Foreword

Often, organizations often do not believe they have the time and resources
to perform the in-depth analyses required to effectively solve and prevent
problems. Instead, they take fast remedial actions to make the problem less
visible and implement a patchwork of “band aid” type solutions which they
hope will prevent recurrence in the future. Then when the problem returns,
there is widespread panic and frustration and the cycle repeats.

On the other hand, Disciplined Problem Resolution efforts (such as SCARs,

CAPAs, 8-Ds –-- etc.) when performed effectively will permanently resolve
the concern at hand and prevent recurrence. Besides being a totally “non-
value add” activity, recurring problems are wasteful, time consuming, and
cause undue frustration and stress to customers and their suppliers.

Organizations who have embraced a mentality of effective problem

resolution and prevention will have created a work environment where
employees work in a relaxed and unstressed atmosphere. Such an
atmosphere is highly conducive to improved productivity and innovative
thinking - an enviable situation for any organization to be in. Under the
leadership and direction of Drs. J. Edward Deming, Joseph Juran and Walter
Schewhart, manufacturers of Electronic Systems and Automobiles in Japan
recognized and adopted this mindset decades earlier and the rest is history.

The underlying objective of this text is to provide Supplier Quality Engineers

and Suppliers a simple “How To” roadmap for completing the SCAR process.

Jose Luis Estrada Noshir Khory

Global Supplier Quality Six Sigma Master Black Belt
Manager CoE, GE Healthcare GE Healthcare, Supplier Quality
 Table of Contents
Page

Section 1 : Introduction & the Primary Purpose of this Text 3

Section 2 : GE Healthcare SCAR Process Flow 3

Section 3 : SCAR Actions 4

Step 1 : Describing or Stating the Problem 4

Step 2 : Containment 4
Step 3 : Investigation 4
Step 4 : Root Cause 8
Step 5 : Permanent Corrective Actions 9
Step 6 : Effectiveness Check 11
Step 7 : Preventing Recurrence 12

Section 4 : Measuring the Overall Integrity of a SCAR 13

Section 5 : Typical Shortcomings Observed in a SCAR 13

Section 6 : Example of a “Good” Completed SCAR 14

Appendix : Suggested Additional Reference Reading Material 17

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Section 1 : Introduction & the Primary Purpose of this Text

The primary intent of this handbook is to serve as a “how to” guide for Supplier Quality Engineers who
want to enable suppliers to perform effective Supplier Corrective Action Requests (SCARs). Corrective
and Preventive Action procedures which are deployed today (such as CAPAs, SCARs, ---) all originate
from a Disciplined (Structured) Problem Resolution procedure originally developed and adopted by
Ford Motor Company a couple of decades earlier when Ford recognized the need for addressing
problems permanently. Ford, who called it the “8-D”, was an Eight Step Disciplined procedure
encompassing Problem Description, Containment, Investigation leading to Root Cause, Corrective
Action and Prevention of Recurrence. The more user friendly “8-D” soon replaced the cumbersome
Military Standard 1520 introduced by the Department of Defense during the Second World War.

This guide will cover “Specific How Tos” and “What to Look Fors” pertaining to the effective execution
of the SCAR procedure.

Purpose of a SCAR : A SCAR is generated by the responsible Supplier Quality Engineer (SQE) to draw
the supplier’s attention to any quality related deficiency that has been observed. The supplier’s
responsibility is to adequately address this deficiency via the SCAR document which the SQE will
review and subsequently approve once the deficiency has been adequately addressed.

Section 2 : SCAR Process Flow

In summary, the SCAR follows the Process Flow listed below :

1)Upon discovering a concern, Supplier Quality Engineer (SQE) initiates and submits SCAR
with a detailed Problem Description to the Supplier

2) The supplier then investigates the problem at hand and submits an Action Plan to the SQE.
The plan details what the supplier plans to do to address the concern. This plan will include
the Investigation, arriving at the Root Cause of the Problem --- etc.

