Memoir: Hot War - Cold War | Page 7

mistake that results from the manner in which these and other unique characteristics are organized or operate needs to consider all of the elements that contributed to the circumstances and environment within which the mistake occurred. The most immediate task, beyond safety to life inside and outside the workplace, is to organize available skills and resources so as to pinpoint the cause of the mistake; determine, specify, and correlate the steps of a corrective action, implement the fix, and reduce the likelihood of the mistake's recurrence.
The Checklist is a Tool of the Corrective Action Team
Several thousand units of a newly designed device, manufactured in one plant, were found to have a defective part. The first-level assembly, into which the defective part was initially installed at a product-line workstation, had then moved on to subsequent workstations where they were incorporated into higher-level assemblies. Eventually, the assembly, with the defective part still installed, made its way through final assembly.??
Several hundred completed devices (the end items), incorporating the defective part, were in post-final-assembly. They were in holding areas, on their way to or already in the shipping department's temporary storage warehouse, or had been loaded on to shipping vans of which the drivers were finishing up paper work to depart for destinations throughout the country to deliver the finished devices to wholesalers, distributors, or ultimate retailer. Another several hundred devices had previously departed the plant and were in the transportation pipeline, at dealers and retailers, or in the possession of consumers. Each completed device (the manufacturer's end item) and its outer shipping container had its own visible serial-number identification.
ANALYSIS
- What was the mistake???
- Did a part break, crack, bend or misalign???
- Was a circuit incomplete???
- Were incorrect materials used or dimensions applied???
- What really happened???
- Have you and concerned supervisors and staff examined physical evidence of the mistake???
- Do you know where in the plant the mistake actually occurred???
- Have you pinpointed and brought to the attention of the management and production staff the specific work unit and workstation where the error was first noticed???
- Did you backtrack along the production line to the workstation and employee where the mistake was made???
- Did you track the mistake forward along the production system to ascertain the extent to which the fault was included in higher assemblies?
- Did you stop the work operation that was creating the mistake???
- Should you institute a work stoppage???
- Did you identify the people, skills, materials, tools, equipment, and data in all related programs, work practices and procedures that caused or contributed to the mistake???
- Do you know which were directly responsible???
- Do you know which were indirect contributors???
- Do you know how they became part of the approved design, vendor support, and/or production process???
- Have you identified where (functions, work units) and with whom (supervisors) the accountability lays???
- Must you correct the mistake on the completed/shipped end items or on items on which rework would be economically or technologically unprofitable or impractical? In answering this question have you considered???
- Safe and economical use of the final product by the ultimate consumer???
- Acceptability under established quality standards and the governing technical specifications and contracts???
- The effect on the part's and the end item's service life???
- Maintainability and accessibility of the part in the end item during normal usage???
- The effect on the cost of operating the end item, and reducing the time between maintenance inspections, parts replacements, and end item overhaul schedules???
- Have you reviewed the design specifications to ensure that the (consumer's) intended use of the device has not been compromised by the defective part???
- If the error will not cause significant deviations from approved drawings, technical and contractual specifications, should you review the situation with the customers (consumers) before taking any further action on those items that now incorporate the defect???
- Should you impose a work stoppage on the affected product lines???
- Do you know what the effects of a work stoppage will be on?
- The affected product lines and the shop activities that support them???
- Your contractual commitments? ?? - Do you have alternate workloads that can be readily inserted into the production line gaps until a corrective action decision for the mistake can be implemented and routine production continue???
- Were parts, assemblies or end items incorporating the error shipped from your plant and/or are they in your packaging/ shipping departments being prepared for shipment? If they were/are:??
- Have you estimated the effects of the mistake on the market place???
- Have you estimated the effects of a decision to recall the defective items from your customers, dealers, and consumers???
- Should further preparation for shipment (preservation and packaging) of the item be halted???
- Are trucks or freight cars now being loaded by your shipping department with items that contain the production error???
- Should the shipments be halted???
- Should