Fast Response Process: Standardized Rapid Reaction To Quality Issues

FAST RESPONSE PROCESS
Standardized Rapid Reaction to

Quality Issues:
Problem Solving
and
Communication
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Motors Worldwide Purchasing.
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QSB WORKSHOP REV. 062705 1
Problem Solving
WHAT IS A PROBLEM?
A Problem is the GAP between the current

situation and customer satisfaction.
In 2005 Problem Report and Resolution (PRR), now

requires the use of the 8D deliverables.

8D PROBLEM SOLVING LOGIC (Example)
FLOW DIAGRAM
Select Define The Contain The
D1 D2 D3
Team Problem Problem
Identify The Root

D4
Cause
Implement Permanent Verify Effectiveness

D5 D6
Corrective Action Of Actions
Institutionalize
Recognize & Formally
D7 Throughout The D8
Organization Disengage The Team

8D PROBLEM SOLVING PROCESS
Select Team Use the team approach by forming a
multidisciplinary problem solving team. Members should
D1 have the expertise and authority needed to solve the
problem effectively.
Define the Problem Part 1 represents what the customer

D2 actually said; Part 2 represents what the engineer or expert
says relative to the problem.
Containment Interim Actions (quick fix) that prevent the

D3 problem from getting to the customer.
Identify the Root Cause Define all the events that produced
D4 the problem. Use a systematic procedure to identify and

verify the root cause: DOE, Fishbone Chart, Drill Deep
Analysis, 7 Diamonds (Include Blue Card).
PROBLEM SOLVING TOOLS (Example)
Flow Chart Fishbone Diagram Pareto Chart
Problem
Histogram 5 Why’s Run Chart

Problem
Why
Why
Why
Why
Why
Root Cause
Scatter Plot Control Chart Pictograph

7 Diamond Process (Example)
Problem Identified
Responsibility
Begin Interrogation
Will Vehicle
Responsibility Process Change Assembly
Is Engineering
Correct Resolve? Engineering
support required?
Production Process? 5
1
No
Yes
Correct
Production Tool? Product Change
Design
2 Required?
Release
Yes 6
Correct Uncertain
Production Part?
3
Yes Statistical
Engineering
Rel. Engineer/ Extremely Complex 7
Parts
SQA/Supplier Problem
Quality?
4
No

Diamonds 1 - 4
Used to determine if production is running the
manufacturing process to design intent.
• Diamonds 1-4 evaluate the stability of the process.
• Once a problem has been identified, the automatic response
must be to immediately perform diamonds 1-4.
• Initial investigation is done where the defect was found.
• If investigation determines the cause of the problem is upstream, then

investigation should be conducted at the upstream source as well.
• Statistical Engineering occurs when the manufacturing process does

meet design intent and the problem still exists.

1 - Correct Process (Example)
Can any of these cause the problem?
• Is the correct Standardized Work posted?
Manufacturing Correct
Corrects Process? • Is Standardized Work being followed?
• Are build documents being adhered to (if applicable)?
• Are gaging requirements / frequencies being adhered
Manufacturing
to?
Correct
2 Tool? • Is the job being done the same on all shifts?
• Does the operator understand what the product
standards are?
• Is it the regular operator? Has there been a lot of
3 Part? turnover on the job?
• Has the operator been properly trained?
• Are the visual aids current?
Quality Sys /
• Does the operator understand the quality outcomes of
SQ / Supplier Parts
4 Quality? her/his job?
• Does the operator know how to communicate when
he/she has a problem?
2 - Correct Tool (Example)
• Are the correct tools & fixtures being used?
1 Process?
(all shifts)
• Are the tools set to the specified requirements?
• Are they properly calibrated?
Manufacturing
Corrects
Correct
Tool?
• Are both shifts using the same tool?
• Are the tools worn?
• Do the tools & fixtures have mutilation protection?
• Has the workstation been error proofed?
3
• Have the tools or error proofing been bypassed?
Part?
• Does the workstation layout allow the operator

to work effectively?
Quality Sys /
SQ / Supplier Parts • Has the Preventive Maintenance been done?
4 Quality?
(check log)
• Are tools functioning correctly?
3 - Correct Part (Example)
1 Process?
• Is the part’s routing current?
• Are the correct parts being used?
• Are parts stocked in the correct location?
Manufacturing
2
Correct
Tool?
• Do the part numbers on the boxes agree with
their location?
• Is error proofing needed?
• Is existing error proofing device working correctly?
Corrects Part?
Quality Sys /
SQ / Supplier Parts
4 Quality?

