Retour A3

FIRST:
Do I have enough protected my cus
Do I have control over traceability? Is d
Is the secured lot (number of batch) we

The palliative, the troubleshooting, the

Steps

1 Clarify the problem

Brake down the problem

2

Look for root cause (Creation and non-detection)

3
 Look for root cause (Creation and non-detection)
3

5 Definitions of the action plan

4
Analyse des causes racines

Implement the actions

6

7
Monitor Results
 Standardize
8
and

InstitutionalizeThroughout The Organization :

nough protected my customer? on my assembly line/process, my stock in transit , in cust
ntrol over traceability? Is dubious production well defined?
d lot (number of batch) well established and communicated to the customer plant?

e, the troubleshooting, the Quality Wall (in accordance with the GP12) are set up and under c

Criteria to be filled in
1

- Presentation of the issue (pictures, diagram, ...)

- Film of the events
- QQOQC
- Palliative or repair put in place and under control

In the case of a deviation from the nominal, the customer was protected
and containment measures have been put in place to avoid the symptom
or effect
The subject has been decomposed into elementary problems.

- Is there a standard, is it applicable? Applied? Effective?

Are the technical causes analysed?
Has Standard (behavioural) been studied?
 - Is there a standard, is it applicable? Applied? Effective?
Are the technical causes analysed?
Has Standard (behavioural) been studied?

Analysing potential root causes of appearance and non-detection of the

problem is made on the Shop floor based on the examination of the
physical condition and on facts.

An action plan is built to eliminate both the root causes of the problem
occurred and non detection

6
There is a monitoring of the action plan.

There is monitoring the effectiveness of actions. 7

A standard has been written or updated at the end of the formalization of the action plan.
Adequate people were trained / informed and received Lesson Learned on the subject.
This Lesson Learned serves other people.
Is the Standard Audit in place (Layer Process Audit)? 8
The progress of the RDP topic was monitored in the EU

Transversalization actions must be clearly described

n transit , in customer plant, in Tier x, etc...

plant?

t up and under control

Questions to ask?

- What: Do I understand the problem? Am I able to reformulate the subject? To remake the film?
- Who is concerned ?
- Since when ? frequency of occurrence of the problem?
- Are there any related topics that are already being processed?
- The gap between the current situation and the situation expected to is it clear?
- What is the recurrence and complexity of the problem? Is this the correct method of resolution?
- Why ? What are the consequences of this problem? Why is this a problem? What is at stake? To
what need of the customer the solution will respond?

- If "nominal deviation": Is the customer protected? What have we learned the nature of the
protective measures taken (increased control, quick corrective action, collecting data concerning
issues?)
- How did you analyse the problem? (Pareto, data from the shop floor, analyse of the KPI ...)
- What did you learn by going on the "field"? (sort decomposition ...)

- Are there several sub-problems? A more important, more urgent, more impactful? One to treat before
another? How did you determine it?

NB : Drive management and support groups to go and see the problems on the floor and take
action and communicate operational information.

Are the technical causes analysed?

Has Standard (behavioural) been studied?
 Are the technical causes analysed?
Has Standard (behavioural) been studied?

"Have I understood all the possible causes of the problem?" Has a brainstorming + 7M ranking been
performed?

- Between 1 and 3 maximum potential causes have been identified.

- Potential root cause analysis was based on the OK / NOK and Standard

- From each potential root cause, I made an analysis "5 Why" to find the root causes

- To check, I make the logical path of "5 Why" in reverse ("and so"). The last "why" must address
"system" or "management" root causes in order to improve the effectiveness of the organization. Why
did the possibility exist for this situation to occur? Why our Production and Quality systems wern't
robust enough to adequately protect the customer?

- Do the Shop floor data used are robust?

- The reproductive test of the problem was carried out to confirm the root cause (s).

- Do I understand why the problem may arise and also why it was not possible to detect it?

- How priority actions have been chosen (criteria: feasibility, cost, time ...)?
- How are other partner departments involved in defining corrective actions?
- Every action has a pilot, a period, a goal and understand the impact that each action on the
disappearance of the root causes.
- All stakeholders know the action plan.

- The progress of the action plan is monitored by the pilot and shared regularly at a formal point
- The follow-up indicator in step 3 is validated

- I verify how the indicator defined in step 3 improves as corrective actions are implemented

- If not, what kind of analysis is made of the non-attainment of the objective? Adjustment?

- The plan is followed until the problem is solved

- The progress of the RDP topic is monitored in the EU

- I ensure that there is a sustainability plan: how are these actions included in the existing standards
and the information / training of the users realized?

- How do we follow in time that there is no drift?

- Are the actions / measures applicable to another perimeter, generalizable? Easily?

- The Lesson learned are communicated and transversalised to other entities

- FMEA, Reverse FEMEA
- LPA in place
 Supplier has to fill in completely all A3 steps with the maximum
detail level (Grpe
Supplier
Name)
0pen date Root causes identification Diagram Cause effect
Por qué ?

