Revision: Original

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Supplier Focused Training Supply Chain
Management Training TSCMT 2.1 Scope
Supplier Corrective Action Response Development
Revision Original
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Instructions

• This training is self-directed
• Try to give yourself adequate time to complete
  this training in one session
• It is suggested that you have the applicable
  procedures or forms available for review while
  reviewing this training
• Review each section carefully
• When available, place your cursor on the
  Speaker icon to listen to additional
  information not necessarily addressed in the text
• Left click your mouse, use the down Arrow key
  or the Page Down key to advance the slides.

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Corrective Action Process
Step 1 Investigate, Gather Data and Define the
Problem
Step 2 Contain the Defect and Protect the Customer
Step 3 Identify Root Cause
Step 4 Implement Permanent Corrective Action
Step 5 Verification of Effectiveness
Step 6 Implement Controls
Step 7 Prevent Recurrence
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Problem Solution Types

• Corrective Action (Reactive)
• Corrective action, which includes root cause
  identification, is a process. Its not a single
  event. It requires planning, execution,
  implementation, verification and documentation.
• Corrective action is a system-wide effort. Its
  not simply an exercise in completing a form. It
  involves collecting the data and information
  needed to eliminate nonconformities to any
  requirement and to prevent recurrence of those
  nonconformities.
• Preventative Action (Proactive)
• This looks at putting in place solutions prior to
  abnormalities occurring. Best identified during
  the design stage prior to transfer to
  manufacturing using Advanced Quality Tools.
• This looks at the current standards and by
  analysing data using the quality control tools
  seeks to make improvements

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Corrective Action Process
Basically, it follows the PDCA cycle
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Root Cause and Corrective Action The basic
parts of the process

• Define
• Identify the flaw, investigate the data, define
  the problem
• Isolate and Contain
• Containment For the protection of your Customer
  and your reputation
• Identify Root Cause
• Why did it happen?
• Implement Corrective Action
• Permanent Corrective Action The long term fix
• Verify Effectiveness
• Monitor to verify implementation - Confirmation
  of Effectiveness
• Implement Controls
• Establish controls to ensure that actions are
  effective and prevent recurrences
• Prevent Recurrence
• Implement Predictive monitors to become proactive
  instead of reactive

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Step 1 Investigate, Gather Data and Define the
Problem
Step 2 Contain the Defect and Protect the Customer
Step 3 Identify Root Cause
Step 4 Implement Permanent Corrective Action
Not Effective
Step 5 Verify Effectiveness of Permanent Action
Step 6 Implement Controls
Step 7 Prevent Recurrence
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Identify the Problem

• What happened ?
• Describe how the abnormality appears
• Is the problem Periodic or Chronic?
• Describe the process condition when the
  abnormality occurs
• Use quantitative tools to measure the impact

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Investigate the Data Finding the real problem

• Collect Data
• Investigate all areas of product flow dont
  overlook 2nd tier suppliers
• Check internal nonconformance databases for
  similar anomalies, use the data to look for
  variation
• If any are found review the countermeasures
  implemented and determine why they didnt work
• Review personnel training records to determine if
  this is a contributing factor
• Review tooling to verify correct configuration
  and revision level
• Talk to people linked to process recreate the
  situation where problem occurred

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Investigation Tools - Trust your data, not your
feelings

• In God we Trust...
  
• Data analysis helps you find your real problem
  areas and determine what is important and where
  to target your resources

All Others Must Bring Data
Pareto Analysis
Check Sheets
Control Charts
Histograms
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Investigation Tool Example - Pareto Charts

• Helps you identify your problems to determine
  root cause
• Allows you to drill down on issues to prioritize
  efforts
• Exposes other problem area
• Main purpose is to tell you what area to work on
  first
• Converts raw data into useful information
• Simple and powerful
• Separates the Vital Few
• from
• the Trivial Many