4 - Part Quality (Example)
Quality Systems is responsible for determining if

1 Process? parts have changed and overall part quality:
Supplier Data
CMM Checks
Manufacturing
2
Correct
Tool?
Fixture Checks
Visual Part to Part
Visual Lot to Lot
Manufacturing
Correct
If part’s quality (out of specification) is
3
Part?
determined to be the problem’s root cause, then
Quality Systems will notify manufacturing and/or
the supplier that there is a problem and work
with manufacturing and/or the supplier to
Parts
Quality Sys /
SQ / Supplier Quality?
validate the corrections.

Referred by Quality Systems Manager
COUNTERMEASURE CARD Card # __________
Date: ______________ Initiated by: _________________

Dept: ______________ Phone: _____________________ Referred to: ________________________ (SQA or SQE, 4)
Part Name __________________ Part # ________________
Referred to: ________________________ (Quality Engineer, 5A)
(Example)
Model ______________________ Unit # ________________
Problem Description: Referred to: ________________________ (Red X, 5B)

___________________________________________________
___________________________________________________ Referred to: _________________________ (Engineering, 6)
___________________________________________________
Referred to: _________________________ (other)
Return to the Quality Department
Assigned to ___________________ Date ______________

Additional Information: __________________________________
Problem Analysis (where defect was found) Yes No _____________________________________________________
_____________________________________________________
1 Standardized Work Followed? _____________________________________________________
_____________________________________________________
2 Correct Tools / Fixtures / Error Proofing? _____________________________________________________
_____________________________________________________
3 Correct Parts?
_____________________________________________________
4 _____________________________________________________
Parts in spec?
_____________________________________________________
Countermeasure ____________________________________ _____________________________________________________
___________________________________________________ _____________________________________________________
___________________________________________________ _____________________________________________________
_____________________________________________________
Completed by ___________________ Date ______________ _____________________________________________________
_____________________________________________________
Problem Analysis (upstream operation, if applicable) _____________________________________________________
_____________________________________________________
Return to the Quality Department _____________________________________________________
Yes No
_____________________________________________________
1 Standardized Work Followed? _____________________________________________________
_____________________________________________________
2 Correct Tools / Fixtures / Error Proofing? _____________________________________________________
_____________________________________________________
3 Correct Parts?
_____________________________________________________
Parts in spec? _____________________________________________________
4 _____________________________________________________
Countermeasure ______________________________________ _____________________________________________________
_____________________________________________________ _____________________________________________________
_____________________________________________________ _____________________________________________________
Completed by _____________________ Date ______________

Practical Problem Author: Phone No: Date:
Solving Report
Problem in shift: Problem found by:
SIP: ___ CARE: ___ GCA: ___ OTHER: ___
Safety Quality Responsiveness People Cost Other
A: __ B: ___ Maintenance: ___ Production: ___
(Example) Report
Problem Description: Sketch:
Problem Definition (Real Problem):
Point Of Cause (where problem is first occurring):
Quality Breakdown Others

Standard: Start Time:
Deviation: End Time:
Problem: Duration:
How Often: Direct Run Loss:
Containment: Who Date Status
Process/Part Check (similar to "7 Diamond Process" Steps 1-4): Diagnostic sheet available:
Y N Y N Check to see if there are any Diagnostic Sheets available to support
1 Has the operator been trained ? solving this problem.
Is the SOS being followed?
2 Is correct tool being used? 4 Do the parts support quality ? Yes: No: ______
3 Is correct part being used?
If Yes, w hich one? Used?
Direct Cause Analysis:
(see other side for 5 Why Analysis)
1) Indicate possible direct causes on diagram. 2) Circle most likely direct causes.
Man Machine
PROBLEM
Method Material

Practical Problem Solving Report
Report No:
Root Cause Analysis:In the first WHY write down the Direct Causes from the front.
(If you found more than one Possible or Direct Cause, please utilize additional sheets for each Direct Cause)
Why?
(Example)
Why?
Why?
Why?
Why?
Root Cause:
Long-Term Countermeasures WHO DATE STATUS
Any Similar Areas where this might apply:

1- Identified 2- Implemented
4- Closed 3- Feedback
Follow-Up and Evaluation:
Verification: Measurements over past ____________ days have shown problem to be: circle one:
(min. 20)
Resolved Not Resolved
Countermeasure Standardized? Further PPS Activity required:
Yes: No: Date: Name: Area: Approval Signature:
If yes, how is the standard documented?
Date/ Signature: Team Leader Group Leader Shift Leader Area Manager
A - Shift
B - Shift

Drill Deep Analysis/Worksheet
Drill Deep Worksheet
Supplier contact:
GM SQE:
Name: Phone: Revision Date:
(Example)
Supplier Duns: Supplier Name and Location:
Issue Title:
Prevent – Why did the

