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Lessons Learned – Human factors considerations for critical hardware lifts

contributor authorNASA - National Aeronautics and Space Administration (NASA)
date accessioned2017-09-04T15:15:37Z
date available2017-09-04T15:15:37Z
date copyright08/30/1999
date issued1999
identifier otherMGVEQCAAAAAAAAAA.pdf
identifier urihttps://yse.yabesh.ir/std/handle/yse/14622
description abstractDescription of Driving Event:
After completion of the rotation of the Z-1 truss segment using a cab-operated 30-ton overhead bridge crane, the lifting device down rods were disconnected from the flight hardware. The task leader instructed the crane director on the floor to move the crane hook up to clear the trunnions. The crane director relayed the instructions over walkie-talkie radio to the crane operator in the cab. The crane operator inadvertently commanded the hook to move in the down direction causing the lifting device down rods to make contact with the trunnions on the Z-1 truss. The operation was stopped. After examination by the task team, the crane hook was moved up and the crane was placed in the parking area and impounded. There was evidence that all four trunnions received metal-to-metal contact from the down rods. A damage assessment is being conducted. There was no damage to the lifting device or Hydra-Set and no personnel were injured.
Root cause: The root cause was determined to be human error caused by a combination of less than optimum design of the crane cab controls; inadequate communications and understanding of hoist speeds; and the failure of the emergency stop-button operator to actuate the emergency stop.
languageEnglish
titleNASA-LLIS-1215num
titleLessons Learned – Human factors considerations for critical hardware liftsen
typestandard
page3
statusActive
treeNASA - National Aeronautics and Space Administration (NASA):;1999
contenttypefulltext
subject keywordsFacilities
subject keywordsFlight Equipment
subject keywordsFlight Operations
subject keywordsGround Equipment
subject keywordsGround Operations
subject keywordsHardware
subject keywordsHuman Factors
subject keywordsIndustrial Operations
subject keywordsLifting Devices
subject keywordsPolicy & Planning
subject keywordsRisk Management/Assessment
subject keywordsSafety & Mission Assurance


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