3) The SQE reviews the Action Plan and approves it if it is found to be effective and
comprehensive

4) Once approved, the supplier implements the proposed Corrective Actions and Effectiveness
Checks

5) Once deemed acceptable, the SQE approves all the actions the supplier has implemented
and closes (“Completes”) the SCAR document

(Depending on the depth, scope and complexity of the problem involved, the SCAR may be executed
by an individual or an investigation team)

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Section 3 : SCAR Actions
The SCAR involves the following seven steps which need to be executed.

Step 1 : Describing or Stating the Problem. In order to facilitate the problem resolution process, the
concern must be clearly described including :

a) Who (company, organization ---) was involved ?

b) What happened (What is broken) ?
c) When did it happen ?
d) Where did it happen ?

e) How did it happen ?

f) How Severe will the consequences be ? (Impact)

g) How many times has it happened (Frequency)?

An Example of an Acceptable Problem Statement is given below :

30% defective relays were detected by the customer (ZT) out of a shipment of 5000 units on
5/12/06 received from the supplier (Gemex Inc.). The defective units were detected on the customer’s
test fixture during final test. The defective relays were completely non functional (that is, they failed
to switch to the ON function).The suspect lot was manufactured by (supplier) Gemex Inc. during
FW19. Impact : Customer (ZT) has sufficient “good”parts in stock. Hence, ZT’s assembly flow
will not be impacted. An incident like this has never occurred before.
Note : The problem statement addresses all the points required of an Effective Problem Statement
(that is, Who, What, Where, ---- When, How ----- etc.) mentioned in the previous slide.

Step 2 : Containment : This first step needs to be initiated immediately by the supplier when the SCAR
is submitted to them. Containment involves any effort which the supplier would take to isolate the
customer from the effects of the problem. For instance, the supplier may want to sort /segregate
parts, perform any specific/special inspection procedures or initiate any special actions to keep the
customer’s assembly process running.

In one “real world” scenario, a supplier (who manufactured a unique high temperature resin used in a
special automotive application) went so far as to procure product from a competitor to prevent a
“line down” situation at the customer’s factory.

In essence, the primary purpose of Containment is to protect the customer from the negative effects
of the problem.

Step 3 : Investigation. This effort enables the supplier to arrive at the root cause which caused the
problem to occur. Getting to the correct root cause is important since all corrective and preventing
actions which follow depend upon correctly identifying the root cause. If the root cause identified is
flawed, the corrective action report is worthless.

All steps involved in the investigation process should be described clearly and concisely.

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Some commonly used investigation tools have been listed below.

Tool1 : Process Flow Diagram

This is a useful tool if the investigator suspects the “culprit (or root cause)” to reside within the
manufacturing process. Often, the investigator may find it useful to develop a Process Flow Diagram
in order to better understand the problem. The Flow Diagram may also provide valuable clues and
help drive the team in the direction of the root cause.

Example : Metal slivers and stone particles are detected in finished aluminum die cast component by
a customer. (See Fig. 1)

Fig. 1

In viewing the process flow diagram (Fig. 1), the investigation team would be led to examine the
de-burring and tumble operations to arrive at a probable root cause.

Tool 2 : The “Five Why” Analysis

This is an effective and commonly used General Purpose Investigation Tool to arrive at the root cause

The routine involves asking “Why” sequentially until the investigator is able to arrive at the root cause
of the problem.

This technique, originally developed by Sakichi Toyoda (of Toyota Motors), indicated that (on average)
the root cause is usually uncovered by the time the investigator gets to the “Fifth Why”. Toyoda made
this observation strictly from his experiences in problem solving on the factory floor at Toyota.

Some investigations, however, may require more or less “Why’s” to be asked during the process. In
arriving at Root Cause, the team must exercise reasonable judgment as to when the “Why-Why”
questioning must stop.

It is recommended that the end point of the questioning terminates at the Systemic Root Cause.
That is, “what was deficient in the Quality System that caused the problem to occur?” This could be,
for instance, the modification of a Standard Operating Procedure or a written Work Instruction or
Procedure within the Supplier’s Quality Management System.

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A Word of Caution. The “5 Why Approach” of getting to Root Cause is not a “Universal Investigation
Tool” that will work in every case. Sometimes, other tools like Sensitivity Analysis (derived from a
Designed Experiment), Measurement System Assessment, Hypothesis Testing, Laboratory Analyses --
-- etc. will prove to be more effective in terms of getting to root cause.