Also Remember The issue occurring with the
highest frequency is not always the most
important. Issues such as cost, delivery and
your Customer can factor into the decision of
prioritizing issues.
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Using a Pareto Chart to Focus Sorts through the
noise
Which cell in the plant is producing the highest
number of defects?
Step 2
Step 1
Part Number 123784-1012 - Gear
Which product produced by that cell has the
highest number of defects?
Which defect type in that product is the most
frequently occurring?
Dept. 101 Gear Production
Crack in Part
Step 3
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Classic Pareto Chart So simpleyet so powerful

• Decide what question is being answered by the
  Pareto
• Determine measurement type and gather data,
  defects categories must be well defined
• Arrange the data in descending order to provide
  prioritization

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Whats Wrong with this Pareto? Whats a
miscellaneous defect?
Miscellaneous defects lead the way!
You have to be precise in your data gathering
techniques Dont lump problems into misc. or
other, break them out
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Whats Wrong with this Pareto? Greatest to least
Not formatted from greatest to least
Greatest to least helps you prioritize your
efforts
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Pareto Chart Review

• Decide what question is being answered by the
  Pareto
• Used to sort out extraneous items to prioritize
  issues
• Helps focus on the biggest items first
• Ordered from left to right in descending order
• May need to do several times to get to an
  appropriate level of detail to be able to work
  with
• Watch for misc. and other categories. You
  cant fix other

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Defining the Problem You cant fix it if you
dont understand it

• Problems can be systemic or isolated in
  occurrence
• Systemic Problems
• Can sometimes be attributed to process design or
  product design
• Continue to occur at the same or varying degree
  of severity on the same or different products
• Isolated Problems
• Caused by problems with compliance, standards, or
  efficiency
• Un-natural occurrence to a process or system
• Problem definition should contain information on
  what limits are acceptable and how the limits
  were exceeded
• Problem definition should be specific to one
  issue. If more than one problem is identified,
  each should be addressed individually to ensure
  an accurate solution is reached

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Why Problem Definition is needed So you dont
chase your tail
You cant quantify the problem if you cant
define the requirement!

• Specification Requirement
• Surface to be free from flaws
• Nonconformance Statement
• Surface has a slight discoloration
• Investigation will Define the Issue
• From this statement, is discoloration a flaw?
• Is this what the Engineer had in mind?
• Do inspectors agree if this is actually a flaw?
• Is it measurable and quantifiable?

Dont chase problems that may not be real
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Defining the Problem Strive to make it Crystal
Clear

• Remember, your investigation should help you find
  the Root Defect of the nonconformance, not a
  symptom of the problem
• A gap discovered during assembly is not the root
  defect
• Analyze the problem
• What do the drawings allow?
• What do the specifications allow?
• Review all parts mating to the unacceptable gap
  and determine which, if any part in the assembly
  is actually short?
• Is the assembly process conforming or creating
  the gap?

Do your homework and analyze the problem and
determine the root defect
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Defining the Problem When youre done, it
should be Crystal Clear

• It should be Complete, Clear Precise
• It should be Factual and Traceable by answering
  the questions What? Where? When? How Often?
• It should be Objective does not place blame
  It doesnt assume cause or solution
• It should be Actionable enough solid
  information to provide a basis for root cause
  analysis
• Confirm the problem definition See for yourself
  Review data Talk to those involved

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Defining the Problem Remember the Titanic!
Remember, it is easy to get caught up in defining
Symptoms. They are readily apparent and easy to
identify but do little good to correct the problem
Most problems are below the surface. People that
know the process, know the weaknesses
Symptoms are only the Tip of the Iceberg. The
things that are readily apparent
The Problem Definition should be a factual
description of the Root Defect
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Step 1 Investigate, Gather Data and Define the
Problem
Step 2 Contain the Defect and Protect the Customer
Step 3 Identify Root Cause
Step 4 Implement Permanent Corrective Action
Not Effective
Step 5 Verification of Effectiveness
Step 6 Implement Controls
Step 7 Prevent Recurrence
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Containment Protecting the Customerand yourself

