lessons learned top-5.ppt
TRANSCRIPT
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Lessons learnt
QUALITY DIVISION - PROPELLANTS & CHEMICALS
QUALITY ASSURANCE & RELIABILITY - PROPELLANTS & CHEMICALS GROUP
SYSTEMS RELIABILITY ENTITY
Dt:10-12-2012
Presentation to PCM & PRSO-SR interface meeting
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Separation within propellant grains/mid web tear observed in
all the three segments of PS0-FM-56 and two segments of
PS0-FM 58 motors
Cause
Lumps of ground Ammonium
Perchlorate (AP) observed at the
time of addition to the mixer
PSOM Segment
Propellant Tear/Separation
Mid Web Tear in PSOM
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Implication of DeviationFrom mission point of view, separation/ tear within propellant is
not allowed. This may cause catastrophic failure of the mission.
All the segments of PSOM-FM-56 and FM-58 got rejected.
Corrective/Preventive Actions
Fine AP is to be added within 2 hrs. of grinding
Fine AP to be added in 3 installments against earlier practice
of 2 installment
Fine AP passed through sieve placed on the kneader during
addition to break the lumps, if any
Scrapping of blades after each addition of AP to the mixer
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Any deviation observed from the standard practice (may bevery minor) to be reported immediately to the supervisor and
wait for the decision before proceeding further.
Visual observation is very important. Carry out visualinspection of the raw materials, mixer, surroundings etc.
Moisture is very harmful for propellant. Take all possible steps
to prevent ingression of moisture during propellant
processing.
Lessons Learnt
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PS0-XL Igniter casting
Issue:
Rejection of Igniter propellant mix during vacuum
casting in the pressure casting vessel
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Cause:
Before propellant casting, the pressure vessel
was covered with a polythene sheet to avoidcontamination which was to be removed prior
to vacuum casting but it was not removed.
As a result, the cast propellant fell on the
Polythene sheet and inside the vacuum
chamber instead of going into the vessel.
Implication:
Mix got rejected.
Vacuum
Chamber
Pressure
casting vessel
Propellant
Polythene
wrapping
Hopper
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Corrective / Preventive action:
Checklist should be available and it is to be filledproperly and authorized by the concerned engineer.
Lessons learnt:
Visual inspection is to be carried out at every step of
operation and logged.
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Issue:
One batch of Adhesive CS2 Part A was rejecteddue to the formation of precipitate during resin
synthesis.
Strain gauge bonding cement, Adhesive CS
2 Part A Synthesis
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CaCl2 guard tube
Conc.H2SO4
To N2 cylinder
Inlet
StirrerConnections got
inter changed
outlet
Reactants
Cause :
During the assembly of the reaction setup, Inlet and outlet
of the moisture trap system [H2SO4 based] got interchanged.
Due to this, the conc. H2SO4 entered the reaction vesselcausing the formation of precipitate during resin synthesis.
Fig: Reaction Set up
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Corrective / Preventive action:
Process document with the reaction setup sketch/drawing is included.
Inlet and outlet were properly labeled.
Training was provided.
Verification of the setup prior to use by the
supervisor.
Lesson learnt: Precautions are to be taken to avoid such human
errors.
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Polarity reversal of
the electrochemical impregnation (EI) bath
Issue:
During the electrochemical impregnation step the nickel
plaques dissolved into the EI bath instead of the nickel
hydroxide active material impregnating into the plaque
matrix.
Nickel hydrogen cells are being used in spacecraft powering systems.
It consists of Nickel and Hydrogen electrodes.
Positive nickel electrode is processed in two steps:
1. Processing of Nickel plaque
2. Impregnation of Nickel hydroxide active material into the plaque.
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Cause:
Due to human error, polarity of the terminals got reversed
during the impregnation operation.
Implication:
The EI bath was rejected.
Corrective action:
Thorough check of the connections prior to the operation.
Lessons Learned:
A Log sheet/ checklist were
incorporated into the system.
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Cause
Lower TBS was due to under curing of Pedcoat liner
Insufficient quantity of curative (TDI) was added during liner
application
During weighing of TDI, empty beaker weight was not tared to
zero. As a result lower quantity of TDI was added to the Pedcoat
premix
TDI Lesser Quantity Weighed
Error in weighingInferior Tensile Bond Strength (TBS) between propellant liner-
insulation in PS0-74 Head Segment
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Implication of weighing error
Due to poor TBS property, the segment PSO-74-HS got rejected.
Corrective/Preventive Actions Weighing balance with printer is to be used.
TDI quantity by volume is also to be verified by putting mark
on the outer surface of the glass beaker
Curing condition of the liner is to be verified on the sample
surface, which is coated along with the main segment.
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A minor error in weighing caused the rejection of a PS0
segment
Ensure the calibration status of the measuring devices
Ensure proper tareing of the container
Re-verify the weighing
Pedcoat Liner Application
Lessons Learnt