lessons learned top-5.ppt

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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