ID Type: PRR PRTS CDP Other ID Number:
Failure Mode:
Effects of Failure Mode:
Cause of Failure Mode:
5 Whys Corrective Action Owner Due Date

manufacturing process not
Why did the manufacturing process
not prevent this failure mode?
M1
M2
prevent the defect?
****************
**************** M3
**
Prevent
****************
**************** M4
**Manuf act uri ng process -
Protect – Why did the Quality

****************prevent ion &
****************
st andardi zed w ork M5
**
****************
**************** M-RC
process not protect the customer

**
Q1
Why did the quality process not
protect GM from this failure mode?
(GM) from the defect?

Q2
****************
**************** Q3
**
Prot ect
****************
**************** Q4
** Qualit y process -
**************** det ect ion &
****************cont ainment Q5
**
Predict – Why did the planning

****************
**************** Q-RC
**
P1
Why did the planning process not
process not predict the failure?

predict this failure mode?
P2
****************
**************** P3
**
Predict
****************
**************** P4
** Planning process -
informat ional cont ent
****************
in FMEAs and CPs
**************** P5
**
****************
5 Whys – Ask “WHY” until actual

**************** P-RC
**
K1
What are the key findings based on
this quality issue?
****************
****************
**
K2
K3
root cause is determined.
****************
**************** K4
**
****************
**************** K5
**

Permanent Corrective Action Identify and implement
permanent corrective actions that will eliminate the problem.
D5 Remember that permanent means forever. The problem
should never be able to occur again.
Verify Effectiveness of Action Verification takes place in

these four areas: Root Cause, Interim Actions, Permanent
D6 Actions, Prevention. Verify the implemented action does
eliminate the problem (short term, long term and other similar
processes) and does not cause any other problems.
Prevent Recurrence (Institutionalize) Preventing recurrence

means preventing changes to the part, process or system that
D7 allow a problem to occur. Prevention covers all similar and
related processes, designs, systems, etc.
Congratulate Your Team Recognize the contributions of

D8 all the team members as a group and individually.

INSTITUTIONALIZE (READ ACROSS)
• Identify similar products and processes which can potentially
have or produce the same failure mode.
• Implement the solution across the organization.
• Update the necessary documentation:
– PFMEA
– Control Plan
– Error Proofing Verification*
– Standardized Work Instructions*
– Operator Instructions*
– Lessons Learned*
• Implement Layered Process Audits* to verify the system is working
consistently.

Read Across Matrix (Example)
READ ACROSS MATRIX (Ref. GM 1927-69,PRR Read Across)
SYMBOL & STATUS KEY:
SUPPLIER: PQE/SQE: O Original Product line and location
Name: Name: X Product line and/or location with similar process
Location: Phone: R Repeat Issues
Duns: GM location / Provider N/A Not Applicable
Contact Name: Contact Phone: Completed & 3rd Party/GM verified
Contact Phone: E-mail: Completed & Supplier verified only
E-mail: Not Completed
Eight Week Period:
Due Date:
A.P.Q.P. Duns #1/ Location Duns #2/ Location
Product / Process
Classification
Part Name & GM Assy. N/C or CS
Customer Concern Failure Mode 5 Why Analysis PRR Number / Issue Corporate
Number Plant CPV Status 1
Champion Symbols
Containment
Cause of Failure Mode Corrective Action
Corrective
Action
Prevent Corrective Action
Protect Corrective Action
Predict Corrective Action
Key Findings Corrective Action

Champion Symbols
Containment
Corrective
Action

Champion Symbols
Containment
Corrective
Action

Read Across - analysis of opportunities of system deficiencies and corrective actions

that encompass all GM parts, manufacturing processes, and other plant locations.

Standardized Rapid Reaction to

Quality Issues:
Communication and Ownership

of Significant
Quality Concerns

FAST RESPONSE
• Fast Response is a system that:
- standardizes reaction to significant External/Internal
Quality failures.
- promotes communication and discipline through daily meetings.
- utilizes a visual method of displaying important information.
In preparation for the Fast Response meeting, at the start of the day,
Quality shall identify significant Quality concerns from the last 24 hours
which may include:
- Customer concerns
- Supplier concerns The workshop team
- Line stops (Internal / Customer) should discuss how
- Dock Audits / Audit issues to define a significant
- Other internal Quality concerns Quality concern.

