REG NASA-LLIS-0521-1994 Lessons Learned Inspection Oversights Led to Model Failure.pdf

1、Lessons Learned Entry: 0521Lesson Info:a71 Lesson Number: 0521a71 Lesson Date: 1994-08-12a71 Submitting Organization: LARCa71 Submitted by: Bernard LewisSubject: Inspection Oversights Led to Model Failure Description of Driving Event: On 11-12-92, research runs were being conducted in the unitary wi

2、nd tunnel. During one test run, the downstream wood fairing on the model side mount splitter plate came loose and was destroyed as it went down the tunnel. The tunnel was not damaged, however, there was damage to some instrumentation tubing as well as lost research time. Although damage was relative

3、ly minor, this failure is significant because it was preventable.Subsequent investigation of the cause of the failure showed that not all of the required fasteners had been installed in the wood fairing, thus causing it to fail. In spite of the fact that the model was inspected more than once prior

4、to the research runs being made, none of the inspectors noticed the missing fasteners. These inspection oversights ultimately led to model failure as well as the failure of the test being run.The damaged instrumentation tubing was replaced. A new wood fairing, this time secured by all required faste

5、ners, was made by the LaRC model shop.Lesson(s) Learned: Inspection oversights ultimately led to model failure as well as failure of the test being run.Recommendation(s): Facility personnel were counseled on the importance of quality workmanship and, most importantly, on the need for a team effort r

6、elative to model inspections. All facility personnel involved have dedicated themselves toward insuring that this type of failure does not happen again.Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Evidence of Recurrence Control Effectiveness: N/AD

7、ocuments Related to Lesson: N/AMission Directorate(s): N/AAdditional Key Phrase(s): a71 Safety & Mission Assurancea71 Test Articlea71 Test FacilityAdditional Info: Approval Info: a71 Approval Date: 1997-04-02a71 Approval Name: Elijah C. Kenta71 Approval Organization: 421a71 Approval Phone Number: 757-864-3345Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-