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NASA-LLIS-1338
Lessons Learned - Stennis Space Center Near-Miss/Ground Support Equipment
Year: 2002
Abstract: Description of Driving Event:
On Monday, April 15, 2002 at approximately 5:45 PM the following incident occurred on the Stennis Space Center A1 test stand, level 5 upper engine work deck.
Subsequent to the removal and replacement of a High Pressure Fuel Pump the upper engine deck extension piece was rolled away from the main upper engine deck with the pump lifting/handling device still on the upper engine deck extension piece. The pump lifting device fell off the upper engine deck pinning a quality inspector between it and the upper engine deck handrail. The arm of the pump lifting/handling device was moved enough for the employee to be moved away and the deck was cleared. The device was secured in the as-rested position and the deck was cordoned off. The employee was able to walk on his own to inside the test stand. The employee was transported to a local hospital for an examination as a precaution. Photographs were taken of the area and equipment involved (contact Michael McDaniel, 228-688-2233).
An investigation/preventive action team was formed by management on the morning of Tuesday, April 16, 2002 to investigate, find the root cause, and make corrective action recommendations.
The A1 test stand had been recently reconfigured from a previous test program to a different test program after a 5 year period. The test team had moved from the A2 test stand to the A1 test stand. The test team did not feel this was a factor due to the similarities between the two test stands. The normal configuration for all pump removals is to use a roll-around work deck extension piece secured to the main work deck via turnbuckles.
On Monday, April 15, 2002 at approximately 5:45 PM the following incident occurred on the Stennis Space Center A1 test stand, level 5 upper engine work deck.
Subsequent to the removal and replacement of a High Pressure Fuel Pump the upper engine deck extension piece was rolled away from the main upper engine deck with the pump lifting/handling device still on the upper engine deck extension piece. The pump lifting device fell off the upper engine deck pinning a quality inspector between it and the upper engine deck handrail. The arm of the pump lifting/handling device was moved enough for the employee to be moved away and the deck was cleared. The device was secured in the as-rested position and the deck was cordoned off. The employee was able to walk on his own to inside the test stand. The employee was transported to a local hospital for an examination as a precaution. Photographs were taken of the area and equipment involved (contact Michael McDaniel, 228-688-2233).
An investigation/preventive action team was formed by management on the morning of Tuesday, April 16, 2002 to investigate, find the root cause, and make corrective action recommendations.
The A1 test stand had been recently reconfigured from a previous test program to a different test program after a 5 year period. The test team had moved from the A2 test stand to the A1 test stand. The test team did not feel this was a factor due to the similarities between the two test stands. The normal configuration for all pump removals is to use a roll-around work deck extension piece secured to the main work deck via turnbuckles.
Subject: Ground Equipment
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| contributor author | NASA - National Aeronautics and Space Administration (NASA) | |
| date accessioned | 2017-09-04T17:33:04Z | |
| date available | 2017-09-04T17:33:04Z | |
| date copyright | 04/15/2002 | |
| date issued | 2002 | |
| identifier other | DBWEQCAAAAAAAAAA.pdf | |
| identifier uri | http://yse.yabesh.ir/std/handle/yse/156025 | |
| description abstract | Description of Driving Event: On Monday, April 15, 2002 at approximately 5:45 PM the following incident occurred on the Stennis Space Center A1 test stand, level 5 upper engine work deck. Subsequent to the removal and replacement of a High Pressure Fuel Pump the upper engine deck extension piece was rolled away from the main upper engine deck with the pump lifting/handling device still on the upper engine deck extension piece. The pump lifting device fell off the upper engine deck pinning a quality inspector between it and the upper engine deck handrail. The arm of the pump lifting/handling device was moved enough for the employee to be moved away and the deck was cleared. The device was secured in the as-rested position and the deck was cordoned off. The employee was able to walk on his own to inside the test stand. The employee was transported to a local hospital for an examination as a precaution. Photographs were taken of the area and equipment involved (contact Michael McDaniel, 228-688-2233). An investigation/preventive action team was formed by management on the morning of Tuesday, April 16, 2002 to investigate, find the root cause, and make corrective action recommendations. The A1 test stand had been recently reconfigured from a previous test program to a different test program after a 5 year period. The test team had moved from the A2 test stand to the A1 test stand. The test team did not feel this was a factor due to the similarities between the two test stands. The normal configuration for all pump removals is to use a roll-around work deck extension piece secured to the main work deck via turnbuckles. | |
| language | English | |
| title | NASA-LLIS-1338 | num |
| title | Lessons Learned - Stennis Space Center Near-Miss/Ground Support Equipment | en |
| type | standard | |
| page | 3 | |
| status | Active | |
| tree | NASA - National Aeronautics and Space Administration (NASA):;2002 | |
| contenttype | fulltext | |
| subject keywords | Ground Equipment | |
| subject keywords | Ground Operations | |
| subject keywords | Human Factors | |
| subject keywords | Occupational Health | |
| subject keywords | Policy & Planning | |
| subject keywords | Test Facility |