The Fast Response meeting:
- shall be held daily to review the significant Quality
concerns gathered by Quality. Meetings are held daily at
minimum, some organizations may hold meetings every
shift.
- is a communications meeting, not a problem solving
meeting. It can be a 10 - 20 minute stand up meeting held
on the shop floor or in a production conference room.
- is a manufacturing review meeting owned by manufacturing
and supported by Quality, Engineering, Maintenance, etc…
At the Fast Response meeting, leadership shall:

- Designate a leader (owner) for each concern/issue.
- Assign owner report out for next meeting
Owners shall be responsible for assuring all problem solving

and exit criteria are met in a timely manner.
• Owner report out shall include updates on the following:
- Standardized Worksheets and Operator Instructions
- Problem Solving Results
Root Cause with supporting data
Permanent Corrective Action with verification data
- PFMEA
- Control Plan
- Layered Process Audits*
- Workforce Notification
- Read Across Matrix
- Other documentation as appropriate
• Report out to Leadership is scheduled on the Fast Response

Tracking Board as deemed necessary.
• The Fast Response Tracking Board should be part of a visual

management system. The format should be displayed as large
as is practical in the meeting area.
FAST RESPONSE TRACKING BOARD (Example)
To optimize visual management, this form is displayed in the meeting
area (ex.: 4’ x 8’ dry erase board, laminated poster, etc…).
EXIT CRITERIA
Standardized Work
(Institutionalized)
Corrective Action
Corrective Action
Lessons Learned
Layered Process
Proof/Detection
Next
Implemented
Overall Status
Containment
Date (of
PFMEA / CP
Date Closed
Root Cause
Owner
Operator
Analysis
Updated
Verified
Report
Audits
Error
Issue Issue Date out to
Number Description Opened Unit I.D. # Owner Staff)
Material
Y 1 1/10/2005 333933 McGrath 4/29/2005 G G G G G G Y G Y Open
Contam inated
G 2 Burrs 2/15/2005 98002222 Adam s CLOSED G G G G G G G G G 4/23/05

Parts
R 3 m islocated on 3/21/2005 9950560607 McIntosh 4/29/2005 G G G R R R N/A G N/A Open
assem bly
R 4 Mixed Parts 3/22/2005 34523339 McGrath 4/29/2005 G G G G R G G Y G Open

Paint dots
found on loose
R 5 3/28/2005 98002222 McGrath 5/11/2005 G G G G G N/A N/A R R Open
& m is-built
parts
Loose 7m m
R 6 bolt on front 3/28/2005 98002222 McGrath 5/23/2005 R R R R R R R N/A R Open
cover
EXIT CRITERIA STATUS KEY

R Required but
not initiated
Points to Review:
Y Initiated but not Ownership
com plete Exit Criteria
G Com plete
Overall Status
N/A Not Applicable

Leadership shall display a visual Quality status.
Any type of visual management can be used: calendar, chart, etc…
Daily Quality Chart
Month Year
January 2004
31 (Example)
29
28 30
22 24 26
21 23 25 27
13 15 17 19
12 14 16 18 20
2 4 6 8 10
1 3 5 7 9 11
LEGEND:
Green No Quality Disruptions
Yellow Internal Quality Disruption

(defined locally)
Red Customer Quality Disruption

(eg. PRR, Pull, Spill)

KEY STEPS
Quality gathers significant issues from the past 24 hours.
Daily Fast Response Meeting assigns owner to each issue.

Outside the meeting the owner utilizes the Problem Solving
process to correct and prevent recurrence.
Issues are tracked on the Fast Response Tracking

Board. Owners are required to give periodic updates at
Fast Response meeting.
Owner responsible for completion of all exit

criteria. Results of Problem Solving process
communicated. Fast Response Tracking Board
indicates exit criteria is green.

FAST RESPONSE
BENEFITS:
• Improves Quality metrics: reduces PPM and warranty costs.
• Reduces PRR’s and increases customer satisfaction.
• Provides a systematic approach for Problem Solving* and
communication of Quality issues.
• Reduces recurrence of Quality issues.
• Assures all issues are resolved.
• Supports continual improvement.
• Strengthens documented implementation of Lessons Learned**
database.

FAST RESPONSE SUMMARY
Organizations shall…
 have a defined process for Problem Solving leading to root cause
identification and elimination.
 use the Problem Solving format prescribed by the customer.

 follow guidelines called out in GM GP5
(Problem Report & Resolution PRR) Process.
 hold a daily Fast Response meeting.
 utilizes a format, like the Fast Response Tracking Board to

identify:
 overall status of the significant Quality concerns.
 ownership of each concern.
 exit criteria required to close a concern.
 display daily Quality status.

