NASA-LLIS-5536
Lessons Learned - Thumb Amputation on Sliding Door Type B Mishap
Year: 2011
Abstract: Description of Driving Event:
During a scheduled quarterly Preventive Maintenance Inspection (PMI) procedure on the Space Station Processing Facility (SSPF's) hardware receiving room, south sliding door (Work Order Report 124505, December 2006) a discrepancy was noted with the safety edge. Due to the discrepancy a Corrective Maintenance Work Order 135211 was generated to "troubleshoot and repair door sliding (HDW south), safety edge not working properly." Another scheduled annual Preventive Maintenance procedure (in March 2007) was satisfactorily completed without any discrepancies noted. However, the problem from the December PMI remained open and was carried on the shop's "to do" list. Work Order 135211was scheduled to be worked on May 31, 2007 for the purpose of correcting the discrepancy with the door's safety edge "not working properly."
Because of the nature of the problem, the contractor's Controls Engineer (CE1) was asked to assist in the event. There were some questions as to how the door's control system functions. Two technicians (T1 & T2) were assigned to the task on the morning of Thursday, May 31, 2007. Prior to beginning the troubleshooting task, technicians T1 and T2 reviewed the work order and filled out a Safe Plan of Action (SPA) assessment form which listed the hazards associated with this specific job/task, including pinch and crush hazards. After the two technicians reviewed and discussed the SPA it was presented to their supervisor who signed and approved the safety plan. The technicians were released to begin the troubleshooting job/task.
The two technicians were scheduled to meet the contractor's Control Engineer at the SSPF Ops Desk prior to beginning the task. Both technicians arrived at the SSPF operations desk to meet CE1 at approximately 10:00 a.m. Prior to meeting at the SSPF Ops Desk, T1 had retrieved a set of door drawings from the system engineer in case the Controls Engineer had some design questions. While T1 and T2 were waiting for the Controls Engineer to arrive at the SSPF Ops Desk, T2 decided to go to the work site to make any necessary preparations. T1 remained at the SSPF Ops Desk waiting for CE1 to arrive. While T2 was at the work site waiting for T1 and CE1 to arrive, he decided to check out the door discrepancy himself prior to the others arriving. T2 enlisted the assistance of another shop technician T3 (T3 was working a different job in the same general area), to help him in re-creating the safety edge discrepancy.
T2 and T3 checked the door with one technician operating the controls and the other technician tapping the safety edge on the door. They verified that contact with the safety edge would stop and reverse the door, but at some point, prior to full close, the safety edge would stop functioning. T3 went back to his assigned task, and T2 waited for T1 and CE1 on the airlock side of the mishap door.
Once CE1 arrived at the SSPF Ops Desk, CE1 and T1 walked to the work site. Almost immediately upon arrival at the work site T1 decided to demonstrate the door discrepancy to CE1. T1 did not ask for assistance from T2, and T2 was unaware that CE1 and T1 were at the mishap door beginning the troubleshooting task. T1, holding a set of rolled-up drawings in his right hand, began to operate the door controls with his left hand while at the same time attempting to activate the safety edge with his right hand holding the drawings. The door continued to travel to closure before T1 realized his finger was in an impact or pinch zone and a portion of T1's right thumb was severed by the sliding door.
During a scheduled quarterly Preventive Maintenance Inspection (PMI) procedure on the Space Station Processing Facility (SSPF's) hardware receiving room, south sliding door (Work Order Report 124505, December 2006) a discrepancy was noted with the safety edge. Due to the discrepancy a Corrective Maintenance Work Order 135211 was generated to "troubleshoot and repair door sliding (HDW south), safety edge not working properly." Another scheduled annual Preventive Maintenance procedure (in March 2007) was satisfactorily completed without any discrepancies noted. However, the problem from the December PMI remained open and was carried on the shop's "to do" list. Work Order 135211was scheduled to be worked on May 31, 2007 for the purpose of correcting the discrepancy with the door's safety edge "not working properly."
Because of the nature of the problem, the contractor's Controls Engineer (CE1) was asked to assist in the event. There were some questions as to how the door's control system functions. Two technicians (T1 & T2) were assigned to the task on the morning of Thursday, May 31, 2007. Prior to beginning the troubleshooting task, technicians T1 and T2 reviewed the work order and filled out a Safe Plan of Action (SPA) assessment form which listed the hazards associated with this specific job/task, including pinch and crush hazards. After the two technicians reviewed and discussed the SPA it was presented to their supervisor who signed and approved the safety plan. The technicians were released to begin the troubleshooting job/task.
The two technicians were scheduled to meet the contractor's Control Engineer at the SSPF Ops Desk prior to beginning the task. Both technicians arrived at the SSPF operations desk to meet CE1 at approximately 10:00 a.m. Prior to meeting at the SSPF Ops Desk, T1 had retrieved a set of door drawings from the system engineer in case the Controls Engineer had some design questions. While T1 and T2 were waiting for the Controls Engineer to arrive at the SSPF Ops Desk, T2 decided to go to the work site to make any necessary preparations. T1 remained at the SSPF Ops Desk waiting for CE1 to arrive. While T2 was at the work site waiting for T1 and CE1 to arrive, he decided to check out the door discrepancy himself prior to the others arriving. T2 enlisted the assistance of another shop technician T3 (T3 was working a different job in the same general area), to help him in re-creating the safety edge discrepancy.
