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NASA-LLIS-1260
Lessons Learned - Discipline Rigor in Routine Processes
Year: 2002
Abstract: Description of Driving Event:
On 24 April 2002, 7:35 a.m. (CST) two employees, working in a Clean Room configured for glass inspection and assembly, were rotating a Flight Cupola Trapezoidal Debris Pane as part of a planned event to setup for the final glass inspection prior to assembling the pane into the frame. During the rotation, the glass made contact with the aluminum table which caused a shatter mark internal to the glass, approximately .300" X .500" at the edge. The incident was reported to the Quality Assurance and S&MA managers and all glass handling activities in the shop was suspended pending a detailed investigation and corrective action. DCMA was en route to the inspection room when the incident occurred. Non-Conformance #17817 was also initiated to document the incident. Lesson Foundation/ Root Cause: The following were determined to be the root causes of the glass damage incident and suggested areas for improvements:
• The glass teetered on the foam blocks used to support the glass during rotation causing the corner of the cupola glass Trapezoidal debris pane to impact the table. Improvements to the foam blocks used for the rotation and other glass shop aids need to be implemented.
• The impact of the glass on the anodized aluminum table surface caused the glass damage. Softer materials for the glass work surfaces need to be evaluated.
• There was a miscommunication between the 2 technicians handling the glass and what to do with the corner blocks. Improved methods of communication between the glass handlers and the task leaders need to be evaluated.
On 24 April 2002, 7:35 a.m. (CST) two employees, working in a Clean Room configured for glass inspection and assembly, were rotating a Flight Cupola Trapezoidal Debris Pane as part of a planned event to setup for the final glass inspection prior to assembling the pane into the frame. During the rotation, the glass made contact with the aluminum table which caused a shatter mark internal to the glass, approximately .300" X .500" at the edge. The incident was reported to the Quality Assurance and S&MA managers and all glass handling activities in the shop was suspended pending a detailed investigation and corrective action. DCMA was en route to the inspection room when the incident occurred. Non-Conformance #17817 was also initiated to document the incident. Lesson Foundation/ Root Cause: The following were determined to be the root causes of the glass damage incident and suggested areas for improvements:
• The glass teetered on the foam blocks used to support the glass during rotation causing the corner of the cupola glass Trapezoidal debris pane to impact the table. Improvements to the foam blocks used for the rotation and other glass shop aids need to be implemented.
• The impact of the glass on the anodized aluminum table surface caused the glass damage. Softer materials for the glass work surfaces need to be evaluated.
• There was a miscommunication between the 2 technicians handling the glass and what to do with the corner blocks. Improved methods of communication between the glass handlers and the task leaders need to be evaluated.
Subject: Configuration Management
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| contributor author | NASA - National Aeronautics and Space Administration (NASA) | |
| date accessioned | 2017-09-04T15:43:42Z | |
| date available | 2017-09-04T15:43:42Z | |
| date copyright | 07/09/2002 | |
| date issued | 2002 | |
| identifier other | PMVEQCAAAAAAAAAA.pdf | |
| identifier uri | https://yse.yabesh.ir/std/handle/yse/45971 | |
| description abstract | Description of Driving Event: On 24 April 2002, 7:35 a.m. (CST) two employees, working in a Clean Room configured for glass inspection and assembly, were rotating a Flight Cupola Trapezoidal Debris Pane as part of a planned event to setup for the final glass inspection prior to assembling the pane into the frame. During the rotation, the glass made contact with the aluminum table which caused a shatter mark internal to the glass, approximately .300" X .500" at the edge. The incident was reported to the Quality Assurance and S&MA managers and all glass handling activities in the shop was suspended pending a detailed investigation and corrective action. DCMA was en route to the inspection room when the incident occurred. Non-Conformance #17817 was also initiated to document the incident. Lesson Foundation/ Root Cause: The following were determined to be the root causes of the glass damage incident and suggested areas for improvements: • The glass teetered on the foam blocks used to support the glass during rotation causing the corner of the cupola glass Trapezoidal debris pane to impact the table. Improvements to the foam blocks used for the rotation and other glass shop aids need to be implemented. • The impact of the glass on the anodized aluminum table surface caused the glass damage. Softer materials for the glass work surfaces need to be evaluated. • There was a miscommunication between the 2 technicians handling the glass and what to do with the corner blocks. Improved methods of communication between the glass handlers and the task leaders need to be evaluated. | |
| language | English | |
| title | NASA-LLIS-1260 | num |
| title | Lessons Learned - Discipline Rigor in Routine Processes | en |
| type | standard | |
| page | 3 | |
| status | Active | |
| tree | NASA - National Aeronautics and Space Administration (NASA):;2002 | |
| contenttype | fulltext | |
| subject keywords | Configuration Management | |
| subject keywords | Flight Equipment | |
| subject keywords | Flight Operations | |
| subject keywords | Ground Equipment | |
| subject keywords | Ground Operations | |
| subject keywords | Hardware | |
| subject keywords | Industrial Operations | |
| subject keywords | Parts Materials & Processes | |
| subject keywords | Risk Management/Assessment | |
| subject keywords | Test & Verification |