Tool 3 : Tool 4 : Brainstorming – The Ishikawa Fishbone Diagram

This is an effective tool to generate collective thinking within the investigation team and organize the
team’s thought processes. (See Fig. 2)

Fig. 2

Tool 4 : Change Analysis – What has Changed ? (This is usually performed during a brainstorming
session by reviewing a process and asking “what has changed ?”.)

Example : The last shipment of plastic parts received from a plastic injection molding supplier were
breaking during assembly in a High Level Assembly (HLA). This pointed to the parts being excessively
brittle. Analysis of the problem by the supplier pointed to a change that was made in the
manufacturing process. The manufacturer of a plastic component (supplier) purchased the raw
material from a new source. Laboratory Analysis showed that the new material had a higher glass
content.

DATA ANALYSIS : Sometimes data sets are confounded and differences are not visually or intuitively
obvious necessitating a more analytical approach. In such situations, available data sets may be
analyzed using more rigorous statistical techniques such as hypothesis or comparison testing (i.e.,
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ANOVA (Analysis of Variance) or “a Student t” test. These statistical tools have been described in
Reference # 10 in the Appendix.

Tool 5 : Pareto Analysis : The Pareto Analysis of available data helps to stratify and prioritize multiple
“events” and extract “few significant” events from “many”.

Example : Defect types discovered during Aug. 2001 in a stamping operation are listed in descending
order of occurrence and plotted on a Pareto Chart. The Paretoized list will help the investigator
address the defects in descending order of importance such as “missing hole” first, “extra hole”
second, and so on.

August 2001
25

20

15
Fig. 3
10

0
Hole Extra Hole Hole O/O Dia. < Spec Dia > Spec Hole Off Burrs
missing Round Center Around
Hole

Tool 6 : Statistical Data Analysis. This type of data analysis is useful when there is a large volume of
data and easy deductions are not readily possible.

1) Radiation data measured from several X-ray machines comprise of multiple sets of data.
Since the data comprises of a large number of data points, visual Inspection (“Eye Balling”)
these set of numbers may be illusive and differences may be difficult to discern. In such
situations, Comparison or Hypothesis Testing of data (ANOVA, “Student t tests”) may be used
to investigate if data sets are statistically different or the same.

2) Simple or Multiple Regression Analysis (Linear and Non-Linear) may be used to check for
cause and effect relationships. If the investigator suspects that mold temperature has an
effect on the hardness of a plastic component, a simple regression analysis may be used to
confirm or negate this suspicion. Multiple Regression Analyses are almost always used in
Designed Experiments (DOEs).

3) Statistical trend analysis may be used to check if process parameters such as DPPM,
Capability Indices (Cp/Cpk) for a given manufacturing process are displaying non-random
trends. For instance, if the Cpk number decreases with time, this is an indication of some non-
random trend occurring in the manufacturing process.

Tool 7 : Scatter Diagrams (Plots)

It is needed to establish relationship between cause and effect or if any correlation exists between
specific events.
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Scatter diagrams (regression lines) help to establish correlation (or lack thereof) between factors. For
example, the scatter plot in Fig. 4 shows a positive and strong correlation between mold temperature
(in a plastic injection molding process) and hardness of an injection molded plastic component
produced by that process. Such type of information could serve as an effective diagnostic or
investigation tool. A detailed analytical treatment on “regression analysis” may be found in Reference
# 10 in the Appendix.

Fig. 4

Tool 8 : Laboratory Analysis to Isolate the Defective Component

Application : In-depth laboratory testing/analyses is necessary to isolate and confirm a defect via a
destructive (or non-destructive) physical analysis. This tool may be used in conjunction with another
Root Cause Investigation tool. Sometimes, examining the failed component may directly lead the
investigator to the root cause.

Example : Electronic components on a circuit board would be an indication that these components
was subjected to excessive heat – perhaps an overcurrent situation. This would then lead the
investigator to examine the components via a destructive physical analyses (DPA) using
sophisticated laboratory equipment.

