1、Lessons Learned Entry: 1209Lesson Info:a71 Lesson Number: 1209a71 Lesson Date: 1999-07-15a71 Submitting Organization: JSCa71 Submitted by: Randy Ortner/ Ronald A. MontagueSubject: Preventive Shop Practices Description of Driving Event: Technicians were trimming composite material using a table saw w
2、ith a diamond-cutting blade. After trimming the employees took a break. When returning they discovered smoke in the room which appeared to be coming from inside the table saw. One technician disconnected the main power switch, while the other pulled the Fire Alarm. There were no injuries to personne
3、l or damage equipment.Root cause: An investigation found that the composite dust had accumulated in the base of the table saw. There was a failure found in the machine dust collection system, which would not allow the removal of dust/material during cutting. The smoke was ignited by heat or spark du
4、ring the cutting process.Lesson(s) Learned: Perform job safety analyses of both routine and non-routine shop practices to identify hazards associated with shop equipment and their operationRecommendation(s): A daily inspection checklist will be performed and signed off by shop personnel to ensure th
5、e vacuum system is operational, and that no composite accumulated dust is in the base of table saw prior to using equipment. A weekly maintenance will be performed on dust collection system. Standard operating procedures in a manufacturing environment should assure that safety features on equipment
6、are functioning properly during all operations. Evidence of Recurrence Control Effectiveness: Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-N/ADocuments Related to Lesson: N/AMission Directorate(s): N/AAdditional Key Phrase(s): a71 Facilitiesa71 Gr
7、ound Equipmenta71 Ground Operationsa71 Industrial Operationsa71 Parts Materials & Processesa71 Risk Management/AssessmentAdditional Info: Approval Info: a71 Approval Date: 2002-06-17a71 Approval Name: Ronald A. Montaguea71 Approval Organization: JSCa71 Approval Phone Number: 281-483-8576Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-
