REG NASA-LLIS-1718-2004 Lessons Learned - Facilities Installation and Maintenance Records as Government Property.pdf

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1、Lessons Learned Entry: 1718Lesson Info:a71 Lesson Number: 1718a71 Lesson Date: 2004-10-1a71 Submitting Organization: JSCa71 Submitted by: Ron Montaguea71 POC Name: Shelia Powella71 POC Email: shelia.k.powellnasa.gova71 POC Phone: 281-483-3142Subject: Facilities Installation and Maintenance Records a

2、s Government Property Abstract: Loss of maintenance schedules during contract turnover led to omission of panel from inspection schedule, increasing risk.Description of Driving Event: An electrician suffered burns from an electrical arc/blast when a pre-existing condition in a power distribution pan

3、el ultimately led to a ground fault in a 3-phase 480-volt power supply. The pre-existing condition was believed to be an access panel fastener that had penetrated conductor insulation. A contributing factor to this incident was the lack of work access history. This was tracked ultimately to the loss

4、 of maintenance data during support contract turnover. Maintenance schedules and data were not routinely obtained by the Government at contract termination. While JSC has been in existence since the mid-1960s, only the past two and a half years of maintenance history were readily available. The only

5、 record of past testing of the breaker was a test certification sticker from the time of installation ten years before the mishap. Records were not available to indicate preventative maintenance had been performed on this breaker. During a ten-year period, there were two occasions when the cables wo

6、uld have been disconnected from the breaker, so that the main breaker could have been removed for testing. As part of these Two opportunities for maintenance, the incoming cables where the fault occurred would have been recognized and corrected (moved and/or repositioned), increasing the likelihood

7、that any insulation damage would have been prevented. Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Specific transformer maintenance records indicate that five-year preventative maintenance was performed 14 months before the mishap on the primary b

8、uilding transformer. However, there was no work order was issued to perform maintenance on the main breaker of the power distribution panel. Lesson(s) Learned: Key as-built and maintenance records must be generated and managed as Government property.Recommendation(s): 1. Cradle to grave approaches m

9、ust be implemented to ensure that historical maintenance records are accurate and complete. 2. All installation and maintenance documentation should be held in a repository maintained by the contractor and owned by the government. 3. Follow-on contractors must have compatible information systems wit

10、h electronic data transfer capability. Evidence of Recurrence Control Effectiveness: Data is now identified in current and successor contract as government property.Documents Related to Lesson: N/AMission Directorate(s): a71 Space Operationsa71 Sciencea71 Exploration Systemsa71 Aeronautics ResearchA

11、dditional Key Phrase(s): a71 Program Management.a71 Missions and Systems Requirements Definition.a71 Missions and Systems Requirements Definition.Configuration control and data managementa71 Systems Engineering and Analysis.a71 Systems Engineering and Analysis.Long term sustainability and maintenanc

12、e planninga71 Manufacturing and Assemblya71 Safety and Mission Assurance.Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-a71 Safety and Mission Assurance.Early requirements and standards definitiona71 Safety and Mission Assurance.Maintenancea71 Safet

13、y and Mission Assurance.Qualitya71 Additional Categories.a71 Additional Categories.Configuration Managementa71 Additional Categories.Energya71 Additional Categories.Facilitiesa71 Additional Categories.Industrial OperationsAdditional Info: a71 Project: N/AApproval Info: a71 Approval Date: 2006-12-06a71 Approval Name: ghendersona71 Approval Organization: HQProvided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-