• Containment Action is required within 3
  business days of notification
• Containment actions are to be treated as
  temporary measures to contain the problem and
  fix it on a short term basis.
• Effective root cause analysis can take time, this
  step identifies the actions necessary to shield
  Customers from further exposure.
• Containment actions should help identify the
  start and stop point of the nonconformance.
• Containment must be assigned to an individual for
  implementation
• It must include measures to ensure Customer
  protection is effective
• It has an agreed effective life span or
  effectivity
• It should terminate once countermeasures are in
  place

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Containment Know where its at

• Effective containment has been achieved when data
  supports that the following conditions have been
  reviewed
• Work in Process
• Finished Goods
• Parts / Material in Transit
• Part / Material already at a customer site
• Parts / Material in the field
• Actions designed to detect similar
  nonconformances have been implemented
• Stop the defect at each point Isolate or
  quarantine the product at all points Identify
  the contained product to keep it separate
  Implement 100 inspection or testing to certify
  the product and confirm with the customer that
  the problem no longer exists.

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Containment Protecting the Customer and yourself

• Multiple and different containment actions may be
  necessary for materials in different stages of
  completion and/or location.
• Action plans detailing the specific actions to be
  taken, assigned responsible individuals, and
  targeted completion dates are appropriate to
  ensure thorough and effective containment is
  achieved.
• Validate effectiveness of action Verification
  is done before the containment action is
  implemented to ensure that the proposed action
  will do what is intended to do without creating
  new problems Validation is done afterward to
  provide before-and-after data demonstrating that
  the action works properly.

Rapid and effective containment is a key to
minimizing Customer dissatisfaction!
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Step 1 Investigate, Gather Data and Define the
Problem
Step 2 Contain the Defect and Protect the Customer
Step 3 Identify Root Cause
Step 4 Implement Permanent Corrective Action
Not Effective
Step 5 Verification of Effectiveness
Step 6 Implement Controls
Step 7 Prevent Recurrence
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Root Cause
Problems are like weeds, if you dont get to the
root, they will come back
and they usually multiply over time
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Root Cause Determination Finding the source

• The Root Cause is the basic reason for an action
  which, when eliminated, will prevent the problem
  from recurring.
• Avoid general classifications like operator error
  or equipment failure, why did the operator error
  or equipment failure happen?
• Should be specific enough to generate specific
  corrective and preventive actions
• Often are not just one issue but a collection
  of issues
• There are many methods used to determine Root
  Cause, we will offer examples of 2 very powerful
  tools
• 5 Why Analysis
• Cause and Effect Diagrams

Determining Root Cause will result in a robust
corrective action that will prevent a recurrence
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5 Why Analysis why, why, why, why, why, why,
why, why, why

• 5 why analysis is a problem solving technique
  that allows you to get at the root cause of a
  problem quickly. It involves taking any problem
  and repeatedly asking why?
• By asking why" (at least five whys is a good
  rule), you can peel away the layers of symptoms
  that can lead to the root cause.
• Often the first few reasons for a problem will
  lead you to other questions and then to others.
  You may find that you will need to ask why fewer
  or more times than five before you find the issue
  related to a problem.

