REG NASA-LLIS-1427--2003 Lessons Learned Unintentional Operation of Fiber Optic Cable Cutter (2003).pdf

1、Lessons Learned Entry: 1427Lesson Info:a71 Lesson Number: 1427a71 Lesson Date: 2003-05-30a71 Submitting Organization: LARCa71 Submitted by: Grant WatsonSubject: Unintentional Operation of Fiber Optic Cable Cutter (2003) Abstract: A close call occurred because of a failure to update the maintenance c

2、hecklist and train personnel after making a system modification. In this incident, the lower aircraft pod had not been revised to reflect procedures for disconnecting the fiber optic cable cutter. The employee performing the functional check loosened, but did not completely separate the cannon plug,

3、 which allowed the firing circuit to be completed during the functional test.Description of Driving Event: An electrically-initiated fiber optic cable cutter in the lower pod of an aircraft unintentionally functioned during a 60-day armament functional check. Fortunately, this event caused no person

4、nel injuries or equipment damage. What we learn from a close call like this can prevent a serious accident in the future.Lesson(s) Learned: This close call emphasizes the importance of updating Standard Operating Procedures (SOPs) and checklists, along with retraining personnel on the SOP changes, w

5、henever changes are made to a system. Safe operations require: 1) a thorough understanding of the operational hazards, 2) development of written procedures/checklists, and 3) training and adherence to the procedures/checklists.Recommendation(s): To prevent the occurrence of this incident in the futu

6、re, a new checklist has been developed and all maintenance personnel have been trained to use the new checklist. Take a moment to examine Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-procedures at your facility. Are the published revisions current

7、 Are revisions explained to operators such that they understand the associated hazards? Are the procedures being followed? Evidence of Recurrence Control Effectiveness: N/ADocuments Related to Lesson: N/AMission Directorate(s): a71 Exploration Systemsa71 Sciencea71 Space Operationsa71 Aeronautics R

8、esearchAdditional Key Phrase(s): a71 Accident Investigationa71 Aircrafta71 Facilitiesa71 Flight Equipmenta71 Flight Operationsa71 Hardwarea71 Human Factorsa71 Mishap Reportinga71 Safety & Mission AssuranceAdditional Info: Approval Info: a71 Approval Date: 2004-06-04a71 Approval Name: Leslie Johnsona71 Approval Organization: LARCa71 Approval Phone Number: 757-864-9409Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-