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NASA-LLIS-1272
Lessons Learned – Systemic Process Control Involving Organizational Departments
Year: 1998
Abstract: Description of Driving Event:
On 20 February, a latch locating tool (approximate weight = 500 lbs.) and its handling fixture (dolly) were loaded on a stake bed truck, strapped down, and transported to a subcontractor in Goleta, CA. During shipment one end of the latch locating tool (drill platform) slipped from the dolly and landed on the truck floor. Upon arrival at destination, the subcontractor refused the shipment due to its apparent faulty shipping condition and the platform and dolly were returned to the point of origin. One of the roller subassemblies was discovered to be missing. Tool Fabrication was able to replace the roller subassembly. A subsequent tolerance check of the tool determined that it was within tolerance and the tool was re-certified. The complete tool was then properly packaged and redispatched to the subcontractor.
Root cause: Successful teamwork requires that the team include all appropriate personnel/ contributors. Also, a small amount of additional information in the right place on key documents can greatly reduce confusion and chance for error. The following details describe a systemic breakdown in the process.
Engineering originated a Work Release Order (WRO) to ship the Mobile Transporter latch locating tool to the subcontractor. The latch locating tool consists of two parts: Part 1 (Drill Structure for prismoid holes: approximate size 5 x 8 feet), and Part 2 (Drill plate for sensor strips @ approximate size 6 x 10 inches) The drill structure has a dedicated storage container (tool engineering considers this a part of the tool.). Instead of shipping the two parts in their respective storage containers, the drill structure was shipped along with its handling fixture (dolly) and Part 2 was left behind.
The handling fixture has two locking bolts to secure the drilling structure during ground handling. The drill structure was not properly restrained by the locking bolts. The bolts were to be installed in the "V" between the front rollers, instead they were installed aft of the front rollers, thus not providing any horizontal movement restraint until the rear rollers reached the locking bolts, allowing the front end of the tool to slip out of the holding fixture and strike the bed of the truck.
Finding 1: Tool was not properly identified by Tool Control. Drill structure and handling fixture were shipped. The drill plate was left behind. Tool Control has the responsibility to:
• Identify the tool to be shipped (ensure the tool is complete)
• Prepare the tool for shipment (package/containerize as required)
• Prepare Request for Shipment form (RFS, MDM - 0625)
• Send "RFS" to Shipping Department (when tool is ready for shipment)
• After shipment, receive "Packing Sheet" and update inventory log, to indicate the tool has been shipped.
Finding 2: Tool was not properly packaged for shipment: dedicated container was not used, resulting in drill structure not being properly secured in the handling fixture.
Finding 3: WRO did not state (nor was it required to provide the detail) that the tool consisted of 2 parts. It did not explain that the handling fixture is not to be included in the shipment.
Finding 4: WRO did not have signature block (nor was it required to provide the detail) for department responsible for tool shipment, namely Production Control.
Finding 5: RFS did not state (nor was it required to provide the detail) that the tool consisted of 2 parts. It did not explain that the Handling Fixture was not to be included in the shipment.
Finding 6: PHS&T (Packaging, Handling, Storage & Transportation) signed the WRO which tasked them to provide "technical support and coordination for major shipment per NHB 6000.1". PHS&T did not get involved in tool shipments. Tool shipment preparation responsibility is entirely within Manufacturing Production Control (Tool Control).
Finding 7: QA (Receiving and Shipping Inspection) failed to detect that what was being shipped was incorrect.
On 20 February, a latch locating tool (approximate weight = 500 lbs.) and its handling fixture (dolly) were loaded on a stake bed truck, strapped down, and transported to a subcontractor in Goleta, CA. During shipment one end of the latch locating tool (drill platform) slipped from the dolly and landed on the truck floor. Upon arrival at destination, the subcontractor refused the shipment due to its apparent faulty shipping condition and the platform and dolly were returned to the point of origin. One of the roller subassemblies was discovered to be missing. Tool Fabrication was able to replace the roller subassembly. A subsequent tolerance check of the tool determined that it was within tolerance and the tool was re-certified. The complete tool was then properly packaged and redispatched to the subcontractor.
Root cause: Successful teamwork requires that the team include all appropriate personnel/ contributors. Also, a small amount of additional information in the right place on key documents can greatly reduce confusion and chance for error. The following details describe a systemic breakdown in the process.
Engineering originated a Work Release Order (WRO) to ship the Mobile Transporter latch locating tool to the subcontractor. The latch locating tool consists of two parts: Part 1 (Drill Structure for prismoid holes: approximate size 5 x 8 feet), and Part 2 (Drill plate for sensor strips @ approximate size 6 x 10 inches) The drill structure has a dedicated storage container (tool engineering considers this a part of the tool.). Instead of shipping the two parts in their respective storage containers, the drill structure was shipped along with its handling fixture (dolly) and Part 2 was left behind.
The handling fixture has two locking bolts to secure the drilling structure during ground handling. The drill structure was not properly restrained by the locking bolts. The bolts were to be installed in the "V" between the front rollers, instead they were installed aft of the front rollers, thus not providing any horizontal movement restraint until the rear rollers reached the locking bolts, allowing the front end of the tool to slip out of the holding fixture and strike the bed of the truck.
Finding 1: Tool was not properly identified by Tool Control. Drill structure and handling fixture were shipped. The drill plate was left behind. Tool Control has the responsibility to:
• Identify the tool to be shipped (ensure the tool is complete)
• Prepare the tool for shipment (package/containerize as required)
• Prepare Request for Shipment form (RFS, MDM - 0625)
• Send "RFS" to Shipping Department (when tool is ready for shipment)
• After shipment, receive "Packing Sheet" and update inventory log, to indicate the tool has been shipped.
