Parts were purchased from an unapproved supplier (e.g. customer has a listing of approved suppliers though we are the distributor - VMI). My predecessor placed the parts on Quality Hold in December of 2006. As of April of 2006 when I took his position, the parts still had not been dispositioned. I had the responsibility of closing out the issues. No problem! After the fact, it was discovered that not all product from the unapproved supplier was placed on QC Hold. It was sent to the customer and the customer rejected it. The root cause seems to be that all product from the unapproved supplier was not placed in QC Hold. My boss thinks that I should issue the CAR to myself, but quite frankly, I think it should be issued to him. The product should've been dispositioned within 14 days of the QC Hold. 7 months later, he should have been the one to step in and find out why the issue had not been resolved. He IS management.

What do you think?

Parts were purchased from an unapproved supplier (e.g. customer has a listing of approved suppliers though we are the distributor - VMI). My predecessor placed the parts on Quality Hold in December of 2006. As of April of 2006 when I took his position, the parts still had not been dispositioned. I had the responsibility of closing out the issues. No problem! After the fact, it was discovered that not all product from the unapproved supplier was placed on QC Hold. It was sent to the customer and the customer rejected it. The root cause seems to be that all product from the unapproved supplier was not placed in QC Hold. My boss thinks that I should issue the CAR to myself, but quite frankly, I think it should be issued to him. The product should've been dispositioned within 14 days of the QC Hold. 7 months later, he should have been the one to step in and find out why the issue had not been resolved. He IS management.

What do you think?

Hello eightthirty,

What does your "Control of Nonconforming Product" procedure say?
Who "owns" the process and activities that you described in your post?
Look at provisions for "responsibility and authority."
Investigate in what manner this process failed to meet the requirements.
Then.....deal with it.

Hope this helps.

Stijloor.

Parts were purchased from an unapproved supplier (e.g. customer has a listing of approved suppliers though we are the distributor - VMI). My predecessor placed the parts on Quality Hold in December of 2006. As of April of 2006 when I took his position, the parts still had not been dispositioned. I had the responsibility of closing out the issues. No problem! After the fact, it was discovered that not all product from the unapproved supplier was placed on QC Hold. It was sent to the customer and the customer rejected it. The root cause seems to be that all product from the unapproved supplier was not placed in QC Hold. My boss thinks that I should issue the CAR to myself, but quite frankly, I think it should be issued to him. The product should've been dispositioned within 14 days of the QC Hold. 7 months later, he should have been the one to step in and find out why the issue had not been resolved. He IS management.

What do you think?

I think that the simplest path to correcting the problem and preventing its recurrence should be identified, and no one should be blamed for causing it. CA is not a blunt instrument, and should never be used as one.

I think that the simplest path to correcting the problem and preventing its recurrence should be identified, and no one should be blamed for causing it. CA is not a blunt instrument, and should never be used as one.

Jim is absolutely right in stating that the CA process should never be used in a punitive manner. When CA becomes personal, the process deteriorates into an internal political game....... Been there, (no, not done that), no fun.

Stijloor.

Define the problem, document within your system; review the “cause of problem” and the “cause of escape” – identified the “root cause/s”, instigate “preventative action/s”, verify “preventative action” on future activities – move on to the next issue, handle in a professional manner – you find it’s the processes that result in actions.

Never start a CAR with an assumption of blame; people at all level will start to hide problems, and it’s the company that will be affected.

The root cause seems to be that all product from the unapproved supplier was not placed in QC Hold. My boss thinks that I should issue the CAR to myself, but quite frankly, I think it should be issued to him. ...What do you think?I think that you have to be very careful. Your boss might be trying to cover his/her derriere. While I wholeheartedly agree that the CA process is not supposed to point finger, hunt witches or assign blame, in a few (and hopefully rare) instances, the root cause investigation could lead to a scenario where by someone with the authority and responsibility deliberately bypasses hold points and knowingly ships non-conforming products, without a customer consent or waiver. That is one of the most egregious infractions in the Q world. If that were the result of the root cause investigation, BLAME should be associated with that behavior and disciplinary actions would be in order.

I agree with the others in that you should use the CAR as tool to ensure it does not happen again. You may be issued with the CAR but that does not mean you are to blame for the fault. Your system is to blame for not preventing it's occurrence. Therefore your system needs to be fixed. Do you own the process? If so then the CAR is your bag, but you can involve whoever you want in fixing the problem, as long as it justifies the end.

The root cause seems to be that all product from the unapproved supplier was not placed in QC Hold.

IMO, I would say that this is not your "Root" cause, as this is an effect of another cause. If you see what I mean, when fixing that problem, would be to simply say, "Make sure it is all put into QC hold next time". Why was it not all put into QC hold? Is this a training/personnel/human error thing? You should also look at why this stock was ordered in the first place.

