REG NASA-LLIS-0048-1991 Lessons Learned - System Component Identification Tagging.pdf

1、Lessons Learned Entry: 0048Lesson Info:a71 Lesson Number: 0048a71 Lesson Date: 1991-12-20a71 Submitting Organization: KSCa71 Submitted by: David PenningtonSubject: System Component Identification Tagging Description of Driving Event: The Firex system components at the VPF are missing numerous identi

2、fication/find number tags. These are used to identify components in procedures and work authorization documents when opening, closing and removing components is required. The lack of coordinated numbers between components and the maintenance instructions generated a confusing atmosphere and led the

3、technicians to choose the wrong components. This action resulted in the erroneous activation of the VPF Firex water deluge system.Lesson(s) Learned: System components are not all identified with find number tags, allowing for erroneous component selection during maintenance operations.Recommendation

4、(s): All systems operations and maintenance contractors should install find number tags on all components of configured systems.Evidence of Recurrence Control Effectiveness: N/ADocuments Related to Lesson: N/AProvided by IHSNot for ResaleNo reproduction or networking permitted without license from I

5、HS-,-,-Mission Directorate(s): a71 Space Operationsa71 Exploration SystemsAdditional Key Phrase(s): a71 Configuration Managementa71 Facilitiesa71 Fire Protectiona71 Ground Operationsa71 Ground Equipmenta71 Hardwarea71 Industrial OperationsAdditional Info: Approval Info: a71 Approval Date: 1994-06-01a71 Approval Name: James G. Klinea71 Approval Organization: KSC/HEIa71 Approval Phone Number: 407-867-7614Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-