Depending on the component or system being examined, extensive laboratory testing may be
necessary. Laboratory testing may also include, inspection under a scanning electron microscope, X-
ray emission spectral analysis (XES), chemical tests, highly accelerated life (HALT) testing ------ etc.

Step 4 : Root Cause

The Investigation is intended lead the investigator to the Root Cause of the concern. Where possible,
the Root Cause must point to a Systemic flaw or deficiency within the system. This could be, for
instance, a lack of a missing or clearly Documented Procedure or a Policy that is not being
adequately pursued. For instance, if the problem was created by an untrained operator, the question
to ask would be “Why was this operator untrained?” Was the training Policy or Procedure inadequate
or not implemented ? Answers to these questions should point to a Systemic Root Cause.

Arriving at the correct Root Cause is important. If the Investigation is flawed and the Root Cause
identified is not identified is erroneous, all corrective and preventive actions which follow will be
worthless and add little value. Note that there could be multiple root causes and they would all need
to be addressed.

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Step 5 : Permanent Corrective Actions

Corrective Actions will address the root causes which have been identified.

Purpose of Step 5 is to:

a) Select the most appropriate Permanent Corrective Action to address the root cause. Often,
multiple possible corrective actions are available. The optimum action which considers all
factors such as costs, effort involved, resources to complete the effort, time involved,
feasibility, ---- etc. which would need to be considered.
b) Verify that all actions will be successful when implemented. This is an “educated guess” taken
by the investigation team and will be later substantiated by the Effectiveness Check
(discussed later in a subsequent Step)
c) Ensure that no other problems are created as a result of the remedial actions taken – THIS IS
IMPORTANT ! Often, the team will decide on a Corrective Action not realizing that this action
will introduce a “new problem” that must be dealt with.
d) A time line for completion for all remedial actions must be defined. A SCAR cannot stay
“open” indefinitely.

All Corrective Action/s must be well thought out where all risks and benefits are considered. This
should not involve any “rush through” actions or “band aids” that may eventually cause the problem
to resurface. This was precisely the reason why Ford Motor Company decided to formulate the 8-D
Problem Solving Procedure – they wanted their problems to be “solved for good”.

Note : Corrective Actions may be “Short or Interim” and “Long Term. That is, a “two part” solution may
sometimes be the practical path to pursue particularly when the long term (permanent) solution is
not feasible immediately.

Example : Consider two “snap on” components metal stamped components vibrate during use. This
aggravates customers who complains about it.

Interim (Temporary) Solution : Components are welded together at multiple points at the interface of
the two metal parts. This solution is quick to implement but is costly and error prone (such as a
missing weld) and would need to be followed by a long term permanent corrective action.

Long Term Solution : The two components are integrated into one (single) stamped part – this is less
expensive and less prone to error. However, the long term solution involves designing and fabricating
a new stamping tool which would involve several weeks to implement at the stamping supplier.

Available Tools for Performing Corrective Actions

Tool 1 : Error Proofing.

This is one of the more effective corrective action tools which may be deployed when deemed
appropriate. Error proofing enables the “process to monitor itself”. A “Go – No Go” (Poke Yoke) fixture
is an excellent example of error proofing. Toyota trains and encourages their assembly line
operators to suggest and develop error proofing (“Poke Yoke) tools to be used in the automobile
assembly process.

Example : If a device needs to be welded at six points of contact, a specially designed electrical
fixture at the end of the process electrically checks for all six welds. If a weld is missing a flashing
light or alarm bell sounds to alert the operator.

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Tool 2 : Using Statistical Tools to Improve Design Margin

Statistical Tools such as Designed Experimentation may be used to reduce the Process Width
(Variability) thereby providing wider Six Sigma Design Margins. Increasing the Design Margin
increases the process capability (Cpk) and also makes the product more robust. See Fig. 5.

In addition, increasing the Design Margin also improves the “useful life” (or reliability) of some
electronic components (primarily integrated circuits) appreciably – this was empirically discovered by
studies conducted by Dr. Pat Scanns of the U.S. Air Force in the 1980s.

Fig. 5

Tool 3 : Decision Matrix to select an optimal solution

A Decision Table may be used to select the optimum solution.