Finding 2: Tool was not properly packaged for shipment: dedicated container was not used, resulting in drill structure not being properly secured in the handling fixture.
Finding 3: WRO did not state (nor was it required to provide the detail) that the tool consisted of 2 parts. It did not explain that the handling fixture is not to be included in the shipment.
Finding 4: WRO did not have signature block (nor was it required to provide the detail) for department responsible for tool shipment, namely Production Control.
Finding 5: RFS did not state (nor was it required to provide the detail) that the tool consisted of 2 parts. It did not explain that the Handling Fixture was not to be included in the shipment.
Finding 6: PHS&T (Packaging, Handling, Storage & Transportation) signed the WRO which tasked them to provide "technical support and coordination for major shipment per NHB 6000.1". PHS&T did not get involved in tool shipments. Tool shipment preparation responsibility is entirely within Manufacturing Production Control (Tool Control).
Finding 7: QA (Receiving and Shipping Inspection) failed to detect that what was being shipped was incorrect.
Subject: Administration/Organization
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| contributor author | NASA - National Aeronautics and Space Administration (NASA) | |
| date accessioned | 2017-09-04T17:57:27Z | |
| date available | 2017-09-04T17:57:27Z | |
| date copyright | 06/20/1998 | |
| date issued | 1998 | |
| identifier other | FOVEQCAAAAAAAAAA.pdf | |
| identifier uri | http://yse.yabesh.ir/std;jsery=autho162s7D8308/handle/yse/180567 | |
| description abstract | Description of Driving Event: On 20 February, a latch locating tool (approximate weight = 500 lbs.) and its handling fixture (dolly) were loaded on a stake bed truck, strapped down, and transported to a subcontractor in Goleta, CA. During shipment one end of the latch locating tool (drill platform) slipped from the dolly and landed on the truck floor. Upon arrival at destination, the subcontractor refused the shipment due to its apparent faulty shipping condition and the platform and dolly were returned to the point of origin. One of the roller subassemblies was discovered to be missing. Tool Fabrication was able to replace the roller subassembly. A subsequent tolerance check of the tool determined that it was within tolerance and the tool was re-certified. The complete tool was then properly packaged and redispatched to the subcontractor. Root cause: Successful teamwork requires that the team include all appropriate personnel/ contributors. Also, a small amount of additional information in the right place on key documents can greatly reduce confusion and chance for error. The following details describe a systemic breakdown in the process. Engineering originated a Work Release Order (WRO) to ship the Mobile Transporter latch locating tool to the subcontractor. The latch locating tool consists of two parts: Part 1 (Drill Structure for prismoid holes: approximate size 5 x 8 feet), and Part 2 (Drill plate for sensor strips @ approximate size 6 x 10 inches) The drill structure has a dedicated storage container (tool engineering considers this a part of the tool.). Instead of shipping the two parts in their respective storage containers, the drill structure was shipped along with its handling fixture (dolly) and Part 2 was left behind. The handling fixture has two locking bolts to secure the drilling structure during ground handling. The drill structure was not properly restrained by the locking bolts. The bolts were to be installed in the "V" between the front rollers, instead they were installed aft of the front rollers, thus not providing any horizontal movement restraint until the rear rollers reached the locking bolts, allowing the front end of the tool to slip out of the holding fixture and strike the bed of the truck. Finding 1: Tool was not properly identified by Tool Control. Drill structure and handling fixture were shipped. The drill plate was left behind. Tool Control has the responsibility to: • Identify the tool to be shipped (ensure the tool is complete) • Prepare the tool for shipment (package/containerize as required) • Prepare Request for Shipment form (RFS, MDM - 0625) • Send "RFS" to Shipping Department (when tool is ready for shipment) • After shipment, receive "Packing Sheet" and update inventory log, to indicate the tool has been shipped. Finding 2: Tool was not properly packaged for shipment: dedicated container was not used, resulting in drill structure not being properly secured in the handling fixture. Finding 3: WRO did not state (nor was it required to provide the detail) that the tool consisted of 2 parts. It did not explain that the handling fixture is not to be included in the shipment. Finding 4: WRO did not have signature block (nor was it required to provide the detail) for department responsible for tool shipment, namely Production Control. Finding 5: RFS did not state (nor was it required to provide the detail) that the tool consisted of 2 parts. It did not explain that the Handling Fixture was not to be included in the shipment. Finding 6: PHS&T (Packaging, Handling, Storage & Transportation) signed the WRO which tasked them to provide "technical support and coordination for major shipment per NHB 6000.1". PHS&T did not get involved in tool shipments. Tool shipment preparation responsibility is entirely within Manufacturing Production Control (Tool Control). Finding 7: QA (Receiving and Shipping Inspection) failed to detect that what was being shipped was incorrect. | |
| language | English | |
| title | NASA-LLIS-1272 | num |
| title | Lessons Learned – Systemic Process Control Involving Organizational Departments | en |
| type | standard | |
| page | 4 | |
| status | Active | |
| tree | NASA - National Aeronautics and Space Administration (NASA):;1998 | |
| contenttype | fulltext | |
| subject keywords | Administration/Organization | |
| subject keywords | Configuration Management | |
| subject keywords | Flight Operations | |
| subject keywords | Ground Operations | |
| subject keywords | Industrial Operations | |
| subject keywords | Logistics | |
| subject keywords | Packaging Handling Storage | |
| subject keywords | Parts Materials & Processes | |
| subject keywords | Policy & Planning | |
| subject keywords | Range Operations | |
| subject keywords | Risk Management/Assessment | |
| subject keywords | Safety & Mission Assurance | |
| subject keywords | Transportation |