1、Lessons Learned Entry: 1272Lesson Info:a71 Lesson Number: 1272a71 Lesson Date: 1998-06-20a71 Submitting Organization: JSCa71 Submitted by: Ronald A. MontagueSubject: Systemic Process Control Involving Organizational Departments Description of Driving Event: On 20 February, a latch locating tool (app
2、roximate weight = 500 lbs.) and its handling fixture (dolly) were loaded on a stake bed truck, strapped down, and transported to a subcontractor in Goleta, CA. During shipment one end of the latch locating tool (drill platform) slipped from the dolly and landed on the truck floor. Upon arrival at de
3、stination, the subcontractor refused the shipment due to its apparent faulty shipping condition and the platform and dolly were returned to the point of origin. One of the roller subassemblies was discovered to be missing. Tool Fabrication was able to replace the roller subassembly. A subsequent tol
4、erance check of the tool determined that it was within tolerance and the tool was re-certified. The complete tool was then properly packaged and re-dispatched to the subcontractor.Root cause: Successful teamwork requires that the team include all appropriate personnel/contributors. Also, a small amo
5、unt of additional information in the right place on key documents can greatly reduce confusion and chance for error. The following details describe a systemic breakdown in the process.Engineering originated a Work Release Order (WRO) to ship the Mobile Transporter latch locating tool to the subcontr
6、actor. The latch locating tool consists of two parts: Part 1 (Drill Structure for prismoid holes: approximate size 5 x 8 feet), and Part 2 (Drill plate for sensor strips approximate size 6 x 10 inches) The drill structure has a dedicated storage container (tool engineering considers this a part of t
7、he tool.). Instead of shipping the two parts in their respective storage containers, the drill structure was shipped along with its handling fixture (dolly) and Part 2 was left behind.The handling fixture has two locking bolts to secure the drilling structure during ground handling. The drill struct
8、ure was not properly restrained by the locking bolts. The bolts were to be installed in the “V“ between the front rollers, instead they were installed aft of the front rollers, thus not Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-providing any ho
9、rizontal movement restraint until the rear rollers reached the locking bolts, allowing the front end of the tool to slip out of the holding fixture and strike the bed of the truck.Finding 1: Tool was not properly identified by Tool Control. Drill structure and handling fixture were shipped. The dril
10、l plate was left behind. Tool Control has the responsibility to:a71 Identify the tool to be shipped (ensure the tool is complete)a71 Prepare the tool for shipment (package/containerize as required)a71 Prepare Request for Shipment form (RFS, MDM - 0625)a71 Send “RFS“ to Shipping Department (when tool
11、 is ready for shipment)a71 After shipment, receive “Packing Sheet“ and update inventory log, to indicate the tool has been shipped.Finding 2: Tool was not properly packaged for shipment: dedicated container was not used, resulting in drill structure not being properly secured in the handling fixture
12、Finding 3: WRO did not state (nor was it required to provide the detail) that the tool consisted of 2 parts. It did not explain that the handling fixture is not to be included in the shipment.Finding 4: WRO did not have signature block (nor was it required to provide the detail) for department resp
13、onsible for tool shipment, namely Production Control.Finding 5: RFS did not state (nor was it required to provide the detail) that the tool consisted of 2 parts. It did not explain that the Handling Fixture was not to be included in the shipment.Finding 6: PHS&T (Packaging, Handling, Storage & Trans
14、portation) signed the WRO which tasked them to provide “technical support and coordination for major shipment per NHB 6000.1“. PHS&T did not get involved in tool shipments. Tool shipment preparation responsibility is entirely within Manufacturing Production Control (Tool Control).Finding 7: QA (Rece
15、iving and Shipping Inspection) failed to detect that what was being shipped was incorrect.Lesson(s) Learned: Interorganizational roles and responsibilities must be clearly understood to preclude systemic breakdowns in work processesRecommendation(s): Description of Driving Event contains findings th
16、at are self explanatory. Bottom line: understand the Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-roles and responsibilities of your organizational units and involve them in work planning. Evidence of Recurrence Control Effectiveness: N/ADocuments
17、 Related to Lesson: N/AMission Directorate(s): a71 Exploration Systemsa71 Sciencea71 Space Operationsa71 Aeronautics ResearchAdditional Key Phrase(s): a71 Administration/Organizationa71 Configuration Managementa71 Flight Operationsa71 Ground Operationsa71 Industrial Operationsa71 Logisticsa71 Packag
18、ing Handling Storagea71 Parts Materials & Processesa71 Policy & Planninga71 Range Operationsa71 Risk Management/Assessmenta71 Safety & Mission Assurancea71 TransportationAdditional Info: Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Approval Info: a71 Approval Date: 2002-08-20a71 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-,-,-
