turnbuckles.Lesson(s) Learned: The extension deck mover left the main engine deck and proceeded to the position of the secured Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-e

8、xtension deck that was put in place for the pump installation job. He then, by himself, pushed the GSE to a position he thought was off the extension deck platform. He could not see the GSE because an orange tarp used for weather and FOD protection was blocking his view of not only the GSE position,

9、 but also the main deck. He told the team he thought the GSE was off the extension deck because he felt a bump which he believed to be the GSE rolling onto the main deck from the extension deck. The technician did not verify that the GSE was actually on the main deck. At this time he loosened and re

10、leased the two turnbuckles located on either side of the extension deck. As the extension deck moved the GSE tilted off the main deck pinning the other employees back against the arm of the GSE and his abdomen against the west main deck handrail. The injured employee sustained contusions below both

11、knees, hip area and lower back. (No bone fractures or internal injuries). He reported to work at his normal shift start time after being cleared for full duty (no restrictions) by the SSC medical clinic.Recommendation(s): Hardware: Modify handrail sections of main deck at each corner location (4) so

12、 they can be installed while the work deck extension are in place and secured. Add/modify brakes/locks to all GSE tooling with wheels. Add sign to all rolling GSE units to ensure break/lock engaged when not in use Procedure Revise planning/work authorization documents with the following: Always veri

13、fy movement of equipment visually. Remove any visual obstructions prior to movement of mobile equipment. Secure GSE with brake/lock when staging/storing. Install handrails prior to movement of equipment on elevated decks. Review this incident with all Team members at workmanship/Safety meetings. Imp

14、lement the use of pre-move/lift checklist. Evidence of Recurrence Control Effectiveness: Effectiveness reviewed from 4/16/02 through 8/31/02 resulted in no recurrence of similar incident.Documents Related to Lesson: N/AMission Directorate(s): N/AAdditional Key Phrase(s): a71 Ground Equipmenta71 Grou

15、nd Operationsa71 Human Factorsa71 Occupational HealthProvided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-a71 Policy & Planninga71 Test FacilityAdditional Info: Approval Info: a71 Approval Date: 2003-06-26a71 Approval Name: Buddy Newbolda71 Approval Organization: SSCa71 Approval Phone Number: 228-688-3152Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-