T2 and T3 checked the door with one technician operating the controls and the other technician tapping the safety edge on the door. They verified that contact with the safety edge would stop and reverse the door, but at some point, prior to full close, the safety edge would stop functioning. T3 went back to his assigned task, and T2 waited for T1 and CE1 on the airlock side of the mishap door.
Once CE1 arrived at the SSPF Ops Desk, CE1 and T1 walked to the work site. Almost immediately upon arrival at the work site T1 decided to demonstrate the door discrepancy to CE1. T1 did not ask for assistance from T2, and T2 was unaware that CE1 and T1 were at the mishap door beginning the troubleshooting task. T1, holding a set of rolled-up drawings in his right hand, began to operate the door controls with his left hand while at the same time attempting to activate the safety edge with his right hand holding the drawings. The door continued to travel to closure before T1 realized his finger was in an impact or pinch zone and a portion of T1's right thumb was severed by the sliding door.
Subject: Advanced planning of safety systems
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contributor author | NASA - National Aeronautics and Space Administration (NASA) | |
date accessioned | 2017-09-04T15:39:02Z | |
date available | 2017-09-04T15:39:02Z | |
date copyright | 05/03/2011 | |
date issued | 2011 | |
identifier other | OZXKMEAAAAAAAAAA.pdf | |
identifier uri | http://yse.yabesh.ir/std/handle/yse/41156 | |
description abstract | Description of Driving Event: During a scheduled quarterly Preventive Maintenance Inspection (PMI) procedure on the Space Station Processing Facility (SSPF's) hardware receiving room, south sliding door (Work Order Report 124505, December 2006) a discrepancy was noted with the safety edge. Due to the discrepancy a Corrective Maintenance Work Order 135211 was generated to "troubleshoot and repair door sliding (HDW south), safety edge not working properly." Another scheduled annual Preventive Maintenance procedure (in March 2007) was satisfactorily completed without any discrepancies noted. However, the problem from the December PMI remained open and was carried on the shop's "to do" list. Work Order 135211was scheduled to be worked on May 31, 2007 for the purpose of correcting the discrepancy with the door's safety edge "not working properly." Because of the nature of the problem, the contractor's Controls Engineer (CE1) was asked to assist in the event. There were some questions as to how the door's control system functions. Two technicians (T1 & T2) were assigned to the task on the morning of Thursday, May 31, 2007. Prior to beginning the troubleshooting task, technicians T1 and T2 reviewed the work order and filled out a Safe Plan of Action (SPA) assessment form which listed the hazards associated with this specific job/task, including pinch and crush hazards. After the two technicians reviewed and discussed the SPA it was presented to their supervisor who signed and approved the safety plan. The technicians were released to begin the troubleshooting job/task. The two technicians were scheduled to meet the contractor's Control Engineer at the SSPF Ops Desk prior to beginning the task. Both technicians arrived at the SSPF operations desk to meet CE1 at approximately 10:00 a.m. Prior to meeting at the SSPF Ops Desk, T1 had retrieved a set of door drawings from the system engineer in case the Controls Engineer had some design questions. While T1 and T2 were waiting for the Controls Engineer to arrive at the SSPF Ops Desk, T2 decided to go to the work site to make any necessary preparations. T1 remained at the SSPF Ops Desk waiting for CE1 to arrive. While T2 was at the work site waiting for T1 and CE1 to arrive, he decided to check out the door discrepancy himself prior to the others arriving. T2 enlisted the assistance of another shop technician T3 (T3 was working a different job in the same general area), to help him in re-creating the safety edge discrepancy. T2 and T3 checked the door with one technician operating the controls and the other technician tapping the safety edge on the door. They verified that contact with the safety edge would stop and reverse the door, but at some point, prior to full close, the safety edge would stop functioning. T3 went back to his assigned task, and T2 waited for T1 and CE1 on the airlock side of the mishap door. Once CE1 arrived at the SSPF Ops Desk, CE1 and T1 walked to the work site. Almost immediately upon arrival at the work site T1 decided to demonstrate the door discrepancy to CE1. T1 did not ask for assistance from T2, and T2 was unaware that CE1 and T1 were at the mishap door beginning the troubleshooting task. T1, holding a set of rolled-up drawings in his right hand, began to operate the door controls with his left hand while at the same time attempting to activate the safety edge with his right hand holding the drawings. The door continued to travel to closure before T1 realized his finger was in an impact or pinch zone and a portion of T1's right thumb was severed by the sliding door. | |
language | English | |
title | NASA-LLIS-5536 | num |
title | Lessons Learned - Thumb Amputation on Sliding Door Type B Mishap | en |
type | standard | |
page | 4 | |
status | Active | |
tree | NASA - National Aeronautics and Space Administration (NASA):;2011 | |
contenttype | fulltext | |
subject keywords | Advanced planning of safety systems | |
subject keywords | Facilities | |
subject keywords | Maintenance |