Corrective Action for a Recurring Nonconformance

[Michael_M]

We have a corrective action to an issue that has happened multiple times. Apparently my 'whys' are not addressing the actual issues so I will ask for your help. I want to fix this problem.

I know I will not be able to put enough information in one post to answer the question so I will refer back often and answer any questions (sorta like the 5 whys).


Problem: Shipping the incorrect part number to the customer.


System: We Manufacture parts and then deliver on a Kanban system (100% of all parts ship to a customer). We have the parts in our stock room and ship to the customer upon receiving a signal that the parts need to ship. For the most part, the 'stock room' is the shipping department. We do have additional part locations and all finished goods have a 'bin' location in our ERP computer system (E2 shop system). Parts are manufactured in-house and placed in stock where they wait to ship. The parts are 'pre-packaged' in shipping lot qty while they wait to be shipped.

If you can help steer me in the right direction (either by providing answers or asking questions), it would help.

 

[smryan]

Re: Looking for assistance to a corrective action

Have you backtracked to the error point yet? Did the customer ask for the wrong part? Did the person taking the order typo? Did the person pulling the parts from stock grab the wrong parts? Were the parts labeled incorrectly?

Before you can fix the problem you have to pinpoint it. If the problem is "human error" it complicates fixing things because humans do make mistakes, so automate as much as possible and put in check points.

 

[Michael_M]

Re: Looking for assistance to a corrective action

Have you backtracked to the error point yet? Did the customer ask for the wrong part? Did the person taking the order typo? Did the person pulling the parts from stock grab the wrong parts? Were the parts labeled incorrectly?

Before you can fix the problem you have to pinpoint it. If the problem is "human error" it complicates fixing things because humans do make mistakes, so automate as much as possible and put in check points.

We have had 3 instances of shipping the wrong part in the last 9 months.

1. two parts look identical only a single internal dimension differentiates the two parts. The change we made was to only pull from the bin location listed (i.e. the two parts are different by location).

2. Part number X was asked for and part number Y was shipped. The two part numbers were not similar in any way other than both were 316 stainless steel (size, shape, weight) all were different. The box that was shipped was mark part X but part Y was in the box.

3. Part number X123 was asked for and part number Y123 was shipped. The boxes are marked with the last 3 numbers and the wrong part was shipped. the fix for this would be easy (mark the entire part number on the box) except we have had 2 other instances in the last 9 months of an incorrect part number being shipped and I think this is only a band-aid on the problem.

Thank you.

 

[lokeky1]

1. Was there a final check of the dimension that differentiate between X and Y before it was boxed?

2. How can Y be in box labelled for X? Could it be the parts were manufactured side by side or one after the other. Was there "line clearance" ie cleared the old packaging away before starting the new product on the same line. Line clearance is practiced in the Pharmaceuticals industry.

3. Could it be one of the cartons was pre-labelled and placed with the wrong stacks at the warehouse?

Possible solutions
1. Are the parts X and Y be identified easily. Can it be colored. Can you use different color carton or labels.

Just some of my thoughts. Hope this helps.

 

[Michael_M]

1. Was there a final check of the dimension that differentiate between X and Y before it was boxed?

The parts are controlled by a traveler up to shipping. There is a possibility that the traveler was not with the parts until the end of the boxing phase (it has happened before so I assume it can happen again).

2. How can Y be in box labelled for X? Could it be the parts were manufactured side by side or one after the other. Was there "line clearance" ie cleared the old packaging away before starting the new product on the same line. Line clearance is practiced in the Pharmaceuticals industry.

it is possible that there were two (or more) travelers near each other at the time. The work space is not fully cleared between tasks and sometimes while performing one task, a new task is assigned so the first task is 'put on hold'.

3. Could it be one of the cartons was pre-labelled and placed with the wrong stacks at the warehouse?

No, we do not have 'labels'. We hand write on the box the last 3 digits of the part number and quantity using a permanent marker.

Possible solutions
1. Are the parts X and Y be identified easily. Can it be colored. Can you use different color carton or labels.

I am looking for any possible solutions and with the help of the questions everyone asks, hopefully a root cause.

