1、Lessons Learned Entry: 1758Lesson Info:a71 Lesson Number: 1758a71 Lesson Date: 2006-04-28a71 Submitting Organization: JPLa71 Submitted by: Thuykien Nguyena71 POC Name: Jon Cowarta71 POC Email: Jon.Cowart-1ksc.nasa.gova71 POC Phone: 321-861-3042Subject: Communicate Departures From Standard Operating
2、Conditions (Video Lesson) Abstract: A video clip lesson learned on the topic of Process Control. During the process of machining a piece of mission critical hardware, a metal lathe was shut down so that a new filter system could be installed. Coolant was emptied from the lathe and replaced with a cl
3、eaning solution. After the operator on the next shift began work on the part, he noticed that the appearance of the fluid was different and shut down the equipment. Cleaning solution contains acids that can permanently damage hardware. The hardware was inspected for damage, and a lock and tag-out pr
4、ocedure was instituted to prevent a future incident. Mission success depends on alert employees who notice problems when the system doesn?t. This 1-minute, 55-second video is a product of the Space Shuttle Program and its Process Control Focus Group.Description of Driving Event: Click here to view t
5、he lesson learned video. Click here to view a QuickTime version of the video. (Longer download time)Lesson(s) Learned: Even minor departures from standard operating configurations, such as non-standard maintenance activities, may initiate process control escapes that can damage mission critical hard
6、ware.Recommendation(s): Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Whenever processing equipment is to be placed in a non-standard configuration, take appropriate measures to prevent operational use, such as a written lock-out/tag-out (LOTO) pro
7、cedure, before it is restored to its nominal state.Evidence of Recurrence Control Effectiveness: N/ADocuments Related to Lesson: N/AMission Directorate(s): a71 Exploration SystemsAdditional Key Phrase(s): a71 Manufacturing and Assemblya71 Safety and Mission Assurance.Advanced planning of safety syst
8、emsa71 Safety and Mission Assurance.Configuration Change Controla71 Safety and Mission Assurance.Maintenancea71 Safety and Mission Assurance.Product Assurancea71 Safety and Mission Assurance.Qualitya71 Additional Categories.Configuration Managementa71 Additional Categories.Hardwarea71 Additional Cat
9、egories.Human Resources & Educationa71 Additional Categories.Industrial Operationsa71 Additional Categories.Parts, Materials, & Processesa71 Additional Categories.Safety & Mission AssuranceAdditional Info: a71 Project: Space ShuttleProvided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Approval Info: a71 Approval Date: 2006-12-18a71 Approval Name: ghendersona71 Approval Organization: HQProvided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-
