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NASA-LLIS-1227
Lessons Learned - Adequacy of multiple checkpoints to ensure correct installation
Year: 1999
Abstract: Description of Driving Event:
A manufacturing engineer found that sixteen fasteners were not installed on Flight Wing 1 (Solar Array Assembly) two (2) days prior to shipment. Investigation revealed deficiencies and/or breakdowns in several discrete process.
Root cause:
1. Engineering design error; fastener was too short.
2. Failure to adhere to manufacturing control processes:
a. Fasteners were not installed and informal notification of fastener size error was done in lieu of formal discrepancy report (DR) documenting incorrect fastener size and lack of fastener installation.
b. Inspection/Manufacturing failure to verify completion of operation at documentation buyoff (Inspection buyoff indicated bolts were installed, but bolts were not actually installed). Operation had Operator & inspection stamps indicating installations actually occurred, which is a process violation.
3. Planning incorrectly posted a Manufacturing Change Notice; the design change adoption process was not followed. When an engineering change initiated to correct the fastener size was processed, planner did not flow the change down to the initial assembly, only subsequent assemblies.
4. Subsequent Engineering/Manufacturing/Quality Assurance hardware reviews ("shakes") failed to identify missing bolts: "Shakedown" verification process inadequate.
A manufacturing engineer found that sixteen fasteners were not installed on Flight Wing 1 (Solar Array Assembly) two (2) days prior to shipment. Investigation revealed deficiencies and/or breakdowns in several discrete process.
Root cause:
1. Engineering design error; fastener was too short.
2. Failure to adhere to manufacturing control processes:
a. Fasteners were not installed and informal notification of fastener size error was done in lieu of formal discrepancy report (DR) documenting incorrect fastener size and lack of fastener installation.
b. Inspection/Manufacturing failure to verify completion of operation at documentation buyoff (Inspection buyoff indicated bolts were installed, but bolts were not actually installed). Operation had Operator & inspection stamps indicating installations actually occurred, which is a process violation.
3. Planning incorrectly posted a Manufacturing Change Notice; the design change adoption process was not followed. When an engineering change initiated to correct the fastener size was processed, planner did not flow the change down to the initial assembly, only subsequent assemblies.
4. Subsequent Engineering/Manufacturing/Quality Assurance hardware reviews ("shakes") failed to identify missing bolts: "Shakedown" verification process inadequate.
Subject: Computer-Aided Design/Manufacturing/Engineering
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| contributor author | NASA - National Aeronautics and Space Administration (NASA) | |
| date accessioned | 2017-09-04T18:25:25Z | |
| date available | 2017-09-04T18:25:25Z | |
| date copyright | 06/03/1999 | |
| date issued | 1999 | |
| identifier other | IIVEQCAAAAAAAAAA.pdf | |
| identifier uri | http://yse.yabesh.ir/std;jsery=autho47037D83FCDCAC42/handle/yse/207609 | |
| description abstract | Description of Driving Event: A manufacturing engineer found that sixteen fasteners were not installed on Flight Wing 1 (Solar Array Assembly) two (2) days prior to shipment. Investigation revealed deficiencies and/or breakdowns in several discrete process. Root cause: 1. Engineering design error; fastener was too short. 2. Failure to adhere to manufacturing control processes: a. Fasteners were not installed and informal notification of fastener size error was done in lieu of formal discrepancy report (DR) documenting incorrect fastener size and lack of fastener installation. b. Inspection/Manufacturing failure to verify completion of operation at documentation buyoff (Inspection buyoff indicated bolts were installed, but bolts were not actually installed). Operation had Operator & inspection stamps indicating installations actually occurred, which is a process violation. 3. Planning incorrectly posted a Manufacturing Change Notice; the design change adoption process was not followed. When an engineering change initiated to correct the fastener size was processed, planner did not flow the change down to the initial assembly, only subsequent assemblies. 4. Subsequent Engineering/Manufacturing/Quality Assurance hardware reviews ("shakes") failed to identify missing bolts: "Shakedown" verification process inadequate. | |
| language | English | |
| title | NASA-LLIS-1227 | num |
| title | Lessons Learned - Adequacy of multiple checkpoints to ensure correct installation | en |
| type | standard | |
| page | 3 | |
| status | Active | |
| tree | NASA - National Aeronautics and Space Administration (NASA):;1999 | |
| contenttype | fulltext | |
| subject keywords | Computer-Aided Design/Manufacturing/Engineering | |
| subject keywords | Configuration Management | |
| subject keywords | Flight Equipment | |
| subject keywords | Ground Equipment | |
| subject keywords | Hardware | |
| subject keywords | Parts Materials & Processes | |
| subject keywords | Policy & Planning | |
| subject keywords | Procurement Small Business & Industrial Relations | |
| subject keywords | Risk Management/Assessment | |
| subject keywords | Safety & Mission Assurance | |
| subject keywords | Software | |
| subject keywords | Test & Verification |