CONTROL OF
NONCONFORMING PRODUCT
Identification, Containment and

Communication

CONTROL OF NONCONFORMING PRODUCT
• Establish a method to ensure product that does not
conform to specified requirements is:
 Clearly identified using consistent identification (tagging).
 Prevented from unintended use or installation (containment).
• Establish a consistent identification process using a Visual

Management method.
(Example) STOP LIGHT METHOD preferred method
- Red = Scrap
- Yellow = Suspect
- Green = Good
(Example)
SUSPEC
SCRAP OK FOR USE
T
DO NOT USE
TAG CONTENT TAG CONTENT TAG CONTENT
IN THIS SECTION IN THIS SECTION IN THIS SECTION
IS AT LOCAL IS AT LOCAL IS AT LOCAL
DISCRETION DISCRETION DISCRETION
PLT001 PLT002 PLT003

REQUIRED FOR SCRAP REQUIRED FOR REWORK, ANY COLOR (except red or yellow)
PRODUCT/CONTAINERS REINSPECT, SUSPECT FOR CONFORMING PRODUCT IS
(SCRAP BINS PAINTED RED DO NOT PRODUCT/ CONTAINERS ACCEPTABLE
REQUIRE A TAG)
(IF YELLOW IS NOT USED TO TAG MUST SHOW LAST
DISTINGUISH SCRAP FROM SUSPECT, OPERATION.TO ASSURE
THE RED TAG MUST HAVE PROPER REINTRODUCTION
DISPOSITION.)
• Nonconforming product shall be prevented from unintended use
or installation through containment.
• Leadership must develop, organize and maintain a system
for control of nonconforming product.
• All nonconforming and suspect product shall be segregated.
SEGREGATION AREAS:
• Segregation areas shall be foot printed or otherwise identified.
Example: - Scrap bins
- Rework Tables
- Spill containment areas
- Nonconforming material hold areas
• Containment shall verify breakpoint:

- using 100% Inspection
- for a duration specified by site leadership

• For product containment issues, containers shall be identified:
- Red = Nonconforming product
- Yellow = Suspect product
- Green = After breakpoint conforming product
• Containment activity and tasks must be customer approved with

supporting documentation:
- work instructions
- referenced in control plan
- operator training records
• Customer Engineering approval may be required.
• All Control Plan inspections and tests shall be performed;

product removed from the approved process flow shall be
reintroduced into the process stream at or prior to the
point of removal.
NOTE: When it is not possible to reintroduce at or prior to
removal: a customer approved rework procedure shall be
used to assure conformance to all inspections and test
requirements.
• Process & authority for releasing product out of rework, repair and
containment areas shall be defined.
• Product containment issues shall be reviewed by Leadership.
• Containment Worksheet shall be used and completed to:

- Provide a systematic approach to containing all suspect product.
- Identify all areas to be checked for nonconforming product.

CONTAINMENT WORKSHEET (Example
(Example)
DEPARTMENT: DEPARTMENT CONTAINMENT OWNER: )DATE:
Laboratory G. Hall 1/6/2003

PRODUCT NAME / NUMBER: 10066044
PRODUCT NONCONFORMANCE:
Burr on flange
PRODUCT CONTAINMENT SCOPE
IDENTIFY ALL AREAS WHERE SUSPECT PRODUCT COULD BE LOCATED
POTENTIAL AREA SUSPECT PROD. VERIFICATION

LOCATION QTY. VERIFIED FOUND? QTY? RESPONSIBILITY
Receiving 500 P.S. 500 P. Smith

Laboratory 6 K.C. 6 T. Brown
WIP Storage Areas 1000 P.S. 1000 P. Smith
Outside Processing - (Plating) 1000 C.J. 1000 C. Jones
Scrap Bins 42 K.C. 42 C. Jones
Rework Areas 0 B.T. 0 C. Jones
Shipping Dock 0 K.C. 0 C. Jones
Heat T reater 0 P.S. 0 C. Jones
At Customer 0 B.T. 0 C. Jones
In T ransit 0 B.T. 0 C. Jones
Service Parts Operations 0 P.S. 0 C. Jones
TOTAL FOUND 2548 2548 C. Jones
SEGREGATE SUSPECT PRODUCT TO (location, as feasible): 2548 pcs to Containment Area

SORT METHOD (eg. visual, gage, mating part): Visual for burrs
SORT CRITERIA (clear pass / fail standards): Max Burr per standard
I.D. METHOD CONFORMING (eg. mark, tag, sign): White paint dot near defect area
I.D. METHOD NONCONFORMING (eg. mark, tag, sign): Mark defect with red paint.
What if potential quantity does not equal total found?

When do you call the
customer?

Do you call the
customer?
For an internal issue:
all suspect product contained
prior to shipment. No chance
of escape.

Do you call the
customer?
For an internal issue:
all suspect product contained
prior to shipment. No chance
of escape.
No
Certify parts that
will be shipped.

Do you call the
customer?
For a potential external
issue: all suspect material
not contained or not confident
all product contained.

