1. Top Focus Case – Problem Description and Corrective Actions
1. Problem definition
NCR Number: Q245464
Cables INL 195 and INL 196 in shifted positions.
Issue date:
P/N: SCA
Customer: Scania
Quantity: 1
2. Current condition
NOK
3. Root Cause Analysis

2. Top Focus Case – Problem Description and Corrective Actions
4. 3x5 Why?
Cables INL 195 and INL 196 in shifted positions.
WHY?
WHY?
Testing operation not capable to detect shifted connector
Not properly prepared counterpart
WHY?
To small internal counterpart dimensions
WHY?
Testing operator can connect to counterpart using force
WHY?
Risk wasn’t evaluated
WHY?
DETECTION ROOT CAUSE
WHY?
Cables INL 195 and INL 196 in shifted positions
Operator during assembly take connection housing wrong side and put wires in wrong place
WHY?
WHY?
Operator didn‘t recheck his work
Operator work was innatentive
WHY?
WHY?
WHY?
OCCURENCE ROOT CAUSE
During developing FMEA risk wasn‘t properly evaluated.
Small possibility no detect
WHY?
Testing operator can connect to counterpart using force
WHY?
Testing operation not capable to detect if testing operator shift connector
WHY?
SPECIFIC ROOT CAUSE
Detection root cause = why the mistake was not detected in process
Occurrence root cause = why the mistake happened
Specific root cause = why process did not prevent the mistake

3. Top Focus Case – Problem Description and Corrective Actions
5. Action Plan
Corrective actions: Additional visual information added to testing operation to keep aware testing operator for this mistake. G.Dubauskas
Investigating possibility to update testing counterpart. Special request sent to counterpart supplier. E.Karitonis
Preventive actions: Additionally instructed operators, retrain testing operators to follow work steps. D.Stukienė
6. Lessons Learned
Properly evaluate risk
7. Standardisation
Review FMEA.
8. Action Verification
Verification after one month. J.Kulbė