1、Public Lessons Learned Entry: 5957 Lesson Info: Lesson Number: 5957 Lesson Date: 2011-06-29 Submitting Organization: KSC Submitted by: Amber Porter Subject: Sensor Package 1 (SP1) Pan/Tilt Unit Damage Abstract: On July 31, 2007, a Sensor Pack 1 (SP1) was found damaged during placement into a shippin
2、g container following a successful Integrated Verification Test (IVT). IVT is an electrical functional verification of the SP1 while integrated to the Canadian Orbiter Boom Sensor System (OBSS). The test was performed on the Level 13 platforms in the Orbiter Processing Facility (OPF) OPF-3, in prepa
3、ration for later installation into the OV-103 (Discovery) payload bay. Description of Driving Event: On the day of the incident, two Orbiter mid-body technicians were tasked to remove SP1 S/N 1003 from its test fixture (called an L-Bracket) and stow it into a shipping container for movement to anoth
4、er part of the Orbiter mid-body. After rotating the sensor and its mounting base several times while attempting to find the proper orientation in the container, one of the technicians noticed a small piece of the sensor, later identified as a rotation stop, lying in the bottom of the container. The
5、technicians notified their supervisor who, in-turn, notified the OPF-3 Bay Manager and USA Safety Management of the broken stop. Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Figure 1: SP1 Transport Container Showing Foam That Was Removed The techn
6、icians that originally removed the SP1 and installed it on the L-Bracket removed the foam from the container. As a result of inadequate direction in the procedure, the technicians on first shift, perceived the need to remove the foam from the container to act as a support to prevent toppling of the
7、SP1. The foam was never properly replaced into the container. The two technicians tasked with replacing the SP1 into the shipping container, having never seen the SP1 in the container, were unaware how the foam and camera should be oriented. The Work Authorization Document (WAD) provided no insight
8、to its proper orientation. Lesson(s) Learned: The procedure had an inadequate level of technical detail. The notes were confusing and inadequate to ensure safe handling of the SP1. Drawings or pictures that show the orientation of the foam and the SP1 in the shipping container would be helpful. Proc
9、esses did not effectively identify complex flight hardware as having special handling requirements. Recommendation(s): Processes did not effectively identify complex flight hardware as having special handling requirements. Assure that complex flight hardware is addressed with the appropriate level o
10、f requirements to assure its safe and damage-free use. Place more emphasis on human factors (See Mil-STD-1472) for the development and validation of procedures for existing and future flight hardware. Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-E
11、vidence of Recurrence Control Effectiveness: N/A Documents Related to Lesson: NASA IRIS #: 2007-215-00006 Click to View Mishap Report Mil-STD-1472 DESIGN CRITERIA HUMAN ENGINEERING Mission Directorate(s): Human Exploration and Operations Additional Key Phrase(s): Engineering Design (Phase C/D).Space
12、craft and Spacecraft Instruments Additional Categories.Accident Investigation Additional Categories.Flight Equipment Additional Categories.Packaging, Handling, Storage Additional Categories.Parts, Materials, & Processes Additional Info: Project: Space Shuttle Approval Info: Approval Date: 2012-08-23 Approval Name: mbell Approval Organization: HQ Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-
