Robust Problem Solving Report

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