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NASA-LLIS-1204

Lessons Learned – Placement of Warnings in Procedural Documents

Organization:
NASA - National Aeronautics and Space Administration (NASA)
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.
URI: http://yse.yabesh.ir/std/handle/yse/139496
Subject: Configuration Management
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  • NASA - National Aeronautics and Space Administration (NASA)
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    NASA-LLIS-1204

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contributor authorNASA - National Aeronautics and Space Administration (NASA)
date accessioned2017-09-04T17:16:05Z
date available2017-09-04T17:16:05Z
date copyright36454
date issued1999
identifier otherZEVEQCAAAAAAAAAA.pdf
identifier urihttp://yse.yabesh.ir/std/handle/yse/139496
description abstractDescription 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.
languageEnglish
titleNASA-LLIS-1204num
titleLessons Learned – Placement of Warnings in Procedural Documentsen
typestandard
page3
statusActive
treeNASA - National Aeronautics and Space Administration (NASA):;1999
contenttypefulltext
subject keywordsConfiguration Management
subject keywordsFlight Operations
subject keywordsGround Operations
subject keywordsHuman Factors
subject keywordsHuman Resources & Education
subject keywordsIndustrial Operations
subject keywordsLaunch Process
subject keywordsParts Materials & Processes
subject keywordsPolicy & Planning
subject keywordsRange Operations
subject keywordsTest & Verification
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DSpace software copyright © 2017-2020  DuraSpace
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