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5 Why Analysis Remember, the tip of the iceberg
Why 1
Why 2
Why 3
Poor spindle design, it must be the Designers
fault!
The oil pump is no good, it must be the
Manufacturers fault!
No electricity, it must be the Electricians
fault!
Q WHY has the machine stopped ? A Overload
tripped out!
Q WHY did the overload trip ? A The
spindle seized!
Q WHY did the spindle seize ? A the
spindle lubrication was insufficient!
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5 Why Analysis Its not always as easy as it
appears
Why 4
Why 5
Wrong filter, it must be the maintenance mans
fault!
Darn Maintenance man!
Q WHY was was the wrong filter installed ?
Q WHY was the spindle lubrication
insufficient? A The wrong filter was
installed!
A Because all of the different filter types
look alike, the wrong filter was placed in the
wrong stock location by Receiving personnel.
Maintenance assumed the filters were stocked
correctly and used the incorrect filter.
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5 Whys Analysis Roll it up and lay it out flat
Problem
Machine failed during use
Why?
Why did the machine fail? The overload tripped
Why?
Why did the overload trip? The spindle seized
Why?
Why did the spindle seize? There was no
lubrication on the spindle
Why?
Why was there no lubrication? The wrong filter
was installed
Why was the wrong filter installed? The wrong
filter was installed because all of the filters
look the same and a mistake was made during the
stocking of the filters by Receiving
Why?
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5 Whys Analysis The final product
Failure occurred because of the wrong oil filter
installed due to inadequate filter identification
which resulted in the incorrect filter being
stocked. Contributing causes were filter
misidentification by Receiving and Maintenance
personnel and a lack or process documentation and
training.
Root Cause
All machines checked to ensure they has correct
filters are installed. One other incorrect
filter found and corrected. Completed by John
Smith, Maintenance Mechanic 9/20/06
Containment
Drill spindle replaced and correct filter
installed 9/20/06 by John Smith, Maintenance
Mechanic. All filters checked and ensured to be
in proper stock locations. Receiving personnel
notified.
Temporary CA
All filters now color coded by size color
indicators have been place on machine filter
fittings to mistake proof the process. Visual
Color Matrix will be mounted in the filter
storage area designating proper filter colors and
machines. Machine filter mounts will be color
coded to ensure proper filter color is installed.
ECD 6/25/06 and to be completed by Sam Jones,
Receiving Supervisor User manual created for
machine to provide Operator maintenance check
points prior to and during use of equipment.
Maintenance and Operator will also be trained to
inspect machine prior to use and for problems
during use. ECD 6/25/06 by John Smith
Permanent CA
Maintenance Supervisor Bill Johnson will audit
stockroom after next 3 filter deliveries to
ensure proper identification and stocking
techniques were utilized. He will also audit
machine filters for next 3 filter change cycles
to verify proper filters are being installed.
ECD 08/21/06.
Verification
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5 Why Analysis

• Remember, dont be fooled into addressing the
  symptoms of the problem, drill deeper to find
  the root of the problem
• Dont be limited to using only 5 whys when using
  this tool, use as many as necessary to get to
  your root cause
• The Corrective Action Plan needs to take into
  address all actions that made up the 5 why
  analysis, they are often important clues to the
  overall reason for failure
• Lack of operator awareness about his equipment
• (He ran his machine to failure and didnt
  observed coolant rate)
• Maintenance training
• (Mechanic was not aware of differences even
  though they looked the same)
• Lack of maintenance documentation on machine
• (No maintenance documentation instructing
  Mechanic, only verbal OJT history)

These issues were not the root cause, but were
contributing factors to the failure
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Cause Effect Diagrams
Sources of Process Variation
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Cause Effect Diagrams

• Sometimes referred to as Ishikawa or Fishbone
  diagrams
• Tool for listing all the possible causes of a
  problem or quality characteristic,
  brainstorming to encourage ideas
• Focuses on the question of What
• Shows basic relationships among the various
  causes
• Provides a framework for planning what data to
  collect
• Shows potential sources of variation in a process

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Cause and Effect Brainstorming Guide Rules,
rules, rules

• Cause and Effect Brain Storming Ground Rules
• Make sure the topic is clear and understood by
  the team
• The whole team must be present
• Quantity of ideas, not necessarily quality
• Use sticky notes to document and organize
• Identify causes, not symptoms
• No criticism of ideas
• Dont start work on ideas during the session
• Write it down as the speaker states it
• Piggy back off other peoples ideas
• Think out of the box
• Run session for approx 15-30 minutes, take a
  break after each session and before reviewing.
  Clear your head.

