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Culture Documents
WHY? Therefore
Root Causes
Why made?
Therefore
WHY?
Why shipped?
Use this path to investigate
Quality system failures?
why the problem was not
detected
WHY? Therefore B
Broken containment
C
WHY? Therefore WHY? Therefore
B
Next
Reported by WHY? Therefore Break Point
C
Next
Problem Resolution Complete Communicate to .. Date: Process Change Break Point Date: Implement System Change Date:
Lessons
Team Javier Rubio Barragán, Cadiz Spain Europe.