REG NASA-LLIS-2456-2010 Lessons Learned Aquarius EGSE Shipping Mishap.pdf

1、Lessons Learned Entry: 2456 Lesson Info: z Lesson Number: 2456 z Lesson Date: 2010-02-16 z Submitting Organization: JPL z Submitted by: David Oberhettinger z POC Name: Stephen Greenberg; Pamela Brown z POC Email: Stephen.S.Greenbergjpl.nasa.gov; Pamela.R.Brownjpl.nasa.gov z POC Phone: 818-354-6306 (

2、Greenberg); 818-354-8081 (Brown) Subject: Aquarius EGSE Shipping Mishap Abstract: A shipping container holding test equipment for the Aquarius project fell off the lift gate while it was being unloaded from a truck, and caused minor injuries to personnel. The root cause was inadequate planning and c

3、oordination of the transportation task. Use trained and certified personnel and equipment for critical equipment moves, perform a dry run of the operation, ensure that System Safety is informed and involved, and integrate contingency planning into transportation plans. Description of Driving Event:

4、In May 2009, a wheeled shipping crate containing an electrical ground support equipment (EGSE) rack for the Aquarius project fell off the lift gate of a contracted commercial transportation van while being unloaded. The van was parked adjacent to the receiving dock at the NASA/Caltech Jet Propulsion

5、 Laboratory (JPL). After the crate was moved to the rear of the vehicle for unloading, the van driver/operator manipulated the incorrect control on the powered lift gate (Reference (1). (Figure 1 illustrates the lift gate control systems susceptibility to operator error.) This caused the lift gate t

6、o tilt instead of lower. The crate rolled off the lift gate and struck the ground, damaging the hinges and breaking off the lid. Only the crate directly contacted the ground, and the EGSE rack with its 2-inch thick foam padding remained secure within the crate. The shipping crate had four casters, b

7、ut the locks on the two downhill casters were unlocked during the operation. Figure 1. Lift gate control panel on the truck that was unloading Aquarius EGSE. The diagram below the image shows that the control panel is not well designed to deter operator error. (The yellow label indicates that the di

8、al on the right is a “Slider” control that positions the gate horizontally.)Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-The EGSE rack was being removed from the vehicle because it had not been approved in the final manifest for support equipment

9、to be transported to Argentina for Aquarius integration and test. Since a need to unload the EGSE shipping crate had been not identified to the project until just prior to the incident, there was insufficient time to coordinate and plan the EGSE off-load. Quality Assurance was present during the inc

10、ident, but System Safety was not notified of this unplanned unloading of Aquarius EGSE. Two individuals were injured as a result of this incident. The first struck his head on the pavement when he fell backward while avoiding the falling equipment. The other suffered a muscle strain while trying to

11、restrain the EGSE rack as it rolled off the tilted lift gate. The container and lid were then moved into the Spacecraft Assembly Facility (SAF) airlock for visual inspection. Visual inspection did not detect any equipment damage other than the detached shipping container lid, and the damaged shippin

12、g crate was replaced. The personnel were treated with basic first-aid, and then they returned to work (Reference (2). The test equipment required recalibration, full functional test, and internal visual inspection. Due to a lingering concern about possible damage, however, replacement EGSE was obtai

13、ned for use with Aquarius flight equipment (Reference (3). There exists some residual concern by the Aquarius project due to the risk posed by plans to move JPL Critical Items (JCI) from Argentina to Brazil, and from Brazil to the Vandenberg Air Force Base launch site. JPL has recently revamped the

14、process of preparing and reviewing transportation plans. The process is now reflected in the formal procedures of JPL Security, and preparation of a transportation plan is now a contractual requirement to be added to JPL subcontracts (Reference (4). Also, the JPL Project and Engineering Management C

15、ommittee (PEMC) has approved adding a transportation plan requirement to the next release of the JPL Flight Project Practices. (See Recommendation #4.) Documentation in a previous lesson learned (Reference (5) of damage to JPL flight hardware during international transit led to a security plan requi

