REG NASA-LLIS-2037-2010 Lessons Learned - Inadvertently Excessed Pulse Width Modulator Circuit Card Assemblies (PWM CCA).pdf

1、Lessons Learned Entry: 2037Lessons Learned Entry: 2037Lesson Info:a71 Lesson Number: 2037a71 Submitting Organization: KSCa71 Submitted by: Michael Bella71 POC Name: Michael Dodsona71 POC Email: michael.dodsonnasa.gova71 POC Phone: 321.867.1348Subject: Inadvertently Excessed Pulse Width Modulator Cir

2、cuit Card Assemblies (PWM CCA) Abstract: Pulse width modulator circuit card assemblies (PWM CCAs), valued at $150,000 each were inadvertently excessed to the KSC excess property storage area. The PWM CCAs were attached to holding fixtures, and were subsequently purchased as scrap metal by a local sa

3、lvage company. The sole decision criterion for excessing items was usage rate. The computerized logistics system documented the holding fixtures as not being in use. The individuals involved in the excessing process believed that they were only excessing holding fixtures. The holding fixtures were e

4、ntered as separate items from the PWM CCAs, because the system lacked the capability to document and track integrated components. Programs should identify risks for disposition and excess of hardware, by analyzing all process flows, permit entry and designation of integrated hardware and train mater

5、ial handling personnel by management covering flight hardware handling and identification.Description of Driving Event: On April 12, 2006 six pulse width modulator circuit card assemblies (PWM CCAs), valued at $150,000 each were inadvertently excessed by the International Space Station program to th

6、e KSC excess property storage area. The PWM CCAs were attached to holding fixtures, and were spares for the ISS battery charge discharge unit. The PWM CCAs and their holding fixtures were subsequently purchased as scrap metal by a local salvage company. The PWM CCAs and holding fixtures were exposed

7、 to the weather at the KSC excess property storage area and in the salvage companys outside storage yard for approximately 11 months. The holding fixtures and not the attached PWM CCAs were identified and processed as excess equipment. The PWM CCAs were flight hardware and remained undetected throug

8、hout the entire excessing process. Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Lessons Learned Entry: 2037On August 9, 2006, the fixtures and PWM CCAs were sold at an auction as part of a miscellaneous lot to a local salvage company. On January 1

9、1, 2007, the Contractor conducted an inventory of items worth $100K or more that revealed the six PWM CCAs were missing. After research and analysis by the Contractor, the PWM CCAs were located, re-purchased and retrieved from the salvage yard on March 9, 2007. After being excessed and stored outsid

10、e for several months, the PWM CCAs were no longer flight worthy resulting in a loss of $900,000. The mishap was classified as a Type B. Lesson(s) Learned: The sole decision criterion for excessing items was usage rate. The computerized logistics system documented the holding fixtures as not being in

11、 use. They had no usage history. The individuals involved in the excessing process believed that they were only excessing holding fixtures. As a result, the Structural/Mechanical Subsystem Manager was put on routing for concurrence or non-concurrence with final excess disposition, rather than the ow

12、ner - the Electrical Power System Subsystem Manager. The individual who entered the holding fixtures into the computerized logistics system entered the holding fixtures as separate items from the PWM CCAs, because the system lacked the capability to document and track integrated components. Further,

13、 the holding fixture drawing did not identify its purpose or reference the PWM CCAs. Neither individual who performed physical verification of the containers realized flight hardware was in them. Note: The verifications were performed by individuals at the beginning and end of the excess process. Un

14、fortunately, the flight parts tags were not placed on the containers in a conspicuous manner, and were NOT noticed by the individuals performing the verifications. However, asset identification numbers, (used for non-flight items like holding fixtures) were prominently displayed on the outside of th

15、e containers and were most likely used for identification. When the excess decision was approved, the holding fixtures (with PWM CCAs attached) were released for sale as surplus. They were then removed from the controlled environment warehouse, and transported to an uncontrolled environment until th

16、ey were sold as scrap. Recommendation(s): 1. Identify risks for disposition and excess of hardware, by analyzing all process flows. 2. Ensure the applicable subsystem owner or user is identified prior to hardware entering the excess process. 3. Modify the computerized logistics system to permit entr

17、y and designation of integrated hardware. Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Lessons Learned Entry: 20374. Train material handling personnel in flight hardware handling and identification. Evidence of Recurrence Control Effectiveness: 1.

18、 A desktop instruction was developed to ensure the applicable subsystem owner or user is identified prior to hardware entering the excess process.2. The Program Office modified the computerized logistics system. It now permits entry and designation of integrated hardware. The user interface was upda

19、ted so that fixtures with flight hardware now indicate that verification of attached flight hardware is required. 3. An enhancement to the Residual Asset Database was implemented to link the drawings and pictures with each submittal.4. Personal Warranty and Operational Discipline programs were also

20、reviewed with all affected personnel.Documents Related to Lesson: Kennedy NASA Procedure Requirement (KNR) 4000.1 Chapter 7 “Turn-In Procedures“Mission Directorate(s): a71 Space OperationsAdditional Key Phrase(s): a71 Additional Categories.a71 Additional Categories.Logisticsa71 Additional Categories

21、.Ground Operationsa71 Additional Categories.Flight HardwareMishap Report References: NASA IRIS Incident Report No. 2007-065-00013Additional Info: a71 Project: ISS programProvided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Lessons Learned Entry: 2037Approval Info: a71 Approval Date: 2010-04-21a71 Approval Name: mbella71 Approval Organization: HQProvided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-