Example : Given three possible options, the team must decide on an option to select. The team
members vote on the options presented for various evaluation criteria and numerical scores are
assigned where 10 is most favorable, 5 is somewhat favorable and 1 is least favorable. The highest
score of 23 provides the most optimal solution. Note that this is a “subjective” tool since it relies on
personal choices and opinions and all such “subjective tools” must be viewed with some level of
caution.

Evaluation Criteria
Acceptance of
Potential Option Technical
Benefits versus Option by
for Problem Effectiveness of Total Score
Costs Personnel
Solution Option Proposed
Involved
Purchase new electric
8 8 7 23 Fig. 6
motor.

Repair and re-use old

motor.
4 3 2 9

Purchase a used
motor
5 5 4 14

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Tool 4 : Inspection (Single or Multiple Levels)

Although not absolutely effective, visual inspection is one of the most commonly used corrective
action tools used in industry today. Empirical studies have indicated that visual inspections are about
80% effective, at best. In some situations, a “300% inspection” is deployed where three independent
operators will inspect a finished product in succession. This will reduce the probability of a defective
part slipping through the inspection gate.

Relying on an automated/computerized vision system or Error Proofing as a detection gate is a far

more effective option.

Tool 5 : Training

In and of itself, training or re-training operators will do little to correct a problem. This is because
humans soon tend to forget what has been taught and go back to their old ways.

However, specific training geared towards driving a mindset (such as an error proofing mindset as
encouraged by Toyota) and suggesting new ideas to make the process less prone to error and defect
generation would be more meaningful.

Also, training in the use of simple statistical tools such as effective deployment of Statistical Process
Control Charts will go a long way in monitoring a process and preventing defects.

Step 6 : Effectiveness Check

The Effectiveness Check is intended to determine if the Corrective Actions are, in fact, “working”.
Often, these checks may take weeks or months to complete. In most cases, the effectiveness of the
actions taken is verified by the “goodness” of parts (or lots) received subsequent to the
implementation of corrective actions. A couple of Examples of Checking for Effectiveness are listed
below.

Example 1 : The Paynter Chart

The Paynter Chart shown in Fig. 6 will provide an indication of process improvement after the
corrective action has been implemented. In Fig. 6, the corrective action took place in the April to June
timeframe and the resulting DPPM levels reported by customers dropped significantly after the
corrective action was implemented. This validated the effectiveness of the corrective action very well.

Customer Reported PPM (Defect) Levels

Problem Jan Feb Mar Apr Jun Jul Aug Sep Oct Nov Dec
System Overheats 1000 9090 8701 9804 (CA) 100 60 76 85 65 65 56
Fig. 7
Coolant Leaks 700 670 900 894 888 (CA) 34 23 33 40 38 41
Non-Uniform
4000 4500 4309 3900 (CA) 10 12 14 11 15 15 13
Display Brightness

The “before” and “after” data may also be compared using a “t” test or ANOVA. If there is an
improvement in DPPM after the corrective action has been implemented, the test will highlight the
fact that the data sets are statistically different.

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Example 2 : Achieve Specific Goals/Targets

Comparing results to a target may also be used as an Effectiveness Check. For example, the target
may be to keep the in-process or customer PPM (defect level) to be less than 100 PPM. If the
corrective action does, in fact, reduce the DPPM to 100 or below, the effectiveness check may be
considered as “completed”.

Example 3 : Statistical Data Analysis – Statistical Process Control

SPC Charts. After the corrective action is implemented, a control chart will monitor the process
performance via a Control (SPC) chart. If process output (quantitatively represented via plotted data
points) is found to remain in statistical control, the effectiveness check is complete.

Step 7 : Preventing Recurrence

There are two facets of preventing the recurrence of a problem. The most obvious approach is to
take steps to ensure that the problem does not recur. As an example, consider the fact that a plastic
component has failed because the wrong raw material plastic was used in the injection molding
process. A conceivable corrective/preventive measure would be to require the raw material supplier
to provide the “correct” plastic pellets in uniquely marked/colored containers.

