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NASA-LLIS-1210
Lessons Learned - Procedural Control (Deviation from Approved Procedures)
Year: 1999
Abstract: Description of Driving Event:
During the performance of closed hatch environmental control / life support system (ECLSS) test, Boeing Engineering authorized a deviation to the pre-approved hazardous procedure. The task and procedure to configure the oxygen supply system was to be performed by a subtask document written by a Boeing ground contractor. The subtask document specifically performed the setup, leak check, oxygen supply and shutdown of oxygen systems. The deviated procedure failed to utilize the steps from the subtask document and could have potentially subjected an in-line flex hose lined with Polytetrafluoroethylene to adiabatic compression caused by pneumatic impact. Teflon-lined flex hoses can ignite from pneumatic impacts from tremendous heat build-up. The subtask documents written steps avoid this potential by specific valve configurations and slow system pressurization rates. The written deviation did however; specify the slow delivery of oxygen to the U.S. Lab. No damage occurred to the flight hardware or GSE as a result of operations performed per the deviated procedure.
Root cause: Deviation from approved written hazardous procedure.
During the performance of closed hatch environmental control / life support system (ECLSS) test, Boeing Engineering authorized a deviation to the pre-approved hazardous procedure. The task and procedure to configure the oxygen supply system was to be performed by a subtask document written by a Boeing ground contractor. The subtask document specifically performed the setup, leak check, oxygen supply and shutdown of oxygen systems. The deviated procedure failed to utilize the steps from the subtask document and could have potentially subjected an in-line flex hose lined with Polytetrafluoroethylene to adiabatic compression caused by pneumatic impact. Teflon-lined flex hoses can ignite from pneumatic impacts from tremendous heat build-up. The subtask documents written steps avoid this potential by specific valve configurations and slow system pressurization rates. The written deviation did however; specify the slow delivery of oxygen to the U.S. Lab. No damage occurred to the flight hardware or GSE as a result of operations performed per the deviated procedure.
Root cause: Deviation from approved written hazardous procedure.
Subject: Configuration Management
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| contributor author | NASA - National Aeronautics and Space Administration (NASA) | |
| date accessioned | 2017-09-04T16:07:19Z | |
| date available | 2017-09-04T16:07:19Z | |
| date copyright | 08/30/1999 | |
| date issued | 1999 | |
| identifier other | SAVEQCAAAAAAAAAA.pdf | |
| identifier uri | https://yse.yabesh.ir/std/handle/yse/70493 | |
| description abstract | Description of Driving Event: During the performance of closed hatch environmental control / life support system (ECLSS) test, Boeing Engineering authorized a deviation to the pre-approved hazardous procedure. The task and procedure to configure the oxygen supply system was to be performed by a subtask document written by a Boeing ground contractor. The subtask document specifically performed the setup, leak check, oxygen supply and shutdown of oxygen systems. The deviated procedure failed to utilize the steps from the subtask document and could have potentially subjected an in-line flex hose lined with Polytetrafluoroethylene to adiabatic compression caused by pneumatic impact. Teflon-lined flex hoses can ignite from pneumatic impacts from tremendous heat build-up. The subtask documents written steps avoid this potential by specific valve configurations and slow system pressurization rates. The written deviation did however; specify the slow delivery of oxygen to the U.S. Lab. No damage occurred to the flight hardware or GSE as a result of operations performed per the deviated procedure. Root cause: Deviation from approved written hazardous procedure. | |
| language | English | |
| title | NASA-LLIS-1210 | num |
| title | Lessons Learned - Procedural Control (Deviation from Approved Procedures) | en |
| type | standard | |
| page | 2 | |
| status | Active | |
| tree | NASA - National Aeronautics and Space Administration (NASA):;1999 | |
| contenttype | fulltext | |
| subject keywords | Configuration Management | |
| subject keywords | Facilities | |
| subject keywords | Flight Operations | |
| subject keywords | Ground Operations | |
| subject keywords | Independent Verification and Validation | |
| subject keywords | Industrial Operations | |
| subject keywords | Launch Process | |
| subject keywords | Parts Materials & Processes | |
| subject keywords | Policy & Planning | |
| subject keywords | Risk Management/Assessment | |
| subject keywords | Safety & Mission Assurance | |
| subject keywords | Test & Verification | |
| subject keywords | Test Article | |
| subject keywords | Test Facility |