 

[Ronen E]

Re: Looking for assistance to a corrective action

We have had 3 instances of shipping the wrong part in the last 9 months.

1. two parts look identical only a single internal dimension differentiates the two parts. The change we made was to only pull from the bin location listed (i.e. the two parts are different by location).

2. Part number X was asked for and part number Y was shipped. The two part numbers were not similar in any way other than both were 316 stainless steel (size, shape, weight) all were different. The box that was shipped was mark part X but part Y was in the box.

3. Part number X123 was asked for and part number Y123 was shipped. The boxes are marked with the last 3 numbers and the wrong part was shipped. the fix for this would be easy (mark the entire part number on the box) except we have had 2 other instances in the last 9 months of an incorrect part number being shipped and I think this is only a band-aid on the problem.

Thank you.

Hi,

IMO this is not a recurring failure, as each one of them is different. It's not bad that you've started a CA, and this could serve as an administrative framework for handling all 3, however I think you'd be better off identifying the root causes for each one separately and implementing measures to fix them individually.

#1: This is suggesting picking and shipping are handled based on bin / location only. If the shipping unit (box, bag etc.) isn't labelled with the PN, this might be a root cause (of course, you could ask "why isn't it labelled?").

#2: Obviously, this calls for "why was part Y in a box marked X?". This would probably send you down looking into your packaging process / packaging controls.

#3: I think for this one you've already identified the root cause and can implement a countermeasure. Or, you could ask "why are only numerals indicated?".

Zooming out for a moment, I'd like to ask something that might be overlooked because it might seem trivial. In you picking (for shipment) process, do you work by PNs? I mean, when the worker picks up the goods from the bins, are they required to do it by looking for a certain (full) PN? Are they required to write down what PN they picked against each line item in the shipping order? Do you have a process of seconding the picking, and signing it off? If not (to any of these), why?

Cheers,
Ronen.

 

[AndyN]

I'd suggest getting all involved to map the process "as is", then when you what's going on and the problem areas, brainstorm how it can be solved. One person can't do a 5 Why and expect it to be accurate.

 

[Ronen E]

The parts are controlled by a traveler up to shipping. There is a possibility that the traveler was not with the parts until the end of the boxing phase (it has happened before so I assume it can happen again).

(Bold type is my addition)
Sounds like a perfect reason for a CA!... Why wasn't the traveler with the parts until the end of the boxing phase?

it is possible that there were two (or more) travelers near each other at the time. The work space is not fully cleared between tasks and sometimes while performing one task, a new task is assigned so the first task is 'put on hold'.

Segregation in manufacturing is very important. If full line clearance is not possible / practical, consider implementing physical barriers to avoid products and paperwork mix-ups.

No, we do not have 'labels'. We hand write on the box the last 3 digits of the part number and quantity using a permanent marker.

Before implementing any countermeasures, you could ask "why were the part designations written on the box erroneous / incomplete?". Alternatively, you could stop here and implement double-checking.

I suggest you don't go implementing anything too quickly. Analyse your options in terms of leverage - what measures have the best ratio of effect (or confidence) to investment (consider not only initial investment but also ongoing burden).

Cheers,
Ronen.

 

[Ronen E]

I'd suggest getting all involved to map the process "as is", then when you what's going on and the problem areas, brainstorm how it can be solved. One person can't do a 5 Why and expect it to be accurate.

I agree on getting more relevant staff involved and on first understanding what's going on.

I don't agree on brainstorming solutions before the problem is pinpointed and a root cause has been identified with sufficient confidence. Jumping to solutions without fully understanding a problem is very enticing and very common in workplaces. Brainstorming often leads to zooming in on the "nicest" solution (also refer group thinking) that is not necessarily the most effective / efficient one, or even a solution at all.

I do support brainstorming as a tool for generating lots of ideas where there seems to be a "mindblock", however it's not always required (and sometimes it can really throw you away). Sometimes, with a good preparation, several good options come up naturally and effortlessly, and then it's a matter of rational selection between them.

Cheers,
Ronen.

 

[AndyN]

Ronen: You missed the bit about mapping the process! I'll almost guarantee that's where the problem will manifest itself...