There is, however, an opportunity to go “a step further”. A frequently used method introduced ans
adopted by Automotive Industry in 2004 is the “Drill Wide” approach. The Drill Wide approach
encourages the problem solving team to “go a step further” by asking the question “What Else can
Go Wrong ?” Therefore, for the example cited earlier (plastic part failure), a possible Drill Wide action
would be to ask “where else a similar problem COULD conceivably occur but has not YET occurred”.

Consequently, assuming that the injection molding company is producing other plastic components,
the raw material for these other components would also have to be shipped in different color coded
containers in order to prevent similar failures with other components as well.

Fig. 8

The Process FMEA is an excellent “Drill Wide” tool which may be deployed to uncover those potential
problems which have the propensity to occur but have not yet occurred.

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The reader may note that widespread use of Drill Wide actions will significantly improve the level of a
manufacturer’s overall quality system. This is so because each problem solving effort will proactively
uncover and resolve other potential problems (which have not yet occurred but have the propensity
to occur) bringing about an overall enhancement of the quality system.

Section 4 : Measuring the Overall Integrity of a SCAR

In order to access the value, effectiveness and integrity of a completed SCAR, the reader may want to
ask the following questions:

1) Has the true Root Cause/s been identified

2) Has the Permanent Corrective Action addressed the Root Cause

3) Is the Permanent Corrective Action “working” – can its effectiveness be verified quantitatively.

4) Were all possible Preventive and Drill Wide Actions considered and documented.

5) Is all the documentation clear, concise and easily understandable to the reviewer who may
totally unfamiliar with the problem.

6) Does the SCAR include all relevant diagrams, photographs, --- etc. which may assist the reviewer
in understanding the problem and all subsequent actions which were implemented.

Section 5 : Typical Shortcomings Observed in SCARs

The following points highlight some commonly occurring shortcoming which are observed in SCARs
which have been submitted by the supplier or which have been marked as “completed”.

1) Problem Statement is inadequate (Example : Problem Statement merely says “Bolt on

Assembly 400313 was missing”)

2) Problem Statement includes part (or all) of the Root Cause (Example : Problem Statement says
“Bolt Torqueing instructions were not posted” at the assembly station)

3) Investigation is too lengthy which confuses the reviewer and does not arrive at the Root
Cause. Investigation statement should be brief, to the point and clearly indicate how the
investigation was able to arrive at the Root Cause

4) Root Cause does not “dig deep enough” and points to Non-Systemic Deficiencies such as
“operator Error, micrometer not calibrated, operator not trained, wrong cable used, missing
bolt --- etc”. The Root Cause should highlight Systemic Inadequacies within the system such
as, for instance, lack of Work Instructions or lack of a Robust Training Procedure.

5) Corrective Action does not address the Root Cause. That is, there is no linkage between the
Corrective Action and the Root Cause.

Example : Root Cause states “Work Instruction is inadequately written” while the Corrective
Action states “Operator has been re-trained and certified”.

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 6) Effectiveness Check is Missing, Inadequate and not quantitatively expressed.
Example : Effectiveness Check states “No defects have been reported thus far”.

Note : The Effectiveness Check must include a quantitative statement such as “ No issues
have been reported over last 5 shipments received or parts received over 6 months, 12 weeks,
--- etc.” Open Ended Statements such as “No issues reported” fail to provide adequate
evidence that the problem has indeed been resolved.

7) Preventive or “Drill Wide” Actions seldom executed and/or listed. (This is a very common
occurrence).

8) SCAR is marked “Completed” despite the fact that ALL ELEMENTS are not fully Completed
Example : The SCAR is marked as “Completed” despite the fact that the Corrective Action is
only partially completed and various actions are still pending or that the Effectiveness Check
has not been fully executed.

Section 6 : Example of an Acceptable (“Good”) Completed SCAR

The following is a fictitious example of what a well documented SCAR should look like.

Supplier Name Omni Inc.

SCAR Number SCAR-00000
Date 5/12/2006
Supplier Contact James Schardt

Problem Statement (Filled in by SQE or SCAR Originator)

30% defective high current relays (Part No. Gem 0234 5) were detected by the customer (ZT)
out of a shipment of 5000 units on 5/12/06 received from the supplier (Gemex Inc.). The defective
units were detected on the customer’s test fixture during final test. The defective relays were
completely non functional (that is, they failed to switch to the ON function).The suspect lot was
manufactured by (supplier) Gemex Inc. during FW19. Impact : Customer (ZT) has sufficient
“good”parts in stock. Hence, ZT’s assembly flow will not be impacted. An incident like this has
never occurred before.

