NASA-LLIS-1204
Lessons Learned – Placement of Warnings in Procedural Documents
Year: 1999
Abstract: Description of Driving Event:
During the Flight 2A (STS-88) mission, the crew was required to install rack pivot pins on the starboard re-supply/stowage rack (RSR). During the operation, the mid-bay pivot pin wedge/fitting assembly on the forward pivot pin was pushed through behind the rack resulting in lost hardware inside the ISS Node (refer to ISS PRACA PR# 1000). A setscrew on the track that receives the pivot pin wedge/fitting assembly was not installed because the RSR was installed before the setscrew was installed. The purpose of the setscrew was to prevent such a loss. Because the setscrew could not be installed without removing the RSR, the assembly order could not be completed and the engineering was revised to delete the setscrew. MOD was informed of the deletion and advised that the crew would have to hold onto the wedge/fitting assembly when loosing the bolt on the assembly for installation of the pivot pin. Root cause: MOD procedures included a warning to the crew to hold onto the pivot wedge/fitting assembly while loosing the bolt, however, the format of the procedure was such that the warning was included after the step that loosened the bolt and wound up an the following page. As a result the crew did not see the warning until too late.
During the Flight 2A (STS-88) mission, the crew was required to install rack pivot pins on the starboard re-supply/stowage rack (RSR). During the operation, the mid-bay pivot pin wedge/fitting assembly on the forward pivot pin was pushed through behind the rack resulting in lost hardware inside the ISS Node (refer to ISS PRACA PR# 1000). A setscrew on the track that receives the pivot pin wedge/fitting assembly was not installed because the RSR was installed before the setscrew was installed. The purpose of the setscrew was to prevent such a loss. Because the setscrew could not be installed without removing the RSR, the assembly order could not be completed and the engineering was revised to delete the setscrew. MOD was informed of the deletion and advised that the crew would have to hold onto the wedge/fitting assembly when loosing the bolt on the assembly for installation of the pivot pin. Root cause: MOD procedures included a warning to the crew to hold onto the pivot wedge/fitting assembly while loosing the bolt, however, the format of the procedure was such that the warning was included after the step that loosened the bolt and wound up an the following page. As a result the crew did not see the warning until too late.
Subject: Configuration Management
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| contributor author | NASA - National Aeronautics and Space Administration (NASA) | |
| date accessioned | 2017-09-04T17:16:05Z | |
| date available | 2017-09-04T17:16:05Z | |
| date copyright | 36454 | |
| date issued | 1999 | |
| identifier other | ZEVEQCAAAAAAAAAA.pdf | |
| identifier uri | http://yse.yabesh.ir/std/handle/yse/139496 | |
| description abstract | Description of Driving Event: During the Flight 2A (STS-88) mission, the crew was required to install rack pivot pins on the starboard re-supply/stowage rack (RSR). During the operation, the mid-bay pivot pin wedge/fitting assembly on the forward pivot pin was pushed through behind the rack resulting in lost hardware inside the ISS Node (refer to ISS PRACA PR# 1000). A setscrew on the track that receives the pivot pin wedge/fitting assembly was not installed because the RSR was installed before the setscrew was installed. The purpose of the setscrew was to prevent such a loss. Because the setscrew could not be installed without removing the RSR, the assembly order could not be completed and the engineering was revised to delete the setscrew. MOD was informed of the deletion and advised that the crew would have to hold onto the wedge/fitting assembly when loosing the bolt on the assembly for installation of the pivot pin. Root cause: MOD procedures included a warning to the crew to hold onto the pivot wedge/fitting assembly while loosing the bolt, however, the format of the procedure was such that the warning was included after the step that loosened the bolt and wound up an the following page. As a result the crew did not see the warning until too late. | |
| language | English | |
| title | NASA-LLIS-1204 | num |
| title | Lessons Learned – Placement of Warnings in Procedural Documents | en |
| type | standard | |
| page | 3 | |
| status | Active | |
| tree | NASA - National Aeronautics and Space Administration (NASA):;1999 | |
| contenttype | fulltext | |
| subject keywords | Configuration Management | |
| subject keywords | Flight Operations | |
| subject keywords | Ground Operations | |
| subject keywords | Human Factors | |
| subject keywords | Human Resources & Education | |
| subject keywords | Industrial Operations | |
| subject keywords | Launch Process | |
| subject keywords | Parts Materials & Processes | |
| subject keywords | Policy & Planning | |
| subject keywords | Range Operations | |
| subject keywords | Test & Verification |

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