Status: Open /Closed Doc. Rev. 1 Problem Statement: Customer: CPR #: P/N: Revision: 2 Containment: a ECD ACD Lot # b Responsible ECD ACD Qty Sorted Qty Good Qty NC c When? Who? d When? Who? e When? Who? f When? Who? 3 Root Cause /Corrective Action: a SPECIFIC CAUSE: WHY 1 WHY 2 WHY 3 WHY 4 WHY 5 Who ? When? Result? ECD ACD Lot # ECD ACD Responsible ECD ACD b DETECTION CAUSE: WHY 1 WHY 2 WHY 3 WHY 4 WHY 5 Who ? When? Result? Who ? When? Result? Exposure and Sort /Rework Status Has interim response been provided to KSS liaisons? Was PFMEA reviewed for potential causes? Corrective Action (How do we fix it?) Date Initiated: Leader: Team: Customer Concern #: Internal /External Special Identification Action Location At Supplier In-transit to KSS Suspect Qty At KSS Plant At KSS Warehouse In-transit to Customer At Customer At External Warehouse Comments Have effected customers (internal /external) been notified? Has interim response been provided to customers? Has customer approved sort /rework plan? Why Did the Problem Occur? Result Verification Action (How do we know it is fixed?) Resp. Preventive Action (How do we keep it fixed?) Why was the problem not immediately identified, why did it flow on, or out? Was Control Plan reviewed for effective control definition? Were process controls reviewed for implementation as defined in Control Plan? Revision date: Tracking #: Responsible Responsible Key Safety Systems, Inc. Robust Problem Solving ReportWho ? When? Result? ECD ACD Lot # ECD ACD Responsible ECD ACD c SYSTEMIC CAUSE: WHY 1 WHY 2 WHY 3 WHY 4 WHY 5 Responsible ECD ACD ECD ACD Responsible ECD ACD d When? Who? e When? Who? 4 Standardization: a Responsible ECD ACD ECD ACD Responsible ECD ACD b Responsible ECD ACD ECD ACD Responsible ECD ACD c Responsible ECD ACD Has permanent corrective action response been provided to KSS liaisons? Corrective Action (How do we fix it?) What other products may have the same, or a similar, problem? Has permanent corrective action response been provided to customers? Preventive Action (How do we keep it fixed?) Resp. Were process control records reviewed for conformance to specification? Verification Action (How do we know it is fixed?) Result Corrective Action (How do we fix it?) Why was the problem not prevented from initially occuring, what failed in the planning stage? Preventive Action (How do we keep it fixed?) Verification Action (How do we know it is fixed?) Resp. Result Corrective Action (How do we fix it?) Responsible Comments Corrective Action (How do we fix it?) Corrective Action (How do we fix it?) Verification Action (How do we know it is fixed?) Resp. Preventive Action (How do we keep it fixed?) Result Verification Action (How do we know it is fixed?) What other systems may have the same, or a similar, problem? Result Resp. Preventive Action (How do we keep it fixed?) What other processes may have the same, or a similar, problem?ECD ACD Responsible ECD ACD 5 Documentation /Lessons Learned: a Yes /No ECD ACD d When? Who? e When? Who? 6 Closure Review /Approval: a When? Who? b Team Leader Quality Manager Plant Manager Date Closed: Has final corrective action response been provided to KSS liaisons? Has customer formally closed the issue? Procedures Management reports Lot traceability documents /system Poke Yoke (renegade) samples Boundary samples Operator Instructions Visual Aids Process Flow Diagram Comments Preventive Action (How do we keep it fixed?) Verification Action (How do we know it is fixed?) Resp. Specifications Document What documents must be updated to capture corrective actions and lessons learned? Responsible Result Has final corrective action response been provided to customers? Training Materials /Curriculum Receiving Inspection plan Control Plan Drawings DFMEA PFMEA Lessons learned Database LAT /CCT plans First Piece Inspection Process control /inspection documentsMother Nature People Materials Enter Problem /Issue Here Fishbone Diagram Measurement Methods MachineryProblem IS Problem IS NOT Who is affected by the problem? Who is not affected by the problem? Who found the problem? Who did not find the problem? Who reported the problem? Who did not report the problem? What type of problem is it? What type of problem is it not? What product /process has the problem? What product /process could have the problem, but does not? What is happening as a result of the problem? What could be happening as a result of the problem, but is not? Where was the problem observed? Where could the problem be, but is not? Where does the problem occur? Where could the problem be located, but is not? When was the problem first noticed? When was the problem not noticed? When has the problem been noticed since? Why is this a problem? Why is this not a problem? When Why IS /IS NOT Problem Analysis Who What WhereC-Car DAB Module Deployment Anomaly Fault Tree Diagram -DRAFT 24 July 2001 Supporting Evidence Refuting Evidence Status Material is confirmed correct Closed Material analysis concluded there Closed was no evidence of material degradation of any kind on the subject cover Closed Closed Dimensional analysis of the Closed subject cover confirmed OK Issue reproduced without two shot Closed bond separation Open Open Open Bromine not present in subject Open cover Data on subject cover vs. good Closed covers shows no difference Material change occurred in Closed March 1996 Analysis of the subject cover Closed confirmed OK Closed Analysis of the subject cushion Closed Cushion does not deploy completely through cover Quality Issue with Cover Incorrect material Material Degradation Improper Handling Incorrect molding parameters Contamination Cover tear seam out of tolerance Bonding issue with two shot cover Incorrect molding parameters Plastic property change over time Plastic resin related Molding process related Paint related Contamination Paint thickness Material change Module assembly issue Cover tear seam ribs not cut Operator error Operation by-passed Cushion obstructed or pinched Operator errorconfirmed OK Issue reproduced with using Closed modules with confirmed folds Subject inflator confirmed as the Closed correct part number Subject inflator confirmed as the Closed Analysis of subject module Closed confirms manifold assy OK Analysis of subject module Closed confirms crimp OK LAT sample data is acceptable, Hold issue duplicated on Japan returns Production records confirm OK Closed fill weight Production records confirm OK Hold leak rate during production, issue duplicated on Japan returns Analysis of subject inflator Closed confirms propellant presence Not possible, ARC does not use a Closed lower load in any other HD38 infl. PV test results and LAT test Open results OK Issue duplicated on Japan returns Hold Low temperature in owners city Closed the day of the accident was within operating range pinched Operator error Cushion not folded properly Operator error Incorrect inflator Supplier material handling error BREED material handling error Gas diverted from entering cushion Loose manifold Missing manifold crimp Quality issue with inflator Low output Missing stored gas Stored gas leak Missing propellant load Reduced propellant load Design Cover design not reliable enough to ensure 100% deployment at cold Vehicle environment issue Cover opening obstructed OOP driver Temperature at deployment below operating range* Discussions with Suzuki have concluded that additional vehicle Open data is not available and further investigation will not be conducted at this time. Other unknown factors at the time of deployment *Specific Cause Why ? Problem Statement Detection Cause Why ? Why ? Why ? Systemic Cause Why ? Why ? Why ? Why ? Specific Root Cause Why ? Why ? Why ? Detection Root Cause Why ? Systemic Root Cause 5 Why Analysis