5 WHY Vote
Brainstorming

A3 / PROBLEM SOLVING  See Blank frame

Manuf with comments by Zones
cofor/Duns

Pilot: Standard respect

Severity impact: S/R/Bkd In-Field 1 - Does the standard exist? 2- Is the standard relevant? 3 - Is the standard applied? 4-Product conform?
Failure Mode: Impact
(Y/N):

STEP 4
Amadeus/Altis… Nb: Amadeus level (F,G2,H): Part reference:
Workshop attendees:
(Names + position)
Hold occurrence causes / 5Why Occurrence (case) Hold non-detection causes / 5Why Non-detection
Oc 1- Det 1- Real causes hold through 5 Whys analysis performed :
Impacted Oc 2- Det 2- last why expected there, detailed whys available in the
vehicle/engine: Oc 3- Det 3- dedicated sheet.
… …
… …
Report also the systemic root causes
1. Problem description Systemic RC : Systemic RC :
Sequence 1 - What is the anomaly, the concern, the risk (what are we talking about ?)

QQOQC Corrective action plan and Follow-up

Illustration
STEP
Detected Generated Actions Pilot Due date Comments
P
xx/xx/ D C A
Presentation of the isssue (pictures, xx

diagram, ...)
WHAT ? Film of the events Oc 1
Anomaly
identification ?
WWWWH (QQOQC )
Palliative or repair put in place and
Oc 2
under control
WHO ?
Who detected, who
Real cause hold
created the
anomaly ?
Oc 3 Actions, pilots, deadlines
WHERE ?
=> Ensures the Natural owner is assigned to each
Where was … issue.
STEP 1

detected ? Where N° post :

Avoiding Recurrence

STEP 5
was created the
anomaly?
Det 1

WHEN ?
Det 2

HOW ? Det 3
How did we detect
the anomaly ?
..

Customer Effect /
..
Risk:

PROBLEM
DECOMPOSITION …
According failure
complexity
…

2. Immediate measures for customer protection (Sorting and containment actions) Verify Effectiveness Of Actions
(Quality gate, fire wall, Control shipping...)
Check the efficiency on the shopfloor
Preventive Action plan progress
Containment
Containment worksheet filled (next file) : Y/N
Modification, PR management, reliability ...
STEP 6
Date Verification Date (1st
STEP 2

Nb
Do I have enough protected
Action Start
my customer?
End
on garanted
batch my assembly
ok) line/process,
Pilot
my stock
Efficacity
in transit , in customer plant, in Tier x, etc... Secured lot nb or secured part
reference
Defect detection rate, scrap level, production
1
Do I have control over traceability? Is dubious production well defined? efficiency...
2
3 Is the secured lot (number of batch) well established and communicated to the Audit result...
4 customer plant?
5 Bring the proof of the Maintenance metrics...
6 The palliative, the troubleshooting, the fire Wall (in accordance with the GP12) conservation measure
….
are set up and under control

PROJECT and MASS PRODUCTION READ ACROSS/Transversalization

3. Defect recording PPAP Documentation updated Yes/No
Bring the proof of the bar chart Product FMEA updated Yes/No PCP (Part Inspection Standard) Yes/No
STEP 7

Process FMEA updated Yes/No Control plan Yes/No

Weekly situation
Mass production Read Across description and list of productions (similar product lines, processes, other plants…):

10000
Institutionalize throughout The Organization : Review Similar Products and Processes for issue
Nb of detected defects

How many Cases (Nb of detected defects) ?

STEP 3

8000 '- I verify how the indicator defined in step 3 (How to complete areas) Project Read Across description and list of projects:
prevention
improves as corrective actions are implemented Transversalization actions must be clearly described :
6000
FMEA up-date  Describe modification that has been made
Make Forecast with target.
4000 Layer Process Audit
2000
Lessons Learned / Systemic Root Standardization
Causesandidentified
transversalisation
STEP 8

1 1
0
W01 W02 W03 W04 W05 W06 W07 W08 W09 W10 W11 W12 W13 W14 W15
A standard has been written or updated at the end of the formalization of the action plan.
Adequate people were trained / informed and received Lesson Learned on the subject.
Containment measure ( when containment established) Customer defect ( how many parts nok) Total checked parts This Lesson Learned serves other people.
Is the Standard Audit in place (Layered Process Audits )?
UMC/QUP
nb : check that audits are performed on a regular, frequent basis by all layers of the
Program Program Owner:

PRODUCT NAME
NUMBER:
PRODUCT
NONCONFORMANCE:

LOCATION POTENTIAL AREA

QTY VERIFIED
CUSTOMER SITE
IN TRANSIT
DOCK
CS2
CS1
GP-12
WAREHOUSE
ASSEMBLY
SCRAP BINS
INJECTION
WIP
REWORK AREAS
SERVICE
OFFICE AREA
(ENG, QUALITY)

