REG NASA-LLIS-3042-2010 Lessons Learned - Don-t Let Reoccurring Issues Become the Norm.pdf

1、Public Lessons Learned Entry: 3042Lesson Info:a71 Lesson Number: 3042a71 Lesson Date: 2010-05-15a71 Submitting Organization: KSCSubmitted by: Annette PittSubject: Dont Let Reoccurring Issues Become the Norm Abstract: In the environment surrounding the processing of space vehicles, it becomes very ea

2、sy for people who work closely with the flight hardware to begin accepting recurring discrepancies as a normal part of flight operations, especially when those discrepancies occur within their own systems. In many cases, the discrepancy arises from problems with a different system, and there is a la

3、ck of communication between the system owners.Description of Driving Event: Over the years, the shedding of foam from the External Tank (ET) during a launch continually damaged tiles on the left side of the orbiter. A tile was even knocked completely off, resulting in temperature-induced structural

4、overstress on an antenna door. From the perspective of those working on the Thermal Protection System (TPS), it became normal to expect this type of damage; and they were unable to control the damage because it came from a different element (the ET). The TPS workers grew to expect this as normal fli

5、ght damage and developed repairs and procedures to address the damage to their own system. Later, foam shedding led to the loss of the Space Shuttle Orbiter Columbia (OV-102).Figure 1. Dark marks indicate location of tile damage before and after modifications to the ETLesson(s) Learned: Any recurrin

6、g discrepancy or nonconformance should never be treated as normal. Recurrence control procedures and guidelines should be put into place and used.Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Recommendation(s): Present postflight report requirement

7、 and data reviews to upper-level technical management. Use recurrence controls on the reportable systems. Perform a rigorous flight readiness review process at all levels. Use test data to support the acceptance of the assumptions and conclusions.Evidence of Recurrence Control Effectiveness: N/ADocu

8、ments Related to Lesson: N/AMission Directorate(s): a71 Space Operationsa71 Exploration SystemsAdditional Key Phrase(s): a71 1.Entry Systemsa71 1.Human Factors/Habitabilitya71 1.Ground processing and manifestinga71 1.Crew Survival Systemsa71 1.Risk managementa71 1.Program planning, development, and managementa71 1.Program level review processesAdditional Info: Project: Space Shuttle Program Approval Info: a71 Approval Date: 2010-08-16a71 Approval Name: mbellApproval Organization: HQ Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-