REG NASA-LLIS-0861-2000 Lessons Learned Inadequate Holding Transport Fixtures Leading to B747SP Rudder Damage.pdf

1、Lessons Learned Entry: 0861Lesson Info:a71 Lesson Number: 0861a71 Lesson Date: 2000-05-18a71 Submitting Organization: ARCa71 Submitted by: Anthony BricenoSubject: Inadequate Holding/Transport Fixtures Leading to B747SP Rudder Damage Description of Driving Event: The upper rudder of the 747SP aircraf

2、t was removed from the aircraft tail. The rudder was lowered lengthwise in the vertical position to a flat bed. The rudder was rotated to a position above the flat bed. The rudder was next rotated to a hinged up horizontal position. The two right hand fittngs were removed and the rudder was rotated

3、over towards the right side. The lower left hand fitting pulled the screws and some surrounding structure from the rudder. This allowed the rudder to fall on the flat bed and then approximately 30 inches to the concrete floor.One area 8 inches by 5 inches of the rudder frame and skin was pulled loos

4、e. One threaded lock was pulled loose and one threaded lock was stripped. Several rivets were popped on one of the counter weight attachments and minor bending on the lower end of the rudder.Lesson(s) Learned: 1. Failure to use appropriate holding/transport fixtures as defined within the specific ta

5、sk job card can result in damage to the rudder.2. Inadequate procedures to achieve safe removal of the rudder from the crane/sling can result in damage to the rudder.Recommendation(s): 1. Critical tasks such as rudder removal have been defined and a checklist has to be prepared to determine process,

6、 skill, tooling, training, and procedures requirements.2. During planning, if an area of the requirements is insufficient or a special circumstance exists, the checklist and documentation will be routed to engineering.3. Upon completion of the critical task planning function, the disciplines involve

7、d will approve Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-the plan.4. Production will write a work instruction for each critical task, attach a pre-task checklistform, and coordinate with personnel involved in performint the task.5. Upon issuing

8、 instructions to the floor, the task supervisor will verify requirements, review and sign the checklist, and make sure each individual has the proper knowledge and skill.Evidence of Recurrence Control Effectiveness: An audit was performed to collect objective evidence that adequate controls have bee

9、n implemented and are working satisfactorily.Documents Related to Lesson: N/AMission Directorate(s): a71 Exploration Systemsa71 Aeronautics ResearchAdditional Key Phrase(s): a71 Aircrafta71 Flight Operationsa71 Flight Equipmenta71 Ground Operationsa71 Ground Equipmenta71 Lifting DevicesAdditional Info: Approval Info: a71 Approval Date: 2000-06-5a71 Approval Name: Eric Raynora71 Approval Organization: QSa71 Approval Phone Number: 202-358-4738Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-