1、Lessons Learned Entry: 1717Lesson Info:a71 Lesson Number: 1717a71 Lesson Date: 2006-03-14a71 Submitting Organization: JSCa71 Submitted by: Ron Montaguea71 POC Name: SheliaPowella71 POC Email: shelia.k.powellnasa.gova71 POC Phone: 281-483-3142Subject: Process Control of Floor Level Procedures Abstrac
2、t: Floor level procedures need to be unequivocal when steps are to be performed in sequence and as specified in procedural documentation.Description of Driving Event: An electrician suffered burns from an electrical arc/blast when a pre-existing condition in a power distribution panel ultimately led
3、 to a ground fault in a 3-phase 480-volt power supply. The pre-existing condition was believed to be an access panel fastener that had penetrated conductor insulation. Failure to perform work practices in accordance with established procedures ultimately resulted in procedural errors. 1. Personnel b
4、egan work prior to scheduled outage with power sources energized. The very first step in the procedure is to implement the outage, but later steps were clearly performed in advance. While the later steps were not in themselves hazardous, the regular practice of performing steps out of order without
5、prior authorization ultimately leads to a breakdown in process control. Management who reviewed and approved the procedure expected the procedure to be followed stepwise but in actuality the steps were re-ordered by employees and their supervisors who believed they had the discretion to reorder the
6、procedure during implementation. This practice largely negates the checks and balances in place during the development of procedures required to ensure that implementation met management expectations. Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-2
7、. Procedures and reference materials were available but not in possession of the electricians at the worksite. The procedure that governed the task itself was in the possession of supervisors who came and went from the worksite during the course of the shift. Only one of the supervisors had the pane
8、l schedule, a line drawing and a one line diagram. 3. A complicating factor was the distribution of multiple copies of the procedure to accomplish the work. There was no reconciliation of entries by personnel who were remotedly locate and in communication by phone. Times and dates occasionally did n
9、ot match or were entered in error. No single master or official copy was in the control of the supervisor; it was in the custody of another craft supervisor. Lesson(s) Learned: Floor level procedures must be developed and implemented in accordance with sound process control practiceRecommendation(s)
10、: 1. Implement refresher training for employees to recognize risks associated with deviating from established processes. 2. Evaluate written policies for applicability, clarity and effectiveness. Institute program to review procedures on a routine basis with assigned field crafts. 3. Follow procedur
11、es in sequence as written. Assure that as tasks are revised in the field that those revisions become lessons learned and incorporated in future procedures. 4. Implement refresher training for employees to recognize risks associated with beginning procedural tasks prior to a scheduled outage. 5. Clar
12、ify electrical hot work policy to include removal of fasteners from energized panels as electrical hot work. 6. Provide field crafts with copies of procedures and pertinent reference materials at the worksite. Ensure one control copy of the procedure has all steps and data entries verified and time
13、stamped as work is completed. Clearly identify working copies vs. control copy on all documents. Consider identifying all expected attachments to procedures by number, title, version and/or date.Evidence of Recurrence Control Effectiveness: Controlling processes for developing procedures have been r
14、evised to address all recommendations. Training has been implemented and spot checks via inspections have been implemented.Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Documents Related to Lesson: N/AMission Directorate(s): N/AAdditional Key Phras
15、e(s): a71 Program Management.Communications between different offices and contractor personnela71 Manufacturing and Assemblya71 Additional Categories.a71 Additional Categories.Configuration Managementa71 Additional Categories.Energya71 Additional Categories.Facilitiesa71 Additional Categories.Industrial Operationsa71 Additional Categories.Policy & PlanningAdditional Info: a71 Project: N/AApproval Info: a71 Approval Date: 2006-06-30a71 Approval Name: tmasona71 Approval Organization: HQProvided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-
