Elsmar Cove Forum Header Graphic The Elsmar Cove Wiki More Free Files The Elsmar Cove Forums Discussion Thread Index Post Attachments Listing Failure Modes Services and Solutions to Problems Elsmar cove Forums Main Page Elsmar Cove Home Page
Miner's MSA (Measurement Systems Analysis) Blog 
Go Back   The Elsmar Cove Forum > Aerospace and Aviation Standards and Requirements > AS9100, Nadcap and related Aerospace Standards and Requirements
Forum Username

Wooden Line

Root Cause Failure Analysis for NADCAP AMS2750D Audit Finding help wanted

Wooden Line
Search the Elsmar Cove
Search Elsmar
Monitor the Elsmar Forum
Follow Marc & Elsmar
Elsmar Cove Forum RSS Feed  Marc Smith's Google+ Page  Marc Smith's Linked In Page   Marc Smith's Elsmar Cove YouTube Page  Marc Smith's Facebook Page  Elsmar Cove Twitter Feed
Elsmar Cove Groups
Elsmar Cove Google+ Group  Elsmar Cove LinkedIn Group  Elsmar Cove Facebook Group
Donate and $ Contributor Forum Access
Courtesy Quick Links

Links that Elsmar Cove visitors will find useful in your quest for knowledge:

Howard's
International Quality Services
Marcelo Antunes'
SQR Consulting
Bob Doering's
Correct SPC - Precision Machining

NIST's Engineering Statistics Handbook
IRCA - International Register of Certified Auditors
SAE - Society of Automotive Engineers
Quality Digest Portal
IEST - Institute of Environmental Sciences and Technology
ASQ - American Society for Quality

Related Topic Tags
ams (aerospace material specifications), ams 2750 - pyrometric requirements, audit nonconformances and findings, furnaces, root cause failure analysis, nadcap (nat'l aerospace & defense contractors accred. pgm)
Reply
 
Thread Tools Search this Thread Rate Thread Content Display Modes
  #1  
Old 15th October 2010, 04:00 PM
zac2944

 
 
Posts: 31
Please Help! Root Cause Failure Analysis for NADCAP AMS2750D Audit Finding help wanted

I'm very new to quality and NADCAP, and just went through my first NADCAP heat treat/hardness testing/metalography audit. We did pretty well, but got dinged with 3 findings. Two were minor calibration cert typos, and one was an issue with how we were performing Temperature Uniformity Surveys (TUS).

I've been able to close out two of the three findings, but I'm stuck on one and I only have one more chance at it. Apparently you only get three trys to get your root cause right then they fail you. Well, the first two were not accepted.

Here's the finding:

Requirement - AMS2750D

3.5.13.3.2 Once data collection begins, temperature data shall be recorded from all TUS sensors at a frequency of at least one set of all readings every two minutes for the duration of the survey. Data from furnace sensors required by the applicable instrumentation type (see 3.3) shall be recorded as follows: (Sensors whose only function is over temperature protection do not need to be recorded.)


Our furnace type (2B) requires a load thermocouple, and we were not recording this with a dummy load during an unloaded TUS.

We have had several prior NADCAP audits miss this and had in several NADCAP consultants that never picked up on this. We just didn't know we were doing TUS incorrectly.

My initial root cause response was that we misinterpruted AMS2750D and the corective action would be to include NADCAP's "Pyrometry Guide" as part of our audit and review process.

I found out after the finding that NADCAP made a clarification to this AMS2750D requirement in their Guide last March, but we didn't pick up on it at the time. I figured if they felt a clarification was required that they would understand how we missed it.

Not the case. NADCAP responded with "Readdress Root Cause response, requirement is stated in AMS2750D, why was it not identified during review process? How will review/flow down of Specification requirements be improved, now and in the future?".

When I submitted a second time saying the root cause was a misinterpretation of the spec I got back "Readdress Root Cause response, human error not an acceptable reply.".

I'm at a loss for how to address this finding and if I don't get it right I might be looking for a new job. We had a system problem, but the human who created the system made a mistake. We were following our internal procedures, but the procedures were incorrect.

Anyone got advice for a quality rookie?

Sponsored Links
  #2  
Old 15th October 2010, 04:34 PM
DrM2u's Avatar
DrM2u

 
 
Posts: 777
Re: Root Cause Failure Analysis for NADCAP AMS2750D Audit Finding help wanted

I happen to agree with NADCAP on this one. You have to look at the cause(s) of failure both from a prevention as well as a detection perspective. Some organizations even look at it from a systemic perspective. This being said, I would suggest:

- Investigate why this was not identified when the requirement was clarified: how do you identify (hear about), manage, communicate within and implement changes in regulations
- Investigate why the failure was not identified after the clarification: what detection methods are employed; how effective is your self-assessment process or detection method; is it a gap in knowledge that require auditor training or the audit sampling process missed this requirement; is it an equipment failure; is it ... you get my drift.
- Look at the cause(s) from a systemic perspective, not a human (error) perspective; your system is supposed to eliminate or reduce the potential for human errors; human error is usually not an acceptable root cause because it is traceable back to a planning or management failure

As one method for root cause analysis I would suggest reading a book called "Thinking for a Change" by Lisa Scheinkopf. It is my preferred method for root cause analysis because of its logical approach to cause and effect analysis.

