Description of Driving Event:
Space Shuttle Program/Work Documentation/Unincorporated Changes
Lesson(s) Learned:
Although progress has been made to improve the quality, accuracy, and traceability of the work instructions ("paperwork" used in the processing of Space Shuttle Orbiters) much remains to be done to provide correct and unambiguous procedures. There are still too many unincorporated changes.
Recommendation(s):
Efforts to improve the quality, accuracy, and traceability of the work paper as well as the timeliness of incorporation of changes to work instructions must be given higher priority by both NASA and USA in a coordinated, systematic effort.
Evidence of Recurrence Control Effectiveness:
NASA concurs with the ASAP recommendation. During the 1999 calendar year, numerous initiatives were accomplished which established the foundation to improve the quality, accuracy, and traceability of work instructions. Examples of these initiatives include appointment of a USA documentation manager and four dedicated project leads, the creation of a new work instruction format and style guide, development of a systematic procedure to perform task and document analysis, development of the new work authorization document authoring and validation environment (WAVE) computer software to allow engineers to quickly and easily modify work instructions, and reduction of deviation backlog. With this foundation, priority was given by USA shuttle engineering to establishing a Year 2000 Strategic Initiative to "Increase the quality and level of workability of work-authorizing documentation." In addition, a comprehensive Category I Document Evaluation & Restructure (CDER) Plan was established to effectively improve the quality, accuracy, and tractability of both flight and groundwork instructions. The CDER Plan will ensure document simplification as the WAVE software, Maximo, and PeopleSoft initiatives are implemented. Work instructions, rewritten to the new standards established in 1999, will include restructuring to only include the work steps needed for that specific task as defined by the needs of the Maximo Job Plan and PeopleSoft Product Structure. Contingency steps, or steps applicable to other hardware, will be removed and placed in a separate work instruction package to avoid confusion. Also, work instructions that could be in multiple formats due to numerous previous contractor requirements will be converted to standard formats. Finally, any existing deviations will be incorporated as part of the rewrite. The end result will be a smaller, cleaner, concise work instruction package, including more graphics and pictures. The procedures will be reviewed and agreed to by the end user. This plan has two primary paths-- one for flight operations and another for ground operations. The determination of which of these paths a work instruction will follow is dependent on the criteria set forth in the PeopleSoft Product Structure and the Maximo Job Plan. PeopleSoft and Maximo are management systems through which a reduction in the time required to incorporate paperwork can be achieved. The conversion of documents to PeopleSoft and Maximo will be heavily site and flow dependent. The goal is to complete approximately 500 planned flight hardware processing work instructions for calendar year 2000, with continued emphasis in subsequent years. Selection of those work instructions is based on pre-established criteria involving run frequency and criticality. By the end of FY 1999, USA had reduced deviations approximately 25 percent, from 7,300 to 5,535. A technical standard panel has been implemented and is chartered to review errors detected by audit teams, determine the root cause of the discrepancies, and take real-time action to prevent their re-occurrence. Also, the implementation of a distributed authoring approach allows engineers to write their work instructions, provide ownership, control and accountability of their work instructions, and increase the number of operational maintenance instructions with zero deviations. To allow the engineer to make quick and easy incorporation of changes and provide on-line review and concurrence by USA and NASA prior to the work instruction being issued to processing operations, a single Universal Test Operations Procedure format has been established for all flight documents in Documentum/PeopleSoft, and a single Job Plan format has been developed for all ground documents in Maximo. A standard electronic deviation template has also been developed. These actions will assure succinct, technically accurate, and user-friendly work instructions.
Documents Related to Lesson:
N/A
Mission Directorate(s):
- Space Operations
- Exploration Systems
Additional Key Phrase(s):
- Aerospace Safety Advisory Panel
- Configuration Management
- Ground Equipment
- Ground Operations
- Parts Materials & Processes
- Spacecraft
- Test Facility
Additional Info:
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