REG NASA-LLIS-0988-2001 Lessons Learned - Ordinance Firing Line Misconnect.pdf

1、Lessons Learned Entry: 0988Lesson Info:a71 Lesson Number: 0988a71 Lesson Date: 2001-01-01a71 Submitting Organization: KSCa71 Submitted by: Malcolm GlennSubject: Ordinance/Firing Line Misconnect Description of Driving Event: At KSC, during performance of Space Shuttle external tank/solid rocket boost

2、er thrust post ordinance installation in the booster forward skirt, the frustrum separation cable was mistakenly connected. The job was to install ordinance components in flight hardware. There were three NASA Standard Initiators (NSI) to install, and cables to connect to two of the NSIs. The work t

3、eam, consisting of three team members, did this work correctly. Then one of the team members noticed the third NSI did not have the cable connected and asked a question about the connection. The work team then connected, in error, the third cable. A problem report was written and the mistakenly conn

4、ected cable was disconnected and safed.Lesson(s) Learned: a71 The team did not follow the paper as written.a71 The team did not call a time out and get help, even when they raised a question about proper performance of the task.a71 If you or any team member is unfamiliar with a task, take whatever m

5、eans necessary to understand the task before starting.a71 The work team did not have much experience on the specific task.Recommendation(s): a71 Rigorously and deliberately follow the paper, step by step, every time you do a task.a71 Call a time out if there is any question.a71 Ensure you are famili

6、ar with the task and are comfortable doing the task. If you have any doubts, ask for help.a71 Be aware of the task specific experience of people and assign tasks accordingly. Different Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-people can be ass

7、igned to the task to balance light experience. When people cannot be balanced based on experience, leadership must recognize and highlight the job as one needing extra attention. Extra attention may include emphasis during briefings, a pre-job walk down or rehearsal, extra on-the-job observations an

8、d a post-job walkdown.Evidence of Recurrence Control Effectiveness: N/ADocuments Related to Lesson: N/AMission Directorate(s): a71 Exploration Systemsa71 Space Operationsa71 Aeronautics ResearchAdditional Key Phrase(s): a71 Configuration Managementa71 Explosives Handlinga71 Flight Operationsa71 Flig

9、ht Equipmenta71 Ground Operationsa71 SpacecraftAdditional Info: Approval Info: a71 Approval Date: 2001-08-20a71 Approval Name: Gena Bakera71 Approval Organization: KSCa71 Approval Phone Number: 321-867-4261Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-