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Constructing the Cause Effect Diagram

• State the problem as an Effect
• Remind the team of Brainstorming Rules
• Suggest only possible causes
• Criticism is not allowed
• Everyone participates
• Do not come to premature conclusions
• Speed and quantity are more important at this
  point
• List causes under appropriate heading
• Manpower ? Materials
• Methods ? Measurement
• Machines ? Environment

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Example of a Cause Effect Diagram
Environment
Method Sheet
Dirty shop
Poor lighting
All filters fit all machines
Filters all stored together in the same stock
location
Poor lighting
Filter bins not identified
Wrong filter installed on machine resulting in
machine failure
Filter bin cluttered
No visual identification

Lack of Training for operator, maintenance and
receiving
Shift changeover
Filter boxes look the same
Work overloaded, too busy
Careless checking
New operator

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Verifying Cause and Effect with Data

• Verify the Root Cause Now you must verify which
  of the possible causes is indeed the single, root
  cause of the problem.
• If you dont verify the root cause
• The outcome is no more than team members
  opinions
• The opinions are likely to be correct, but you
  must verify them to be sure
• To verify the Root Cause
• Develop a method for making the problem come and
  go by changing the root cause being analyzed
• Test the method
• If the occurrence of the problem is directly
  affected by the changes made, the root cause is
  verified

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Stating the Root Cause Think, think, think

• Once you have completed your analysis and
  determined what you feel is the root cause, you
  will have to provide a root cause statement
• The Root Cause Statement is where you state the
  actual root cause of the problem. In the case of
  the 5 Whys, DO NOT restate the last Why of the
  5 Why analysis as the Root Cause Statement. They
  may be more contributing factors. Example
• 4th Why Equipment malfunctioned due to power
  surge
• 5th Why Power surge due to electrical storm

Root Cause The machine malfunction occurred
because it was not fitted with electrical
protection to protect it from storm related power
surges
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Step 1 Investigate, Gather Data and Define the
Problem
Step 2 Contain the Defect and Protect the Customer
Step 3 Identify Root Cause
Step 4 Implement Permanent Corrective Action
Not Effective
Step 5 Verification of Effectiveness
Step 6 Implement Controls
Step 7 Prevent Recurrence
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Corrective Action How are you going to fix this?

• Action Taken to Correct the Specific
  Nonconformance
• What actions are you taking to correct the
  specific nonconformance?
• Who is responsible for the completion of the
  actions Provide the names of the person(s) who
  is responsible for correcting the specific
  nonconformance.
• What are the timelines for the actions, including
  completion What are the milestone dates for
  correcting the specific nonconformance.
• If multiple tasks are required, detail them
  individually, not just the completion date of all
  the actions.

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Corrective Action Making it Permanent

• Be sure youve identified and verified the root
  cause
• Make sure the corrective action addresses the
  stated root cause,
• You must have determined and verified the single
  cause that, when eliminated, completely
  eliminates the problem.
• Otherwise, youll risk developing no more than a
  partial or temporary solution.
• Avoid jumping to a single conclusion
• It may not prove to be the best alternative, in
  terms of cost, time or another factor.
• Always come up with at least two best
  solutions, so that you can compare them.
• Be sure another problem isnt created
• Consider what other effects a corrective action
  may have. Be careful not to take a corrective
  action that may solve one problem, but creates
  another.

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Permanent Corrective Action

• Criteria to consider when Implementing Permanent
  Action
• Impact on Customer Satisfaction
• Cost
• Time
• Ease of implementation
• Scope of your authority
• Can you apply error/mistake proofing techniques?

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Mistake Proofing Passive or Active?

• Active Mistake Proofing
• Active Mistake Proofing often referred to as Poka
  Yoke, could be a physical device or work element
  that prevents recurrence of a mistake. Active
  mistake proofing disables the mistake from being
  made again. Example a floppy disk fits in the
  disk drive only one way.
• Passive Mistake Proofing
• Passive Mistake Proofing is an advisory or
  cautionary intervention on how to perform an
  action but lacks the physical device or element
  used in a active mistake proofing.

