1、Lessons Learned Entry: 0623Lesson Info:a71 Lesson Number: 0623a71 Lesson Date: 1999-06-02a71 Submitting Organization: KSCa71 Submitted by: Charles EnsignSubject: Tethered Satellite System De-integration Process Lesson Learned Description of Driving Event: The Tethered Satellite System (TSS) Satellit
2、e Support Assembly (SAA) was inadvertently scheduled for delivery to the Florida Space Institute prior to de-integration of live ordnance. The scheduled delivery resulted from a request for donation of the SAA following utilization of TSS on STS-75. During offload operations of the SAA at Cape Canav
3、eral Air Force Station (CCAS), a technician recognized six NASA Standard Initiators (NSIs) still installed on the hardware. The NSIs were all examined and determined to be “live“ category B ordnance with Faraday caps installed. Explosive Ordnance Disposal (EOD) personnel then removed the six devices
4、 for proper disposition. The remainder of the satellite equipment was subsequently closely examined to verify there were no other hazards. No personnel were exposed to the live NSIs. The event was classified as a “Close Call“ and entered into the Incident Reporting Information System (IRIS) database
5、 for review and implementation of corrective action(s). The cause of this incident was determined to be inadequate configuration control of flight hardware during the de-integration process. This resulted in a loss of accountability for hazardous items integral to the design. This is a situation par
6、ticular to flight hardware not scheduled for re-flight. Hardware scheduled for re-flight (unlike TSS) possess adequate configuration control of hazardous items.Lesson(s) Learned: Failure to maintain adequate configuration control for flight hardware hazardous items nearly resulted in personnel being
7、 exposed to live category B ordnance.Recommendation(s): Configuration Control should clearly detail the status of all hazardous items for the entire de-integration process. An ISR has been submitted to change the Engineering Configuration List to Provided by IHSNot for ResaleNo reproduction or netwo
8、rking permitted without license from IHS-,-,-include a field to identify hazardous items. This will encompass all flight hardware including hardware not scheduled for re-flight.Evidence of Recurrence Control Effectiveness: N/ADocuments Related to Lesson: N/AMission Directorate(s): N/AAdditional Key
9、Phrase(s): a71 Configuration Managementa71 Energetic Materials - Explosive/Propellant/Pyrotechnica71 Explosives Handlinga71 Flight EquipmentAdditional Info: Approval Info: a71 Approval Date: 1999-06-07a71 Approval Name: Ronald Goodina71 Approval Organization: EC-H3a71 Approval Phone Number: 407-867-3183Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-