16、rement (Reference (6) for shipments outside the continental U.S. References: 1. JPL Mishap Report No. 1887, May 28, 2009. 2. JPL Mishap Report No. 1886, May 28, 2009. 3. “Aquarius EGSE Shipping Mishap,“ JPL Problem/Failure Report No. 15044, May 28, 2009. 4. “Transportation Documentation,“ JPL Data R

17、equirement Description (DRD) No. TE-004, April 17, 2009, in “Subcontract Plans and Documentation for SDRL and DRDs, Rev. 0,“ JPL Document No. DocID 78172, September 15, 2009, p. 132. 5. “Exercise Strict Controls in the Packaging and Oversight of Critical Hardware Shipped by Third-Party Courier Servi

18、ces,“ NASA Lesson Learned No. 1849, NASA Engineering Network, April 1, 2008. 6. “Off-Site Transportation of Flight Hardware, Rev. 1,“ JPL Document No. DocID 69052, July 8, 2009, Paragraph 2.2. 7. “Shipments of Deliverable Hardware, Rev. 1,“ JPL Document No. 64352, update pending. Lesson(s) Learned:

19、Although, the likely proximate cause of the Aquarius EGSE transportation mishap was operator error by the contracted van driver operating the lift gate, the root cause was inadequate planning and coordination of the transportation task. Recommendation(s): 1. Use material movement personnel and equip

20、ment that have been trained and/or certified to move JCI. Verify that project personnel involved in preparations for loading and shipping JCI are familiar with requirements for special (e.g., international) shipping. 2. Cognizant personnel should stop unplanned JCI transportation operations until a

21、review by all required JPL organizational participants has taken place. For all planned and unplanned transportation of JCI, including loading and unloading operations, ensure that System Safety, Hardware Quality Assurance (HQA), and Shipping/Receiving (Reference (7) have been informed of the operat

22、ion. (It is acceptable, on a case-by-case Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-basis, for either System Safety or HQA to be present during the operation. This is to be determined as a joint decision between System Safety and HQA.) 3. If us

23、e of contracted transportation services and equipment is required, perform a dry run of the operation without moving JCI. Confirm that the transportation company has provided adequate qualified staff, and verify vehicle equipment (e.g., lift gate) functionality during the dry run. 4. When released,

24、Revision 8 of the JPL Flight Project Practices (JPL DocID 58032) will require that each project develop a Transportation Plan to describe project plans for safe transportation of flight hardware and critical support equipment. In addition, transportation plans for the Aquarius project (and future fl

25、ight projects planning international shipments) should incorporate contingency planning to anticipate the availability of less than optimal transportation resources for JCI. Evidence of Recurrence Control Effectiveness: JPLs corrective action plan for this mishap includes adding a Paragraph 6.12.10

26、(“Engineering Practices: Protection and Security of Flight Hardware“) to Revision 8 of the Jet Propulsion Laboratory standard “Flight Project Practices,“ JPL DocID 58032. The paragraph will state, “Each project develops a Transportation Plan to describe its plans for safe transportation of the fligh

27、t hardware and critical support equipment.“ JPL will also reference this lesson learned as additional rationale and guidance supporting the new JPL rule. Documents Related to Lesson: N/A Mission Directorate(s): z Exploration Systems z Science z Aeronautics Research Additional Key Phrase(s): z Additi

28、onal Categories.Security z Additional Categories.Safety & Mission Assurance z Additional Categories.Procurement, Small Business & Industrial Relations z Additional Categories.Logistics z Additional Categories.Lifting Devices z Additional Categories.Ground Operations z Safety and Mission Assurance.Product Assurance z Additional Categories.Transportation Additional Info: z Project: Aquarius Approval Info: z Approval Date: 2010-04-20 z Approval Name: mbell z Approval Organization: HQ Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-