Fool proof
systems never work; sometimes I am driven to this conclusion. See the
following
story.
The Factory had a type of special type of
component which should be used for ‘Severe Service’. The only difference
between the one which is used for ‘Normal Service’ is a special coating on the
surface of the component. The order was for a special severe/service product,
the marketing people conveyed to design department. Design department issued a special
Bill of materials (BOM) suiting that. This BOM went to the planning department.
When the planning Engineer raised the indent (manually prepared Purchase
requisition) for the items, the wrong item was requested, the one without
coating . The Purchase Order was made out of the wrong item and it went for
technical approval(vetting) to Design department. The error was overlooked by
the design department. The Purchase Order
was released for the wrong item. There was delay in supply of the item
from the supplier. Everybody was following up that item. As soon as it arrived,
the item was inspected as per Purchase Order(as it was for “without coating”),
used in the assembly and then went for testing.
The product withstood to the ‘Severe’ stage
and final testing, later it got installed at the customer’s project(may be a
case of factor of safety).
How did this get exposed that the wrong
items went into the product?
Later there was a similar order for
another customer. Again wrong items got ordered. That day, the line supervisor
for the assembly was on leave and another supervisor was officiating for him.
The new supervisor checked the items as per
specifications required and found that it was in variance from the BOM. He
raised the alarm. Then QA checked the previous order, just in case . The error
was identified only then.
What is the root cause here? In
how many places did ‘ASSUMPTION’ wreak its havoc?