Complaint about Adhesive

Melissa

Starting to get Involved
#1
Hi everyone, Looking for some opinions
A little background first:
We are a rotary die cutting facility...without going into to much detail the product we make has to adhere to another device. The customer found 2 of these adhesion pieces(that we make) still had liner on them, making them unusable. This would be a problem from the Operator of the machine who did not notice that the liner split and had to splice another roll onto the die cutter. I am wondering how to word this and what would a good corrective action be? We are unable to inspect parts as they come in as it comes in rolls. I am unable to stand out there to watch the operator run the machine to make sure this doesn't happen again. everything is sent back to the customer in rolls as well so it would be impossible for me to check every piece.
 
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Ninja

Looking for Reality
Trusted Information Resource
#2
Howdy Melissa,

Have to make a number of assumptions with the little detail you give about where the liner is, why it's there, whether or not any should be on the final part or not, etc.

If the operator didn't notice that the liner was still there when it shouldn't be...can you make it more obvious?
I've seen a whole lot of clear liners (38um Polyprop, etc.) that are hard to see...but that same material comes tinted blue/green/red/etc as well which is pretty obvious. Is this an option for your incoming stock?

As for wording, tell the bald truth in detail...at the end of the day it's what you do to prevent it from happening again that is much more important.
FWIW, someone standing watching the operator isn't much help anyway...four eyes are better than two, but still not perfect. How do you raise the detectability of an error so it doesn't make it out the door?

HTH
 

Melissa

Starting to get Involved
#3
The problem is, the roll ripped, the operator missed checking those 2 parts and the liner was accidentally left on the part. IT is impossible to check after you keep running the product as it ends up in a roll

The liner from the adhesive should be removed and the parts will be on clear sheet of adhesive, this time the adhesive liner ripped (on a die cutter) and the operator didn't notice as it kept running. The paper the adhesive is attached to ripped wasn't able to be removed by the machine and the operator didn't notice this. This operator HAS to splice at least 7 times a day so i a checklist for splicing wouldnt work well either as we need to keep the machine running. Is there more information i could give that would help?
 

Ninja

Looking for Reality
Trusted Information Resource
#4
Rotary die cutting is a decent volume per hour...out of curiosity, 2 parts out of how many?
 

LUFAN

Involved In Discussions
#5
That has to be a known failure mode of the process, and I can see where @Ninja is going with his comment. Without investment into some sort of automated inspection equipment, warning system, and maybe even a camera you can mount with a monitor at operator eye level, this sounds like it's a Human Factors issue that's going to be hard to mitigate unless more resources can be applied.

How many times has this error occurred?
 

Melissa

Starting to get Involved
#6
Rotary die cutting is a decent volume per hour...out of curiosity, 2 parts out of how many?
That has to be a known failure mode of the process, and I can see where @Ninja is going with his comment. Without investment into some sort of automated inspection equipment, warning system, and maybe even a camera you can mount with a monitor at operator eye level, this sounds like it's a Human Factors issue that's going to be hard to mitigate unless more resources can be applied.

How many times has this error occurred?

This error has never occurred before, 2 parts out of 806000 PC -- we are a contract mfg. This is a very picky customer. But our best customer and I believe a CAPA will make them happier, but it looks like this may boil down just human error.
 

Ninja

Looking for Reality
Trusted Information Resource
#7
As a customer, root cause being a human "oops" is not something I ever want to see. I want to see why the human COULD make the error, that's your root cause.
Potential solutions to solve this 2.5ppm issue can be suggested, with costs attached...then I can convince myself as the customer that 2.5ppm isn't worth the cost of addressing and we all walk away happy...especially if you send me 100 pieces for free to make up for it.

If it happens again in the near future...we'll have a hard chat about it...
Out of curiosity again, has this happened before for this customer? Or for any customer ever before?

At that point, it isn't QMS stuff anymore, it's customer relationship management.
 
Last edited:

John C. Abnet

Teacher, sensei, kennari
Leader
Super Moderator
#8
Good day at @Melissa ;
@Ninja is spot on because as a root cause "human error" is not (because that is not a root cause).

I would recommend that your organization do a "deep dive" using a Kepner Tregoe or 5whys or other discipline (5whys may be best suited to your organization), to drive down to the true root cause. I would also recommend that the session include someone NOT familiar with the process, as they often ask the best questions. Go beyond the obvious. For example, instead of detection (always the last option), how can it be prevented? Is the material necessary? Other options? If the splicing adds to the risk, how can that risk be eliminated. In regards to "keep the machine running", hmmmm. That may be true, but would be worth comparing the "cost" (real and perceived as result of an unhappy customer), against the cost of stopping the machine if/when necesssary.

As noted by others,....not easy (impossible) for us to give you specific direction.

Hope this helps
Be well.
 

Mike S.

Happy to be Alive
Trusted Information Resource
#9
I don't pretend to understand this process or the root cause(s) or contributing cause(s) of this particular incident. But, some processes rely on a human to do something because there is no more practical way to do it. In such case, sometimes human error can be a root cause, IMO. I started a thread long ago on this, and I think it created a lot of controversy and a lot of replies.

I believe that human error as a true root cause is overused and is rare, but not always wrong.
 

Ninja

Looking for Reality
Trusted Information Resource
#10
Totally agree with Mike for your internal analysis and addressing/minimizing the issue.
Sometimes humans are the focal point...because there is no financially viable alternative (ie. practical way). That's why you add costs to the possible solutions...to show the customer that there ARE solutions, but they are not practical.

I would not, however, put humans as a root cause out for discussion with the customer unless you already have a solid and friendly working relationship.
 
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