Do you call the
customer?
For a potential external
issue: all suspect material
not contained or not confident
all product contained.
Yes!
Contact :
Assembly Plants
Service Parts (SPO),
Tiered Suppliers as required.
Do you call the customer?
For an internal issue: For a potential external

all suspect product contained issue: all suspect material
prior to shipment. No chance not contained or not confident
of escape. all product contained.
No Yes!
Certify parts that Contact :
will be shipped. Assembly Plants
Service Parts (SPO),
Tiered Suppliers as required.

A nonconformance alert and containment procedure shall establish
the timeline, tasks and communications necessary to meet customer
requirements.
Quality issue
notification
(Example)
Concern
with certification or Begin shipping
was suspect stock certified stock.
Initiate containment
shipped? N
actions, determine
suspect population,
begin Fast
Response*. Y
Contact external
customer.
Develop &
implement external
containment
and certification
plans.
Continue Fast
Begin shipping Response* &
certified stock. Close Issue.

Quality issues can be:
Quality issue
notification » Supplier initiated.
» Issues found by external customer.
Initiate containment Initiate containment actions immediately at

actions, determine all infected locations!
suspect population,
initiate Fast Response*. Begin Fast Response* process – problem
solving efforts.
Is there a concern with the certification

Concern procedure or has suspect stock been shipped?
with certification or » If YES to either question, contact
was suspect stock customer immediately!
shipped? » If NO, then begin to ship certified stock.

Contact External Needs to be a “live” conversation – no voice or email.
Customer A phone list for contacts is established.
Establish conference calls when required by customer.
» A supplier executive acts as lead and

single point for communication.
» All stakeholders including Tier suppliers
participate in calls.
(Example)
GM Contacts
Initial contact must be made with at least one person at each affected facility.
GM SQ Mgmt Team Name Responsibility E-mail Phone
GM EngineerTeam Name Responsibility E-mail Phone
GMT 560 (Flint)

Department Name Responsibity & shift E-mail PHONE

Initiate at customer locations with appropriate sort
instructions.
Develop & implement A Customer should be informed of the following
items:
containment
and certification plans • Certification method.
• Description and picture(s) of the marked parts.
• Description and picture(s) of any marked or
added labels.
Identify parts/labels.
Begin shipping
Begin to ship certified stock.
certified stock
Notify customer of breakpoints.
CERTIFIED STOCK SHIPMENTS

(Example)
Assembly Ship Arrival Tracking Assembly Ship Arrival Tracking
Carrier Quantity Carrier Quantity
Plant Date Time Date Time number Plant Date Time Date Time number
Arlington Silao
Flint 880 Toluca
Pontiac Mishawaka

Work through problem solving process.
Continue Fast Consider for Quality Gates*/C.A.R.E.*

Response* & Close and Layered Process Audit*
Issue
Continue to follow customer’s
notification process requirements.
• The organization’s nonconformance alert notification and containment

process includes communication and actions for all stakeholders:
• Customer(s)
• Tier-2s, etc.
• Internal stakeholders
• The process should include closing the loop with permanent resolution and
issue closure.
• Problem Solving*
• Lessons Learned*
• All containment issues shall be reviewed by leadership.

CONTROL OF
NONCONFORMING PRODUCT
BENEFITS:
• Assures all suspect and nonconforming product is contained.

• Increases customer satisfaction and communication.
• Reduces repetitive Quality spills.
• Assures all issues are resolved with all customer contacts:
internal and external.
• Assures a systematic approach for all issues.

CONTROL OF NONCONFORMING PRODUCT
SUMMARY
Nonconforming product shall be:

 clearly identified using consistent identification (tagging).
 contained through the use of a Containment Worksheet.
 segregated in well identified areas.
 released using a defined process and authority.
 reintroduced into the process stream at or prior to the
point of removal.
 Organization shall have a nonconformance alert and

containment procedure that meets customers requirements
(timeline, steps, communication, etc).
 Product containment issues shall be reviewed by Leadership.

STANDARDIZED OPERATIONS
WORKPLACE ORGANIZATION
A clean, well-organized work environment.
STANDARDIZED WORK INSTRUCTIONS

What work are we to do and how long should it take?
OPERATOR INSTRUCTIONS
How are we to perform the work?

WORKPLACE ORGANIZATION
Workplace Organization encompasses a systematic
approach to ensure:
• work areas are organized for safety, quality,

ergonomics and optimal use.
• only required and regularly used equipment, tools and
materials are present in the work area.
• work areas are controlled using visual management.
• product and information flow is easily understood.
• housekeeping is defined by work area instructions.
• regular management reviews (Layered Process
Audits*) are performed.
• waste elimination and continual improvement.
• a clean, bright workplace.

