1、Lessons Learned Entry: 0926Lesson Info:a71 Lesson Number: 0926a71 Lesson Date: 2001-02-20a71 Submitting Organization: MSFCa71 Submitted by: Neil BussiereSubject: Space Shuttle Program - Process Control Focus Group Machining/Equipment/Machine Maintenance Can Affect Hardware Integrity Description of D
2、riving Event: A machinist preparing to cut a Space Shuttle Main Engine turbopump part on a Vertical Turret Lathe (VTL) noticed that the cutting fluid did not exhibit a white milky appearance as expected. The machinist also detected an unusual odor and consistency to the fluid. The machining operatio
3、n was immediately terminated and area management was notified. The management team determined that the fluid was actually cleaning fluid introduced into the VTL over the weekend as part of normal routine maintenance. Although the cleaning fluid had not yet been removed there was no evidence of a Red
4、 Tag on the VTL to restrict its usage.Lesson(s) Learned: Any machine which is inoperable should exhibit visible evidence that the machine is out of service. Should the cleaning fluid in the VTL or any other unintended materials come in contact with space flight hardware the integrity of the hardware
5、 could be compromised.Recommendation(s): Maintenance should have Red-tagged the machine and the power source disengaged to prevent its use until such a time as the machine maintenance was completed and the machine could operate as intended.Evidence of Recurrence Control Effectiveness: Red Tags or Lo
6、ck-Out tags on or adjacent to a machines power source prevent any potential operator from starting a machine which is inoperable or could potentially cause damage to hardware.Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Documents Related to Lesson
7、: N/AMission Directorate(s): a71 Exploration Systemsa71 Aeronautics ResearchAdditional Key Phrase(s): a71 Aircrafta71 Communication Systemsa71 Facilitiesa71 Hardwarea71 Hazardous/Toxic Waste/Materialsa71 Human Factorsa71 Industrial Operationsa71 Parts Materials & ProcessesAdditional Info: Approval Info: a71 Approval Date: 2001-03-05a71 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-,-,-