• MISTAKES CAN STILL OCCUR!

• Example Color coded work instructions, Quality
  Alerts, etc.

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Step 1 Investigate, Gather Data and Define the
Problem
Step 2 Contain the Defect and Protect the Customer
Step 3 Identify Root Cause
Step 4 Implement Permanent Corrective Action
Not Effective
Step 5 Verification of Effectiveness
Step 6 Implement Controls
Step 7 Prevent Recurrence
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Verification of Effectiveness Did it work and
can you prove it?

• Provide your plan to verify the effectiveness of
  your corrective actions. Detail the verification
  actions you will undertake to ensure what you
  said is what you did and it was effective in
  curing the nonconformance.
• For example, if you say you will perform audits,
  retain the audit record of actions as proof to
  the corrective action coordinator,
• If you are going to inspect parts, record the
  serial numbers and the results,
• If you are looking at calibrated tools, determine
  a survey quantity and record the tracking numbers
  and results.

Make sure you know the problem is fixed!
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Verification of Effectiveness Did it work and
can you prove it?

• Verification actions must be proven. Statements
  such as all actions complete is not sufficient
  proof of an effective verification
• Who is responsible for the completion of the
  actions. Provide the names of the person(s) who
  is responsible for verifying the specific
  nonconformance has been corrected
• What are the timelines for the actions, including
  completion. Provided the milestone dates for the
  verification actions
• Never leave verification to your Customer unless
  the Customer concurs
• If you had to, could you prove it!

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Step 1 Investigate, Gather Data and Define the
Problem
Step 2 Contain the Defect and Protect the Customer
Step 3 Identify Root Cause
Step 4 Implement Permanent Corrective Action
Not Effective
Step 5 Verification of Effectiveness
Step 6 Implement Controls
Step 7 Prevent Recurrence
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Implement Controls

• Once you have implemented and verified a
  permanent action, the next step is to establish
  controls to ensure that the actions are effective
  over time and to prevent any future recurrences
  of the problem.
• Use quantifiable methods
• Consider what methods will allow you to monitor
  changes over time. Control charts, run charts,
  follow-up audits or other time-related tools and
  techniques may be appropriate for tracking data
  and trends.
• Be sure that whatever controls you implement will
  allow you to quantify the effects of the
  corrective action.
• Otherwise, you wont truly know whether the
  problem is truly eliminated.

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Implementing Controls

• Document Corrective Action efforts
• What steps were taken to determine action.
• The procedures, policy and/or process steps
  resulting from the corrective action.
• Tools and techniques used to quantify the problem
  and the effectiveness of corrective actions.

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Step 1 Investigate, Gather Data and Define the
Problem
Step 2 Contain the Defect and Protect the Customer
Step 3 Identify Root Cause
Step 4 Implement Permanent Corrective Action
Not Effective
Step 5 Verification of Effectiveness
Step 6 Implement Controls
Step 7 Prevent Recurrence
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Preventing Recurrence

• Use Corrective Action steps to take Preventive
  Action
• Preventive action can be approached in the same
  way as corrective action, using the same steps
  and techniques.
• The difference is that youre addressing
  potential problems instead of existing problems.
• What changes have been made to the quality system
  to prevent this or similar problems from
  occurring in the future?
• Use statistical process control (SPC), failure
  mode and effects analysis (FMEA) or other
  techniques to gain the necessary understanding.
• Be sure that the Quality System includes clear,
  complete procedures, as well as appropriate
  controls.
• If you discover inconsistencies, lack of
  documentation or other weaknesses, you should
  take preventive action.
• Use your internal audit process to sustain the
  gain

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Triumph Contacts

• Thank you for reviewing the Triumph Aerospace
  Systems Group Supplier Corrective Action Primer.
• If you have additional questions, please contact
  your Triumph Business Unit site Quality Assurance
  contact for additional information.
• Dont guess, if you need help contact your
  Triumph Quality Assurance Contacts
• Thank You