REG NASA-LLIS-1204-1999 Lessons Learned Placement of Warnings in Procedural Documents.pdf

1、Lessons Learned Entry: 1204Lesson Info:a71 Lesson Number: 1204a71 Lesson Date: 1999-10-21a71 Submitting Organization: JSCa71 Submitted by: Dale HulsSubject: Placement of Warnings in Procedural Documents Description of Driving Event: During the Flight 2A (STS-88) mission, the crew was required to ins

2、tall rack pivot pins on the starboard re-supply/stowage rack (RSR). During the operation, the mid-bay pivot pin wedge/fitting assembly on the forward pivot pin was pushed through behind the rack resulting in lost hardware inside the ISS Node (refer to ISS PRACA PR# 1000). A setscrew on the track tha

3、t receives the pivot pin wedge/fitting assembly was not installed because the RSR was installed before the setscrew was installed. The purpose of the setscrew was to prevent such a loss. Because the setscrew could not be installed without removing the RSR, the assembly order could not be completed a

4、nd the engineering was revised to delete the setscrew. MOD was informed of the deletion and advised that the crew would have to hold onto the wedge/fitting assembly when loosing the bolt on the assembly for installation of the pivot pin. Root cause: MOD procedures included a warning to the crew to h

5、old onto the pivot wedge/fitting assembly while loosing the bolt, however, the format of the procedure was such that the warning was included after the step that loosened the bolt and wound up an the following page. As a result the crew did not see the warning until too late.Lesson(s) Learned: Warni

6、ngs must be place before any procedural step to ensure the reader / operator is aware of any issues prior to implementation.Recommendation(s): For future Flight Operations Reviews (FOR), the ISS S&MA community is aware of this issue and will in the future review the flight operations products (e.g.,

7、 Operations Checklists, Malfunction Checklists, etc.) with an emphasis on warning/caution note placement. At no time should a procedural step precede a referenced warning or caution note. ISS MER-Safety routinely checked the Provided by IHSNot for ResaleNo reproduction or networking permitted withou

8、t license from IHS-,-,-Flt 2A.1 (STS-96) Flight Note procedures sent to the crew for placement of warning/caution notes, as well as their content. Additionally, this lesson learned will be referenced in PRACA PR# 1000 as part of the Recurrence Control. It is believed that placing a procedure step be

9、fore a referenced warning/caution note is a rare oversight and that increased ISS Program visibility of such an occurrence via the PRACA Report and the Lessons Learned should adequately address the problem. Evidence of Recurrence Control Effectiveness: N/ADocuments Related to Lesson: N/AMission Dire

10、ctorate(s): a71 Exploration Systemsa71 Aeronautics ResearchAdditional Key Phrase(s): a71 Configuration Managementa71 Flight Operationsa71 Ground Operationsa71 Human Factorsa71 Human Resources & Educationa71 Industrial Operationsa71 Launch Processa71 Parts Materials & Processesa71 Policy & Planninga7

11、1 Range Operationsa71 Test & VerificationAdditional Info: Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Approval Info: a71 Approval Date: 2002-05-30a71 Approval Name: Ronald A. Montaguea71 Approval Organization: JSCa71 Approval Phone Number: 281-483-8576Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-