If you don't already use "5-Whys" to drill down to the root of the problem you should try it.

I agree with all the previous posts.

CAR's shouldn't be for assigning blame, but for resolving the issue and making sure it doesn't happen again.

Assign the blame in the root cause analysis.

By answering the CAR you're just the responder, not necessarily at fault. Unless your management is petty and ignorant and rates people by how many CAR's are assigned to them.

Such good responses so far.

A CAR is assigned to a process, not a person. A person's name goes on it only as owner of the process and, as such the person who would be managing the fix.

As Stjloor said, the process owner or person under Responsiblity/Authority for placing the materials on hold should be given the CAR. A secondary/assist is the person responsible for disposition (was there supposed to be a MRB?) and this person can be listed on the CAR as such. This would be the current process owner and not the one in place at that time, because the object is to fix the process in a mindset of avoiding this from happening again.

That is the explanation you can give to whomever will be assigned this CAR. As other posters have said, a CAR should not be confused with a disciplinary action. It's merely a tool to track activities that are involved with changes to correct a system's dysfunction. I want to urge you take care in how this is communicated, as Sidney said, if you are not the process owner.

Sounds like you are the process owner or one of them. Of course something is fishy if you are acting as an internal auditor and you are dispositioning material...you are not suppose to audit yourself. Just make it clear in the CAR description what happened. Is the root cause of the issue the material not getting dispositioned or is root cause really a poor change management system, moreover, one person leaving a position and one person coming in and stuff not getting done because of the change over? :tg: I love having one big solid tooth, it make peeling apples really easy...

Controlling non-conforming product is like a couple of other procedures (document control, records, audits etc.) in the company - they are cross-functional, and often no-one 'owns' the process. It's a bit of a Cinderella process, really. It often is perceived as making people 'look bad' for the reasons noted in the OP and it takes someone with a good bit of knowledge on how it's supposed to be operated.

I rather doubt anyone is actually the process owner. It doesn't fall 'naturally' to any part of the organization and can end up being treated like 'pass the parcel'.

If no-one actually owns it (and I mean really owns it), then I'd suggest finding a good candidate who can fully comprehend the requirements, how the process is supposed to operate and benefit the organization by being used to keep track of stuff which is 'bad' and use the data from it for CI actions.......

Controlling non-conforming product is like a couple of other procedures (document control, records, audits etc.) in the company - they are cross-functional, and often no-one 'owns' the process. It's a bit of a Cinderella process, really. It often is perceived as making people 'look bad' for the reasons noted in the OP and it takes someone with a good bit of knowledge on how it's supposed to be operated.

I rather doubt anyone is actually the process owner. It doesn't fall 'naturally' to any part of the organization and can end up being treated like 'pass the parcel'.

If no-one actually owns it (and I mean really owns it), then I'd suggest finding a good candidate who can fully comprehend the requirements, how the process is supposed to operate and benefit the organization by being used to keep track of stuff which is 'bad' and use the data from it for CI actions.......

We have no problems knowing who owns the control of non-conforming product. QC do. If you have processes whereby no-one takes ownership, you lose all control and you get exactly what that IBM advert used to show:

"I thought you were supposed to do it" syndrome.

You are failing not only your business, but at least two (4.1 & 5.5, assuming ISO9001) clauses in the standard by lack of responsibility and ownership for and of your processes.

Hello Eightthirty:

What does the following statement mean from your orginal posting"

"I had the responsibility of closing out the issues."

What does "closing out the issue" mean? I would think that closing out the issue means cleaning up all loose ends including the issue that you are discussing now.

Regards,

Dirk

Ask the 5 Whys - everytime you get what looks like the correct answer, ask why that happened. Do this until the answers become boring.

There will be enough blame to go around for everybody, and maybe some systems will get fixed.

Do this until the answers become boring.That is what I call a precise and scientific approach to root cause investigation....:tg:There will be enough blame to go around for everybodyThat is the sure fire way to make any dysfunctional organization even worse: spread the blame!:mad:

Thank you for all of your responses! You have all provided very valuable insight.

First of all, I think my inexperience with CAR's and ISO in general led me to believe that it was related to disciplinary action. Your replies have assured me that it is not supposed to be the case.

I say "supposed to be" because not too long ago, I filled out a CCF with the problem, short term solution, permanent preventative action and mistake proofing. My boss came to me and asked "how did this happen?". The CCF was the result of an order entry error by another operator. I did not feel the need to point fingers, but he thought it was my error until he spoke with me. That contributed to my belief that I should be more specific. I certainly don't want to be named as the root cause of all these issues, but at the same time I understand that I shouldn't have to point fingers. The purpose of the system is to resolve existing issues and to prevent it from happening again.