5S is a Best Practice system utilizing five steps
to achieve neatness and order in the workplace.
ENGLISH TERMS (JAPANESE)

• Sort (Seiri)
- Sorting out what is needed from what is not needed.
• Set in order (Seiton)
- A place for everything and everything in its place.
• Shine (Seiso)
- Clean the area, tools, equipment and remove scrap.
• Standardize (Seiketsu)
- Set standards and follow them.
• Sustain (Shitsuke)
- Ongoing compliance promotes pride and ownership so
that it becomes a way of life.

S-1: SORT – Divide the needed and unneeded items at
the job site, removing any unneeded items.
Before
•Four areas of focus:
- Equipment
- Tools
- Inventory/Storage
- Personal items
• Sort and Tag:

- Place a green tag on any item in regular use.
- Place a red tag on any item which isn’t used or is not in
working condition.
- Place a yellow tag on any item that use or condition isn’t
known for sure.
S-2: SET IN ORDER – A place for everything and
everything in it’s place.
• Categorize: After
- How often do I use this item?
• Determine a location:
• There is a “best” place for every item.

- If used frequently – keep near
If not – place at the rear.
- Use Shadow Boards.
• Set limits for material levels:

- Standard packs.
- Work in process.
- Container size and identification.

S-3: SHINE - Eliminate the source of dirt and leaks (oil, air, water, etc…).
• Clean machines, tools, floors, cabinets.
• Develop instructions for cleaning methods and frequency.
• Organize for cleaning (correct materials, rags, brooms, etc.).
• Find ways to reduce the time required for cleaning. (Examples)
Before After
Out-of-standard conditions can be easily identified and corrected.

S-4: STANDARDIZE - Standardize the area visually and
mark location of each item.
• Color coding for designated areas.
• Designate area shapes.
• Consistent label height and color throughout facility.
• Storage containers and storage areas practices.
(Example)

S-4: STANDARDIZE (CONTINUED)
• Determine cleaning schedule and methods.

• Standardize cabinet organization.
• Define a simple method to identify problems using visual controls.
(Example)
All items are

properly
identified

S-5: SUSTAIN – Ongoing compliance and continual improvement.
• Leadership commitment and involvement (top down).
• Drive 5S throughout the organization.
• Incorporate housekeeping into Operator Instructions.
• Training is the key to continual improvement.
• Establish formal housekeeping audit/checklists.
• Incorporate 5S compliance into a formal Layered Process Audit *

program.
• Keep trying to find a better way.

Create a checklist:
5S Evaluation (Example)
Date: Name : Area:
Item Notes for Next

Item 5S Evaluation & Scoring Criteria
Description Score Level of
No. Rating Scale: 0-5 (Poor = 0, Excellent = 5)
(0-5) Improvement
Removing All items not necessary to performing work are removed from
1
Unnecessary Items the workplace; only tools & products are present at work
Storage of All cleaning equipment is stored in a neat matter ; handy &
2
cleaning easily available when needed.
All floors are clean and free of debris, oil & dirt. Cleaning of
3 Floor cleaning
floors is done routinely - - daily at a minimum.
No outdated, torn or soiled announcements are displayed. All
4 Bulletin boards
bulletins are arranged ina straight and neat manner.
Fire hoses and emergency equipment are unobstructed &
5 Emergency Access stored in a prominent easy-to-locatemanner. Stop switches &
breakers are marked or color-coded for easy visibility.
Work-in-process, tools & any other material are not left to sit
directly on the floor. Large items such as tote bins are
6 Items on floor
positioned on the glance; lines are straight and at right angles
with no chipped or soiled paint.
Aisles & walkways are clearly delineated and can be
7 Aislewys - marking identified at a glance; lines are staight and at right angles
with no chipped or soiled paint.
Aisles are always free of material & obstructions: nothing is
Aislewys -
8 ever placed on the lines & objects are always placed at right
maintenance
angles to the aisle lines.
Storage of boxed, containers & material is always neat at
Storage &
9 right angles. When items are stacked, they are never crooked
arrangement
or in danger of toppling over.

A well organized workplace is the best place to visualize your
Standardized Work – work flow, operator movement, time, etc.
FLOOR LAYOUT (Example)
Before After
LATHE
FIRE EXT. Dept. 816
Insp
Back up
CNC
LATHE
Back up Broach
R000987654
RAW 1
Insp

F1234567890
SCRAP
FIN 4
BROACH
BROACH
CNC
CNC
Dept. 816 
FIRE EXT.