Good luck with 3rd response.
Thanks to DrM2u for your informative Post and/or Attachment!
Sponsored Links

  #3  
Old 15th October 2010, 05:16 PM
zac2944

 
 
Posts: 31
Re: Root Cause Failure Analysis for NADCAP AMS2750D Audit Finding help wanted

Thanks for your help DrM2u.

If I may, I'd like to work through your 5-why type questions.

Quote:
- Investigate why this was not identified when the requirement was clarified: how do you identify (hear about), manage, communicate within and implement changes in regulations
I did include this in my root cause, stating that review of NADCAP's advisories and guides was not a part of our review process. I was sticking to AMS2750D and failed to include the NADCAP advisories and guides.

Why did this happen?
I didn't know it existed. I was never trained specifically on how to prepare for a NADCAP audit. My auditor training simply states "review all applicable specification and requirements", and knowing what is required can be a challange. I know my audit focused on AMS2750D, so I focused on that. Maybe improved auditor training could be part of a root cause here?


Quote:
- Investigate why the failure was not identified after the clarification: what detection methods are employed; how effective is your self-assessment process or detection method; is it a gap in knowledge that require auditor training or the audit sampling process missed this requirement; is it an equipment failure; is it ... you get my drift.
We do have a recall system (excel spreadsheet) to stay up to date and review certain customer and regulatory specs (Notice to Suppliers, Notice of Change, etc), but this NADCAP material wasn't on that recall.

Why did we fail to have this material on our recall?
We didn't have a proactive system to locate all required specs, requirements, advisories, etc. Maybe a review/improvement of this system is in order?


Quote:
- Look at the cause(s) from a systemic perspective, not a human (error) perspective; your system is supposed to eliminate or reduce the potential for human errors; human error is usually not an acceptable root cause because it is traceable back to a planning or management failure
I agree with you on this. I think I need to work on my investigative skill to become better at finding system flaws. And thanks for the book recommendation. I'll be adding it to my library shortly.
  #4  
Old 15th October 2010, 05:36 PM
DrM2u's Avatar
DrM2u

 
 
Posts: 777
Re: Root Cause Failure Analysis for NADCAP AMS2750D Audit Finding help wanted

Following your logic, you might want to take a second look at your document control process, in particular as it applies to documents of external origin (i.e. making sure that you have the latest and greatest revision on hand). A list of external regulations that is reviewed on a quarterly basis might just do the trick. I don't think that any auditor would ding you for following your procedures and not having a new requirement implemented a week after it was issued. Some regulatory bodies like FDA have sites where users can subscribe to be notified of any regulatory changes, therefore eliminating the need to review documents quarterly as I said in my example.

Regarding the detection method, auditor training probably would not make any difference if you don't train and audit to the latest requirements. It might be part of your (corrective) actions as new requirements are released, though. There is nothing wrong with tracking a failure in detection back to a failure in prevention or planning. Often times I found that poor up-front planning caused both prevention and detection failures down the road.

One might ask now why was there a failure in planning?!? Was it resources, knowledge, culture, management, etc?!? Some great mind (and someone else might be able to verify if it was Deming or not) said a long time ago that most failures are ultimately traceable to the executive management.
Reply

Lower Navigation Bar
Go Back   The Elsmar Cove Forum > Aerospace and Aviation Standards and Requirements > AS9100, Nadcap and related Aerospace Standards and Requirements

Do you find this discussion thread helpful and informational?


Bookmarks


Visitors Currently Viewing this Thread: 1 (0 Registered Visitors (Members) and 1 Unregistered Guest Visitors)
 
Thread Tools Search this Thread
Search this Thread:

Advanced Forum Search
Display Modes Rate Thread Content
Rate Thread Content:

Forum Posting Settings
You may not post new threads
You may not post replies
You may not post attachments
You may not edit your posts

BB code is On
Smilies are On
[IMG] code is On
HTML code is Off


Similar Discussion Threads
Discussion Thread Title Thread Starter Forum Replies Last Post or Poll Vote
FPA (Failure Prevention Analysis) and FMA (Failure Mode Avoidance) info wanted andtyl FMEA and Control Plans 6 18th April 2011 12:00 PM
Internal Audit Finding - Root Cause Analysis: Auditor or an Auditee Responsibility? Polly Pure Bread Internal Auditing 24 23rd December 2009 12:35 AM
Management Review does not highlight Internal Audit Finding - Root Cause Analysis 6thsense ISO 19011 *and* ALL other Auditing Discussions 11 18th November 2009 04:03 PM
Non-conformance Root Cause Analysis Finding: Stupidity? Aaron Lupo Problem Solving, Root Cause Fault and Failure Analysis 11 3rd October 2001 02:28 PM
Root Cause Failure Analysis - Educate Me: What Is Root Cause Analysis? Aaron Lupo Problem Solving, Root Cause Fault and Failure Analysis 10 27th April 2001 11:02 AM



The time now is 05:57 PM. All times are GMT -4.
Your time zone can be changed in your UserCP --> Options.


   


Marc Timothy Smith - Elsmar.com
8466 LeSourdsville-West Chester Road, Olde West Chester, Ohio 45069-1929
513 341-6272
NOTE: This forum uses "cookies".