Not sequentially following steps in a work instruction

Not sequentially following steps is an audit finding.

  • If there is evidence, "Yes" it's a finding

    Votes: 3 25.0%
  • Without more knowledge, I say "No", not a finding

    Votes: 1 8.3%
  • I would definitely dig deeper before any citation

    Votes: 8 66.7%
  • Given the limited information, no way to accurately say

    Votes: 3 25.0%

  • Total voters
    12
G

grego79

#1
Audit scenario...

After reviewing assembly work instructions you find that the operator is performing assembly operation steps #5 & #6 out of sequence. You ask the operator "why would you arbitrarily decide to change work instructions steps" and they respond by saying - "It doesn't matter what steps you do as long as it all gets done."

Just looking for feedback and comments of how you would address this issue.


Grego
 
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Randy

Super Moderator
#2
Re: 9001:2000 Auditor Finding or Not!?

What are the requirements?

Are the requirements being met?

What is the definition of NC?

ISO 9000:2005

3.6.2
nonconformity
non-fulfilment of a requirement (3.1.2)

3.1.2
requirement
need or expectation that is stated, generally implied or obligatory

NOTE 1 “Generally implied” means that it is custom or common practice for the organization (3.3.1), its customers (3.3.5) and other interested parties (3.3.7), that the need or expectation under consideration is implied.

NOTE 2 A qualifier can be used to denote a specific type of requirement, e.g. product requirement, quality management
requirement, customer requirement.

NOTE 3 A specified requirement is one that is stated, for example in a document (3.7.2).

NOTE 4 Requirements can be generated by different interested parties (3.3.7).

NOTE 5 This definition differs from that provided in 3.12.1 of ISO/IEC Directives, Part 2:2004.

3.12.1
requirement
expression in the content of a document conveying criteria to be fulfilled if compliance with the document is to be claimed and from which no deviation is permitted


Use the Standard for your answer. When you use the Standard there is nothing left to haggle over. Now as to CA and cause, that is not the auditor's problem.
 

BradM

Staff member
Admin
#3
Re: 9001:2000 Auditor Finding or Not!?

Audit scenario...

After reviewing assembly work instructions you find that the operator is performing assembly operation steps #5 & #6 out of sequence. You ask the operator "why would you arbitrarily decide to change work instructions steps" and they respond by saying - "It doesn't matter what steps you do as long as it all gets done."

Just looking for feedback and comments of how you would address this issue.


Grego
Hello Grego:bigwave:

Is the operator correct? Does it matter?

I would be interested in the situation. If the work instruction was written with a sequential order, someone thought it was important and it should be followed. The operator(s) needs to be trained. If it truly does not matter, the procedure should be rewritten (doesn't matter). :2cents:

Added Moderator Note: I revised the title for better applicability to the subject. If it is not correct or needs to be changed, please let me or another moderator know
 
Last edited:

GStough

Staff member
Super Moderator
#4
Re: 9001:2000 Auditor Finding or Not!?

Added Moderator Note: I revised the title for better applicability to the subject. If it is not correct or needs to be changed, please let me or another auditor know
:topic:

Or another moderator....:notme: ;)
 

Coury Ferguson

Moderator here to help
Staff member
Super Moderator
#6
Audit scenario...

After reviewing assembly work instructions you find that the operator is performing assembly operation steps #5 & #6 out of sequence. You ask the operator "why would you arbitrarily decide to change work instructions steps" and they respond by saying - "It doesn't matter what steps you do as long as it all gets done."

Just looking for feedback and comments of how you would address this issue.


Grego
Does it improve the results (Time, Costs, etc)? If so, change the documentation, in my opinion.
 
S

somerqc

#7
As an internal auditor, my first question is "does it really matter?". Next, is it potentially a more efficient way of completing the task? Doesn't matter? Change instructions to indicate that. Is it better? Change it.

If it does matter and isn't better - determine if systemic or localized. May be a personnel issue rather than a system issue.

:2cents:

John
 

Stijloor

Staff member
Super Moderator
#8
Audit scenario...

After reviewing assembly work instructions you find that the operator is performing assembly operation steps #5 & #6 out of sequence. You ask the operator "why would you arbitrarily decide to change work instructions steps" and they respond by saying - "It doesn't matter what steps you do as long as it all gets done."

Just looking for feedback and comments of how you would address this issue.


Grego
Grego,

Simple approach:

1. Interview other operators.
2. Verify impact of the out-of-sequence operations.
3a. If no impact, no action required.
3b. If impact, write nonconformity report.

Sometimes, in an effort to capture the process/activities, work instructions are written in an unnecessarily complex/detailed manner.

Stijloor.
 
J

Jeff Frost

#9
Look at your first line of your posting. “After reviewing assembly work instructions you find that the operator is performing assembly operation steps #5 & #6 out of sequence.” This is the finding of nonconformity identified during the audit. The organization has document in writing the method and sequence for the assembly of the product which the assembler is not following.

The assemblers comment that “It doesn't matter what steps you do as long as it all gets done” is irrelevant. He or she may not be aware that not following the process described in the work instruction may be detrimental to the product which could effect its operation and or pose risk to the user.

I like to give real life examples related to following process instructions an here is one in summary. As the pilot of a DC 10 aircraft is making his take off run down the runway the right engine of his aircraft disengages and falls off the wing shortly after take off requiring him to take emergency actions to save his aircraft and all those onboard.

The investigation identifies that even though McDonnell Douglass, the manufacture of the aircraft, has a written instruction for removing and install engines on this aircraft it was identified that the operator removing and installing the engine did not follow the describe method and used a forklift, not the required engine lift, to lower and raise the engine when a new right engine was being installed resulting in undetected damage to the bolts holding the engine on the wing. The operator (I am using your operator’s statement here) stated that “It doesn't matter what steps or method you do as long as it all gets done”.

Is it important to follow the assembly instructions? You bet it is because in this real example from late 1970’s to early 1980 the operator’s actions of not following the work instructions damages the product (the aircraft) and put real people in danger.
 
Last edited by a moderator:

SteelMaiden

Super Moderator
Super Moderator
#10
Just to throw in my :2cents::

Sometimes we manage to micromanage/overdocument by requiring that tasks need to be performed in a certain step by step order when in reality, as long as all the taks are performed there is no impact to the process.

If you have steps that need to be done in a certain order, write up the documentation to show that. If it makes no difference, just say to perform those tasks.

ex:
(and yes I know that there should be more info, it is only an example)

Add water and coffee grounds to the coffee maker before turning the pot on.
vs.
  1. Add water
  2. Add Coffee grounds
  3. turn on the pot.
OK, it is a lame example, but I'm just taking a quick break from an audit.:lmao:
 
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