E Incident Overview

Record ID INCIDENT-000016293 Created By Stephen Muthui

Date of Detection 6/28/2022 Purchase Order 4522829215_U

Purchase Order Line

100 Goods Receipt
Item

Material
Material Number 68736729_U POLYSACK SUNLIGHT HW PINK 12X1KG
Description

Global Material Type Packaging Supplier Vendor Site TEXPLAST INDUSTRIES LTD

Supplier
Texplast SAP Batch Code
Manufacturing Site

Vendor Batch SLED/BBD

Date of Manufacture Material Blocked? Yes

Transport Issue? No Cluster Africa

Sourcing Unit K001_Kenya-Nairobi HPC Make Plant Defect Group Packaging Component Production

the packaging material is either out of spec

versus the limits defined in the specification,
Defect Type or not to standard versus what is considered
Loss Tree Language English
Definition normal i.e.: made from wrong material, ,
made from the wrong material, too
thick/too thin

Defect Type material: out of spec or not to standard Defect Type Code PC180

Packaging Material Incident

Secondary EC
Level Classification

Required
3G, 5W+H, and Immediate Corrective
Incident Severity C Investigation
Actions
Sections

polysacks labelled as 1kg pink but are Proposal Rejection

Problem Definition
physically present as 500g pink Justification

Additional Required
None Supplier Comments
RCA Sections

Preventative Action
Related Incident
Comments
 Additional Batch Codes
Name SAP Batch Code

Impact
Ordered Quantity 1000.000 Defective Quantity 2000.00

Defective Qty UoM pieces Rejected Quantity 2000.00

Rejected Qty UoM pieces Number of Repeats 2

Disposition Downtime 0

Cumulative
Downtime UOM Hours
Downtime

Cumulative
Defective Cost
Downtime UOM

Rejected Cost

Costs
Local Global
Cost Incident Sub- Categor
Name Cost Currenc Cost Division Cluster PMU MCO
Group Severity Division y
y (EUR)

Other Impacted Manufacturing Location(s)

Name

3G: Observations at the Actual Place

Describe the Location Observations at the
Record ID Created By Created Date
(Spot) Spot
OB-000537 Packing of finished goods Mislabeling of bale MATTHEW MUNGAI 7/6/2022 4:21 AM EDT

OB-000539 Packing of finished goods Mislabeling of bale MATTHEW MUNGAI 7/6/2022 4:33 AM EDT
 5W1H: Phenomena Definition
Record ID What? When? Where? Which? Who? How?
Sunlight pink 24X After bailing stage One product is
500g polysacks before the The labeling and labeled at a time
At bail press Random
PS-000575 labelled as product is taken to the packer before labeling of
process/stage Occurrence
Sunlight pink 12X finished goods (Bailers) another product
1Kg polysacks storage begins.

Incident Investigation
Lifecycle Sourcing
Record ID Department Due Date Priority Title Type
State Unit

Immediate Corrective Actions

Record ID Actions Taken Created By Created Date
Develop work instructions
AI-005827 specifying packing operations MATTHEW MUNGAI 7/6/2022 5:19 AM EDT
with labeling requirements.
Training conducted on labeling
AI-005828 MATTHEW MUNGAI 7/6/2022 5:21 AM EDT
work instructions

4M: Machine Method Man Material Analysis

Name 4M 4M Categories 4M Possible Causes

TWTTP: The Way to Teach People

Interview Date & Do you understand
Time the work?

How is outcome
How is work being
free of
done correctly?
defects/errors?

Lack of
What do you do if you
training/inadequate
have a problem?
training?

Operator out of job?

Operator's Name
(Over 3 months)

Comments Comments (Done

(Understand Work) Correctly)

Comments (Free of Comments (Having

Defects) a Problem)
 Operator new to
Training not repeated
job? (Less than 1
for long time?
week)

HERCA: Human Error Root Cause Analysis

Ergonomics issues Complex/difficult/u
during operation? nclear activities?

Operation need to
Process allow for
be described
mistakes?
clearer?

Info missing in job Visual management

element sheet/SOP? not clear/lacking?

Lack of basic
Tools not adequate?
conditions?

Missing tools required Problems due to

for standard? excessive workload?

Line/work area
Workstation
organization
disorganized?
correct?

Used
Unfavorable
components/tools
conditions?
look similar?

Source of inattention Is there a general

for operator? lack of motivation?

Root Cause Analyses

Phenomena Phenomena
Record ID Lifecycle State Sourcing Unit Date Closed
Definition Definition
K001_Kenya-Nairobi <Enter Phenomena
RCA-000003440 Initiated
HPC Make Plant Definition>

Preventative Actions
Preventative Action
Record ID Actions Taken Created By Created Date
Plan
Develop work instructions
specifying packing
AI-005827 MATTHEW MUNGAI 7/6/2022 5:19 AM EDT
operations with labeling
requirements.
Training conducted on
AI-005828 MATTHEW MUNGAI 7/6/2022 5:21 AM EDT
labeling work instructions
 Related Incident
Name Related Incident Created By Created Date

Return Material Authorizations

Return
Supplie
Materi Your Our
r RMA RMA Invoice Estimat
Materi Sent al Attenti Return Order Order
Name Manuf Numbe Approv Numbe ed
al Date Authori on From Numbe Numbe
acturin r ed By r Credit
zation r r
g Site
From

Signatures
Name Signature Name Signature Meaning Signature Status

Record Details
Incident Type E Organization TEXPLAST INDUSTRIES LTD

Supplier View No Created Date 6/28/2022 2:54 AM EDT

Last Modified By System Last Modified Date 7/6/2022 5:29 AM EDT

Cancellation
Legacy ID
Justification

Costs Associated?