REG NASA-LLIS-1210--1999 Lessons Learned - Procedural Control (Deviation from Approved Procedures).pdf

1、Lessons Learned Entry: 1210Lesson Info:a71 Lesson Number: 1210a71 Lesson Date: 1999-08-30a71 Submitting Organization: JSCa71 Submitted by: Jim Kohlbrand/ Ronald A. MontagueSubject: Procedural Control (Deviation from Approved Procedures) Description of Driving Event: During the performance of closed

2、hatch environmental control / life support system (ECLSS) test, Boeing Engineering authorized a deviation to the pre-approved hazardous procedure. The task and procedure to configure the oxygen supply system was to be performed by a subtask document written by a Boeing ground contractor. The subtask

3、 document specifically performed the setup, leak check, oxygen supply and shutdown of oxygen systems. The deviated procedure failed to utilize the steps from the subtask document and could have potentially subjected an in-line flex hose lined with Polytetrafluoroethylene to adiabatic compression cau

4、sed by pneumatic impact. Teflon-lined flex hoses can ignite from pneumatic impacts from tremendous heat build-up. The subtask documents written steps avoid this potential by specific valve configurations and slow system pressurization rates. The written deviation did however; specify the slow delive

5、ry of oxygen to the U.S. Lab. No damage occurred to the flight hardware or GSE as a result of operations performed per the deviated procedure. Root cause: Deviation from approved written hazardous procedure Lesson(s) Learned: Deviations from approved procedures must be carefully managed to preclude

6、the commission / omission of steps designed to assure safety and successRecommendation(s): KSC provides for an overall review and readiness for critical flight tests and component installations referred to as a Test Readiness Review (TRR). Recommend reiterating the written policy, CETI-055, to all T

7、est Directors/Task Leaders with emphasis placed on procedural deviations. Background: Test Readiness Reviews outline objectives for the Test Director/Task Leader to provide management an Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-evaluation of t

8、he readiness of flight elements, support systems, and test procedures required to accomplish ground processing test objectives and safety of personnel/hardware. Evidence of Recurrence Control Effectiveness: N/A Documents Related to Lesson: N/AMission Directorate(s): N/AAdditional Key Phrase(s): a71

9、Configuration Managementa71 Facilitiesa71 Flight Operationsa71 Ground Operationsa71 Independent Verification and Validationa71 Industrial Operationsa71 Launch Processa71 Parts Materials & Processesa71 Policy & Planninga71 Risk Management/Assessmenta71 Safety & Mission Assurancea71 Test & Verificationa71 Test Articlea71 Test FacilityAdditional Info: Approval Info: a71 Approval Date: 2002-06-17a71 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-,-,-