1、Lessons Learned Entry: 0918Lesson Info:a71 Lesson Number: 0918a71 Lesson Date: 2000-10-17a71 Submitting Organization: JSCa71 Submitted by: Ronald A. MontagueSubject: Evolution of Mission Requirements for Support Equipment Description of Driving Event: During installation of the Thermal Micrometeorit
2、e Guard (TMG), the Short Extravehicular Mobility Unit (EMU) #3018 fell from the EMU ground test fixture (EGTF) to the floor. The primary cause of the mishap was that the EGTF was not used in a manner for which it was designed or assessed. The EGTF was designed and certified for 4-pin operations. The
3、 design of the TMG required a 3-pin operation during installation (one pin had to be removed.) The existing procedure for installation of the TMG on the SEMU did not address how the SEMU is to be handled or positioned, nor was there a procedure for the use of the EGTF. During this particular mishap,
4、 the TMG installation was being conducted with the front of the SEMU down. With the front of the SEMU facing up, this type of mishap would probably never occur because of the design of the pin receptacles. Proper procedures for installation of the TMG with the SEMU in an EGTF could have prevented th
5、is incident. Even thought this potential for mishap has existed since the EGTF was introduced in 1983, its presence was either recognized and not documented in a hazard analysis or not recognized at all. No formal training plan or objectives exist for personnel who handle flight equipment in the EMU
6、 laboratory. While OJT apprenticeship was implemented for these operations, there are neither measurable requirements nor documentation to support successful completion of training.Lesson(s) Learned: Equipment at all phases of processing and buildup must be used in the manner it was designed and tho
7、roughly re-evaluated as requirements change.Recommendation(s): 1. It is imperative that documented procedures accurately reflect defined processes, especially when configurations change, work environments change, or new equipment is introduced. Provided by IHSNot for ResaleNo reproduction or network
8、ing permitted without license from IHS-,-,-Procedures embarked upon without verification of their adequacy and correctness can lead to a false sense of security that all work is being done safely.2. Managers and employees at all levels must ensure that complacency is not allowed to creep into the wo
9、rk environment.3. Hardware must only be used for its intended function. As the need arises to expand that function, it must be accomplished through an appropriate evaluation and review process.4. Risks inherent in all phases of process execution must be assessed to ensure that appropriate safeguards
10、 and controls are clearly specified in training and procedures.Evidence of Recurrence Control Effectiveness: N/ADocuments Related to Lesson: N/AMission Directorate(s): a71 Exploration Systemsa71 Aeronautics Researcha71 Sciencea71 Space OperationsAdditional Key Phrase(s): a71 Administration/Organizat
11、iona71 Configuration Managementa71 Flight Operationsa71 Flight Equipmenta71 Ground Operationsa71 Ground Equipmenta71 Hardwarea71 Policy & Planninga71 Risk Management/Assessmenta71 Test Articlea71 Test Facilitya71 Test & Verificationa71 Training EquipmentAdditional Info: Provided by IHSNot for Resale
12、No reproduction or networking permitted without license from IHS-,-,-Approval Info: a71 Approval Date: 2000-10-20a71 Approval Name: Eric Raynora71 Approval Organization: QSa71 Approval Phone Number: 202-358-4738Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-
