REG NASA-LLIS-3636-2012 Lessons Learned Different Groups in Different Locations Working On the Same System but Under Different Contracts.pdf

1、Public Lessons Learned Entry: 3636 Lesson Info: Lesson Number: 3636 Lesson Date: 2010-08-26 Submitting Organization: KSC Submitted by: Annette Pitt Subject: Different Groups in Different Locations Working On the Same System but Under Different Contracts Abstract: The Microwave Scanning Beam Landing

2、System (MSBLS) contract, originally controlled by Johnson Space Center (JSC), was split across NASA centers. The Kennedy Space Center (KSC) has operation and maintenance (O therefore, the DFRC and WSTF contractor teams are required to report any anomalies and resolve technical issues with the collab

3、oration of the KSC team. Since the groups were not managed under the same contract, responsibilities were not clearly identified, which resulted in miscommunication and possible detrimental consequences. Description of Driving Event: Prior to the STS-124 launch, several issues with the MSBLS 60Hz Po

4、wer cables at DFRC Runway 22R caused a smoldering fire and smoke at the MSBLS primary and backup shelters resulting in part failure and equipment damage, as well as loss of power to one of the MSBLS JR System. The failure resulted in smoke in the shelter, florescent light flickering and melting of t

5、he thermal breaker monitor panel. Per Safety Assurance Analysis document SAA-00199, subsequent failure of the other system could result in possible loss of life and/or vehicle At the time of the failure, KSC placed several phone calls to different personnel and received slightly different versions o

6、f events; however, it was clear the primary cause (as understood at KSC) was maintenance of MSBLS power cable. Although the Operations and Maintenance responsibility is split between KSC and JSC, sustaining engineering for all equipment, regardless of location is done at KSC. KSC is required to repo

7、rt any MSBLS issues to the Launch Readiness Director (LRD), who is at KSC. Both DFRC and WSTF had subcontracts with other companies to perform maintenance and operation. On numerous occasions, when the teams in charge of O&M had issues, not enough information about system problems was provided in or

8、der for KSC to report the issue to the LRD or to provide a solution. The Risk Review Board concluded that during STS-124, a failure to maintain configuration control, follow engineering Work Authorization Documents (WADS), and provide proper problem reporting resulted in the miscommunication. Please

9、 see attached presentation from the Risk Review Board. Lesson(s) Learned: One group is in charge of O&M and another group is in charge of sustaining engineering of the same system can cause problems. There are different contract rules and policies. More importantly, there are many misunderstandings

10、in the interpretation of the O&M responsibilities and the sustaining engineering responsibilities. As a result of being on separate contracts, the KSC NASA NavAids engineers did not sign off on the Certificate of Flight Readiness stating that WSSH or DFRC were in compliance and ready for shuttle lau

11、nch/landing activities, since they did not witness the maintenance of the system, due to a lack of communication between the locations. Recommendation(s): Clearly define the roles and responsibilities during the planning phase. Identify one contractor to perform both O&M and sustaining engineering f

12、or similar systems at various locations. Ensure processes and reporting methods are in place to account for complex contracting relationships. Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Evidence of Recurrence Control Effectiveness: N/A Documents

13、 Related to Lesson: N/A Mission Directorate(s): Space Operations Additional Key Phrase(s): Cross Agency coordination 1.Acquisition / procurement strategy and planning 0.Vehicle concepts 1.Engineering design and project processes and standards 1.Launch Systems 1.Ground Operations 1.Ground Equipment 1

14、Ground support systems Center distribution of programs and management activities Additional Info: Project: Space Shuttle Program Approval Info: Approval Date: 2012-01-04 Approval Name: mbell Approval Organization: HQ Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-