Containment Actions

No containment actions are necessary since the Customer has sufficient number of “good parts” in
stock.

Investigation

Investigation Tools Used : Five Why and Laboratory Analysis

1) Analysis of the failed units revealed that the contact points within the relay were fused and
welded together
2) The contact points were fused because they were probably subjected to excessive current.
3) Closer examination showed that contacts were fused because the wrong contact arms were
used in the assembly process. The wrong contact arms which were used were rated at a
much lower current value and therefore overheated and the contact points welded together.
The correct contact arms were rated at a much higher current value.
4) (a) Wrong contact arms were used since there were no Clear Work Instructions posted in the
Stock Room which would indicate to the part picker that the relay in question needed special
14
 high current contact arms. As a result the picker selected the “wrong” contact arms and
delivered them to the relay assembly line.
(b) The high current contact arms visually looked very similar to the low current contact arms
and both types of contact arms were stored in close proximity to each other in the stock
room.

Contact arms (points)

fused together due to
overcurrent situation

Fig. 9

Relay - Part No. Gem-0234-5

Root Causes :

1) Lack of Clear Work Instructions

2) Appearance similarity of high and low current contact arms

Action Plan/Corrective Actions :

1) Responsible Person/Owner : Joseph McDonald

2) Adequate Work Instructions will be placed at the Stock Room where the contact arms are
stored
3) The high current contact arms will be colored red (low current arms are steel gray in color)
4) The high current contact arms will not be stored in close proximity to each other in the stock
room
5) Large color photographs of the high current (red) contact arms will be posted at the stock
room location and at the high current relay assembly station so that both the part picker and
the assembly operator know fully well what to look for and assemble into the high current
relay

Due Date : All Corrective Actions to be implemented by 6/12/06

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Preventive and “Drill Wide” Actions :

1) An electronic test fixture will be installed at the high current relay assembly station. This
fixture test will inject a high current into the relay and ensure that the correct arm is used in
the high current relay. If the fixture detects a “wrong” contact arm in the relay, a red light will
flash.

2) A Process FMEA will be performed for the entire high current relay assembly process to
identify and mitigate any other potential areas of risk where a failure has the propensity to
occur but has not yet occurred.

Due Date : All Preventive Actions to be implemented by 7/12/06

Effectiveness Check :

Customer (ZT) will monitor six consecutive lots of relays (totaling about 30,000 parts) and
check for any failed units in these lots after all corrective actions have been implemented. The
absence of any defects from these six lots will constitute completion of the Effectiveness Check.

Due Date : Effectiveness Check to be implemented by 12/12/06

SCAR Closure :

All Corrective/Preventive Actions were implemented on 7/10/06.

Effectiveness Check : No failures detects on six lots received over 3 month timeframe. Total number
of parts involved = 6000.

SCAR Closed on 11/10/2006

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Appendix : Suggested Additional Reference Reading Material

1) “Corrective Action Handbook” – Denise Robitaille.

2) “Closed Loop Corrective Action” – Ford Motor Company, Dearborn, Michigan.

3) “Failure Mode and Effects Analysis” – Noshir Khory, GEHC Supplier Quality

4) “Correct, Prevent, Improve” by Jeanne Ketola and Kathy Roberts.

5) “The Root Cause Analysis Handbook” by Max Ammerman.

6) “Root Cause Analysis – The Core of Problem Solving & Corrective Action” by
Duke Okes.

7) “Root Cause Analysis” by Bjorn Anderson and Tom Fagerhaug.

8) “Disciplined Root Cause Investigation – How To” Guide – Noshir Khory, GEHC Supplier
Quality

9) “Poke Yoke : Improving Quality by Preventing Defects” – Nikkan Kogyo Shimban

10) “Six Sigma Overview and Applications” - Noshir Khory, GEHC Supplier
Quality

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