TOTAL FOUND

COMMENTS: SUSPECT PRODUCT TO (location, as feasable)

SORT METHOD (eg. Visual,gage, mating part):
SORT CRITERIA (clear pass/fail standards):
I.D METHOD CONFORMING (eg. Mark, tag sign):

I.D METHOD NONCONFORMING (eg. Mark, tag,sign):

 Date:

SUSPECT PROD VERIFICATION QUANTITY

FOUND? QTY? RESPONSIBILITY OF DEFECTS
 Defect recording and graph

Defect number and follow-up after PACT (short term action):

N° OP N° week W01 W02 W03 W04

Customer defect ( how many parts nok) 1

Containment measure ( when containment established) 1

Total checked parts

Weekly recording
10
9
Nb of detected defects

8
7
6
5
4
3
2
1 1
1
0
W01 W02 W03 W04 W05 W06 W07 W08 W09 W10 W11

Containment measure ( when containment established)

 ISSUE ANALYZE Retour A3

Cause and effect diagram (7 M) : Every 5 M must be filled in :

Technical: Non Robust Definition, Robustness of FMEA, Capability Process, Poka
: Cause dismissed Yoke, ..
Material Machine Measure
Occurence cause
Analyse in all field : reception, material handling, labelling, shipping, repair,
rework, etc..
Non Detection
cause Standard (behavioral): Supports Standardized Work and Job Rotation ,
qualified operators, all Trainers are trained to and apply the same method of
training, requalification after a long absence, is bad workmanship possible?,
bypass are operational and are they sufficiently tested, ...?

Management: VRS or LPA, Work in off-peak hours, Weekend, isolated staff

during production day (or during week-end), test of on-call

7 M : Each “bone“(box) of the fish has to be completed in both form (each box
fullfilled) (If some of them are not selected, explain why ?) and substance

Methods Environment Labor Management

(Middle)
 Color the cell:
UNDERSTAND THE DYSFUNCTION NOT SELECTED
Actions defined to check if the final cause is real/proven,
not the action plan to solve the issue (this action plan has to be described in step
POTENTIAL 5
SELECTED WITH ACTION PLAN
SYMPTOMS ? 1 WHY ? 2 WHY ? 3 WHY ? 4 WHY ? 5 WHY ? Action to Check the cause Pilote

Check Technical aspect, behavioural level , Management, organizational 1

measures,…
- Each answer must be specific
- Don’t stop to 5 if more are needed to reach systemic causes ( standard
non applied  standard not known  training not done, or training not 2
efficient,... )

10

11

12

CO
ET Usinage d'une nouvelle patte de fixation, et fixation d'un carter
MP
AT de protection contre nacelle
OS
AN
T
 Color the cell: Actions defined to check if the final cause is
UNDERSTAND THE DYSFUNCTION NOT SELECTED real/proven,
not the action plan to solve the issue (this action plan
POTENTIAL has to be described in step 5
SELECTED WITH ACTION PLAN

SYMPTOMS ? 1 WHY ? 2 WHY ? 3 WHY ? 4 WHY ? 5 WHY ? Action to Check the cause Pilote

Check behavioural level , Management, organizational measures,…

1
- Each answer must be specific
- Don’t stop to 5 if more are needed to reach systemic causes

down time, Reactivity, on-call absence, week-end, isolated staff without

Management, poka-yoke or non-operational surveillance system, 2
information Top down too slow, alert to the customer has not been made,
etc...

10

11

12

CO
ET Usinage d'une nouvelle patte de fixation, et fixation d'un carter
MP
AT de protection contre nacelle
OS
AN
T
To be checked: YES

The A3 standard has been rolled out by a multi-competency team

( list of the participants and their position are available)

The Problem is formalized clearly

(QQOQCP / 5W2H: What / Why / Where / When / Who / How / How
much)

Each bone of the 7M Diagram has been analysed and fulfilled (mini 2 boxes
documented by bone).
Eventually, 2 Diagrams have been managed : 1 for 'Detection'area + 1 for
"Occurrence" area.
For each boxe non selected, the justification/explaination is available.

An Occurrence 5 Why has been rolled out :

Causes are corresponding 1to1 to the ones selected in the 7M diagram
Each causes contains at least 5 whys with a clear logical link (use 'therefore')

A Detection 5 Why has been rolled out :

Causes are corresponding 1to1 to the ones selected in the 7M diagram
Each causes contains at least 5 whys with a clear logical link (use 'therefore')

All the hold Root Causes are reported on the A3 synthesis page:
- Actions associated to each root causes are prioritized,
- For each action : there is a pilot and a date

A3 integrates a measure of effectiveness (scrap rate, sorting results,…)

proving the effectiveness of the analysis and the action plan

The actions of Transversalization are described :

- the perimeter of the mass-production Read Across is described ( list of plants,
parts…)
- the perimeter of the Project Read Across is also described ( list of project)
NO