REG NASA-LLIS-1215-1999 Lessons Learned Human factors considerations for critical hardware lifts.pdf

1、Lessons Learned Entry: 1215Lesson Info:a71 Lesson Number: 1215a71 Lesson Date: 1999-08-30a71 Submitting Organization: JSCa71 Submitted by: Case Van Dyke/ Ronald A. MontagueSubject: Human factors considerations for critical hardware lifts Description of Driving Event: After completion of the rotation

2、 of the Z-1 truss segment using a cab-operated 30-ton overhead bridge crane, the lifting device down rods were disconnected from the flight hardware. The task leader instructed the crane director on the floor to move the crane hook up to clear the trunnions. The crane director relayed the instructio

3、ns over walkie-talkie radio to the crane operator in the cab. The crane operator inadvertently commanded the hook to move in the down direction causing the lifting device down rods to make contact with the trunnions on the Z-1 truss. The operation was stopped. After examination by the task team, the

4、 crane hook was moved up and the crane was placed in the parking area and impounded. There was evidence that all four trunnions received metal-to-metal contact from the down rods. A damage assessment is being conducted. There was no damage to the lifting device or Hydra-Set and no personnel were inj

5、ured.Root cause: The root cause was determined to be human error caused by a combination of less than optimum design of the crane cab controls; inadequate communications and understanding of hoist speeds; and the failure of the emergency stop-button operator to actuate the emergency stop.Lesson(s) L

6、earned: Human factors considerations must be considered when planning safety-critical tasksRecommendation(s): Several short-term recommendations were considered to mitigate the mishap recurrence. The crane operating procedure has been modified to include a detail list of crane speeds that are to be

7、used when operating within close proximity of flight hardware. The pre-task briefing will reinforce the use of the E-Stop (i.e. Emergency Stop) during operations. The operating procedure will be modified Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-

8、,-to include a list of all crane crew certifications, including those of relief personnel on the crew. Long term recommendations include development of a process to change out the crane crew that have vigilant type duties more often and keeping the crane operator more involved in the task during dwe

9、ll times. A study of the cranes cab control panel design will also be conducted to optimize Human Engineering Factors. In addition, a dry run should be considered to ensure that the operator is confident to avoid human errors. Evidence of Recurrence Control Effectiveness: N/ADocuments Related to Les

10、son: N/AMission Directorate(s): N/AAdditional Key Phrase(s): a71 Facilitiesa71 Flight Equipmenta71 Flight Operationsa71 Ground Equipmenta71 Ground Operationsa71 Hardwarea71 Human Factorsa71 Industrial Operationsa71 Lifting Devicesa71 Policy & Planninga71 Risk Management/Assessmenta71 Safety & Missio

11、n AssuranceAdditional Info: Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-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-,-,-