When I made the statement ""I had the responsibility of closing out the issues.", I meant that the employee who started the process in December of 2006 was layed off in April. I assumed his responsibilities.

I used the 5 Why's to determine the root cause. A CAR had already been issued regarding the purchase from an unapproved supplier. I thought that the root cause of additional merchandise making it's way to the customer was that all product was not placed on hold. The solution, in my opinion, would have been management review to ensure that the QC process is taking place as it should in a timely and effective manner.

At any rate, I find it odd that if I am issuing a CAR, I should be the respondent. I think the fact that a person who no longer works for the company is involved is what is confusing me.

I'm working with my Assistant General Manager, above my manager, trying to resolve the problem. I don't want to just slap information on the CAR, so we are working with the Director of Quality to try to determine the real root cause. Any additional thoughts would be much appreciated.

Thank you!

What is a "CCF?"

What is a "CCF?"

Customer Compliant Form - Sorry, I thought that was common jargon.

Customer Compliant Form - Sorry, I thought that was common jargon.You probably mean "complaint" - totally different from "compliant"

I've been in Quality for many years, dealing with many organizations, and I never heard a form referred to by the initials CCF.

It is always good form to include the spelled out word or words at least once when using an acronym or abbreviation.

You probably mean "complaint" - totally different from "compliant"

I've been in Quality for many years, dealing with many organizations, and I never heard a form referred to by the initials CCF.

It is always good form to include the spelled out word or words at least once when using an acronym or abbreviation.

Oops! Typo...sorry. Another long day among many more to come. Thanks for your advice on acronyms and abbreviations. Will do!

I got a bit confused with your post regarding forms, people and the exact extent of the problem, sorry. However the solution to your issue is clear cut:

I would say regardless of who is to blame, if you have devised a method to fix the problem and have ensured the system has been improved to prevent it happening again, you have done your job.

Not sure if I moving away from the thread, however being a small company (30 – 40 employees) I use one "form" for all Non-conformance events, referenced as "Unique number/year/code" e.g. 012/2007/CC - Codes as listed.

CR - Customer Return
PR - Process
PF - Product Function
SQ - Supplier Quality
CC - Customer Complaint
AF - Audit Findings
EV - Environmental Issues

Handle within an Excel spreadsheet I can progress all occurrences until preventative verification, present an overall report on total / type / trends of problems to Management – see the whole picture in one place.

I should add Contract Review / Customer Supplied information / Design issues, however at this stage our reviews identify “the point of process” failures. Accountability for the “proven” root cause is classified as:

My Company
Customer
Supplier
Not Confirmed (used when it can’t be placed in one of the above)

I just find it simpler than many different forms.

Do other covers use multiform for each classification of NCR’s

I got a bit confused with your post regarding forms, people and the exact extent of the problem, sorry. However the solution to your issue is clear cut:

I would say regardless of who is to blame, if you have devised a method to fix the problem and have ensured the system has been improved to prevent it happening again, you have done your job.

I understand. The problem I'm having is trying to pinpoint the real root cause, so I can determine the fix. I don't feel like the situation(s) were monitored to ensure timely closure of the issues. I'd love to say that will never happen again, but we are human. There needs to be some sort of checks and balances system. Assigning one person to the task in our Corporate QC department or one person on the branch level just doesn't cut it in my eyes. I will reread the documentation on this issue (again - never hurts) to find out what (if any) checks and balances type system is in place. If one does not exist, I will definitely submit that suggestion. In the meantime, I'm still following up daily with my Assistant General Manger and Director of Quality to see what they make of it.

Not sure if I moving away from the thread, however being a small company (30 – 40 employees) I use one "form" for all Non-conformance events, referenced as "Unique number/year/code" e.g. 012/2007/CC - Codes as listed.

CR - Customer Return
PR - Process
PF - Product Function
SQ - Supplier Quality
CC - Customer Complaint
AF - Audit Findings
EV - Environmental Issues

Handle within an Excel spreadsheet I can progress all occurrences until preventative verification, present an overall report on total / type / trends of problems to Management – see the whole picture in one place.

I should add Contract Review / Customer Supplied information / Design issues, however at this stage our reviews identify “the point of process” failures. Accountability for the “proven” root cause is classified as:

My Company
Customer
Supplier
Not Confirmed (used when it can’t be placed in one of the above)

I just find it simpler than many different forms.

Do other covers use multiform for each classification of NCR’s

I wish! Good for you, though! I think my company over compensated the amount of detail into their ISO Procedures. Once I have a better understanding and longer tenure with the company, perhaps I can suggest simplifying it, but I don't know how easy that would be. Thanks for the info! I'll definitely keep it in mind!

Not sure if I moving away from the thread, however being a small company (30 – 40 employees) I use one "form" for all Non-conformance events, referenced as "Unique number/year/code" e.g. 012/2007/CC - Codes as listed.

