Description of Driving Event:
Postflight discovery of a wrench and an equipment name plate in the forward skirt of one STS-79 Solid Rocket Booster (SRB) has heightened concern for the overall integrity of Space Shuttle processing quality assurance procedures.
Lesson(s) Learned:
Postflight discovery of a wrench and an equipment name plate in the forward skirt of one STS-79 Solid Rocket Booster (SRB) has heightened concern for the overall integrity of Space Shuttle processing quality assurance procedures.
Recommendation(s):
NASA, in concert with the several Space Shuttle contractors, should conduct an in-depth review of Space Shuttle processing quality assurance procedures focused on creating a more formal, documented approach to accounting for tools and other material introduced to and removed from flight hardware work areas.
Evidence of Recurrence Control Effectiveness:
The Space Shuttle program element contractors presented their tool control programs to the Space Shuttle System Safety Review Panel (SSRP) meeting in December 1996. The SSRP reviewed the tool control programs of all the contractors and determined that each of the tool programs was effective for the type of work per-formed. The SSRP recommended that tool accounting audits be maintained or increased, and that metrics be maintained to assure that each tool control program remains effective. In a letter dated March 20, 1997, the Space Shuttle Systems Integration Office confirmed that NSTS 07700, "Space Shuttle Program Definition and Requirements," requires tool control for only the launch and landing project, and recommended that Volume XI of NSTS 0770 be expanded to include tool control at the manufacturing facilities. A change request to NSTS 07700, Volume XI, adding the program requirement to include tool control at the element manufacturing facilities, was approved by the Program Requirements Control Board (PRCB) on July 10, 1997.
Documents Related to Lesson:
N/A
Mission Directorate(s):
- Space Operations
- Exploration Systems
Additional Key Phrase(s):
- Administration/Organization
- Aerospace Safety Advisory Panel
- Ground Operations
- Human Resources & Education
- Packaging Handling Storage
- Safety & Mission Assurance
Additional Info:
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