CR - Customer Return
PR - Process
PF - Product Function
SQ - Supplier Quality
CC - Customer Complaint
AF - Audit Findings
EV - Environmental Issues

Handle within an Excel spreadsheet I can progress all occurrences until preventative verification, present an overall report on total / type / trends of problems to Management – see the whole picture in one place.

I should add Contract Review / Customer Supplied information / Design issues, however at this stage our reviews identify “the point of process” failures. Accountability for the “proven” root cause is classified as:

My Company
Customer
Supplier
Not Confirmed (used when it can’t be placed in one of the above)

I just find it simpler than many different forms.

Do other covers use multiform for each classification of NCR’s

Thanks Britman, I think that is relevant to this thread, in that it gives the OP the opportunity to better understand the process of recording, monitoring and correcting non-conformance, as well as giving ideas on how to maybe improve their own system.

Our company uses a lot of hand written forms, which, as I gradually take charge of the QMS, I am trying to reform it all. The recording of Non-Conformance is my first challenge and I have created a nice little database in access that seems OK, but needs to be expanded upon.

It simply takes our current system of recording 3 categories of non-conformance - Non-Conforming Material, Customer Returns and Customer Complaints. Your categories expand on these classifications and may actually give us more meaningful data when analysing the concerns. So thanks for sharing your techniques.

I understand. The problem I'm having is trying to pinpoint the real root cause, so I can determine the fix. I don't feel like the situation(s) were monitored to ensure timely closure of the issues. I'd love to say that will never happen again, but we are human. There needs to be some sort of checks and balances system.


First, you're not there yet.

You're supposed to remove the cause of problems. ISO 9001 requires it, and more importantly, it's the right thing to do. "Monitoring" or "checks and balances" don't remove the cause of problems. They're a band-aid and a distraction.

Increased inspection has been repeatedly demonstrated to worsen quality rather than improve it. It may satisfy management's desire to "get something done," but that's not a good justification for doing the wrong thing.

Second, how to get there.

From the previous posts in this thread, we already have a pretty good idea of the immediate cause of the problem: somebody, or bodies, screwed up. The problem facing the organization is why?

If you are still at the "somebody did something wrong" level in your investigation, you probably still have more whys to ask. Perhaps it's time to bring out the fishbone chart, as a way to look for systemic causes. Ideally, there would be lots of people who could help root out the problem cause. It surprises me a little that the quality department isn't driving it.

Of course, the cause really could be human error. It does happen, even when the system is not error prone. Sometimes managers contribute by not being clear about job expectations or failing to hold people accountable for things like taking shortcuts, lack of attention to detail or insufficient care.

Perhaps that is the situation in your company, which brings me to the very excellent advice from Sidney Vianna:
I think that you have to be very careful. Your boss might be trying to cover his/her derriere.Good luck.
Cliff Kachinske

Dear Friend,
give yourself the CAR and as preventive action report to your boss all outstanding items but copy other relevant authorities such that your actions are known to others. Do a follow up with a definite timely and state that past that point you will take the executive decision. Try that and tell me what happens.

Hello, Berlinnet! Welcome to the Cove! We sure do appreciate your participation, and for joining a spirited debate for your first post.
**********
Working with documentation most of my life, I have always used on of the stapler pullers to pull the stapler from the top/flat part of the staple. It would always destroy the paper. I just never gave it much thought, and dealt with the mediocrity. About four years ago, out of the blue, I put two and two together, to an extent. Looking at the curved in part of the staple, and the two forks on the remover, they looked about the same size. VIOLA! I bent up the back prongs, and the staple came right out! No destroyed paper.

Right tool for the wrong application. No one ever told me how to use them (they just assumed). I dealt with mediocrity, not thinking there must be a better way.
*********
I'm not sure how this will go; only time will tell. Maybe you will have to take the CAR; hopefully it will be implemented a little more effectively. The result will largely depend on the management. There's a huge probability of failure if this becomes a finger-pointing exercise. There are 'graveyards' of failed relationships and failed opportunities of improvement simply due to taking the quick road. It's easy to just assign blame, without taking the time to get to what's really going on.

There is probability for improvement. Improvement would be that if this failure is significant, that the organization improve the process where it does not happen again. Now, I don't know what that entails, other than spending some time for everyone to truly understand the process and what went wrong. Then, listening to each other to set up some pretty smart processes for the future.

To my silly example, a CAR is one of the great tools of the process, if used correctly. It can help everyone figure out a better way to do things.

If used incorrectly to assign blame, then mediocrity abounds, and another QMS will probably end up in a graveyard.

You may want to implement the use of a 5Why on this. The "Why" will make things look differently. Then you can put the results on the CAR.

Just a thought
MsHeeler