STANDARDIZED WORK PROVIDES A FOUNDATION FOR:
• ensuring operators are consistently performing the same

tasks and procedures.
• an efficient production sequence.
• reduced variation within a process.
• waste reduction, problem solving and quality control.
• identifying value added tasks.
• continual improvement.
• a lean organization.
• auditing operator conformance to work instructions
(Layered Process Audit*).
(Example)
OPERATION:
FROM:___________________________ QUANTITY PER SHIFT:______________ CUSTOMER CYCLE TIME:________________
TO: _____________________________ SHIFT:________ OPERATOR CYCLE TIME:_______________
STEP ELEMENT TIME STANDARD IN- QUALITY CRITICAL
NO. WORK ELEMENT HAND WORK MACHINE WALK PROCESS STOCK Q CHECK
C OPERATION
SAFETY
Standardized Work Instructions shall

Include:
- Work Elements
- Operator Movement
- Operation Cycle Time
WORKSTATION AREA DRAWN TO SCALE
TOTAL

Implementation of Standardized Work Instructions
• Multi-disciplinary team(s) shall identify and list all operations to
implement Standardized Work Instructions.
Examples of how to prioritize:

- Customer Quality Concerns
- Necessity for a Defined sequence or method of work
- Off-line Rework
- High RPN
- Employee Flow-through
• Multi-disciplinary teams shall develop Standardized Work Instructions.
• Impacted and new employees shall be trained in the use of

Standardized Work (Standard Operator Training*).
• Multi-disciplinary team(s) shall continuously develop and improve

Standardized Work Instructions.

STANDARDIZED WORK INSTRUCTIONS (Example)
OPERATOR
MOVEMENT
WORK
ELEMENTS
OPERATION
CYCLE TIME
Display of Standardized Work Instructions
Standardized Work Instructions shall be displayed at each operation.
• Operations performed same way every time.

WORK
• Reduces the risk of omitting components.
ELEMENTS
• Quality checks and frequency are indicated.
• Process improvements easily identified.
• Training is simplified and consistent.

OPERATOR
• Reminds operator of correct sequence.
MOVEMENT
• Alerts operator to safety concerns.
• Assures operator is following approved
process (Layered Process Audits)*.
• Assures leadership operation is running as approved.

OPERATION
• Operator knows if equipment is showing signs of wear.
CYCLE TIME
• Machine and operator hand work and walk time separated.
• Time allocated for quality checks are included.

(Example)
GROUP / TEAM Torque Converter Blank PROCESS NAME: TC Cover Line
OPERATION
NAME / #
Op. 10
ELEMENT TIME QUALITY SAFETY ERGO IN PROCESS NO. OPERATOR

CHECK STOCK
WORK ELEMENTS DIAGRAM A
HAND MACHINE WALK 1
Load Coil (Time to load each coil)
2.0 5
Manual index press to set travel 6.0 3 2
2.0
Adjust travel 16.0 6 4 `1
1
Run first piece 6.0
50 pc Hold
Quality checks per operator instructions 3.0
3.0
Run press in manual mode 12.0
2.0
Check first 5 pieces per operator instructions 40.0
A
Set press to auto 2.0
5
2.0
Run press 6.0
2
4
6 1
Gage 2pieces/press/hour from hold bin 5.0
2.0
Place finished product from hold station into gondola 22.0
50 pc Hold
Tag full gondola with internal move tag 15.0
2.0
Notify fork lift driver to move full gondola to shipping dept. 4.0
2.0
Move empty gondola into position (remove all tags/labels)
Repeat all steps in set-up, gage, inspect and run on all 3

presses 5
16.0 3 2
4
6 1
TAKT TIME 26.4 TOTAL HANDWORK 119.0 50 pc Hold

CYCLE TIME 18 MACHINE CYCLE TIME 18.0
WALK TIME 33.0
OTHER ACTIVITIES
CONTROL BLOCK J.E.S. LOCATION: Posted on press control panel (Each press) SAFETY AUDIT Verify light curtains at beginning of shift
QUALITY AUDIT Perform gaging as stated in the control plan.

ASSIGNED OPERATORS
SAFETY REQUIREMENTS W.P.O. Perform audit at beginning of shift
1ST SHIFT FRED JONES
MATERIAL Notify fork lift operator when gondola is full (400/container)
HANDLING Tag material with OK to move tag.
2ND SHIFT AL SMITH Safety shoes (steel toe)
DATA Record downtime, post performance data to team board at

RECORDING end of shift, record scrap data.
SUPPLEMENTAL OPERATORS Safety glasses with side shields
1ST SHIFT Kathy Barnes Hearing protection
2ND SHIFT Larry Walker Kevlar gloves

Best People Practices Chart Contact your coach or
coordinator with any changes,
Address: AA-007 questions, or quality concerns.
Operation Name: Line: 1 Shift:

Area:
Head ABCDE/RUNNER/ABCDE ALL
L6 Head Assembly Work Flow Diagram
Part Production Procedure
Total Current Cycle Time: 65.5 sec
Item
# Elements Target Cycle Time: 55 sec
1 Unload 'ABCDE/Runner/ABCDE'
2 Place cluster on rack
3 Tape runner with blue tape and masking tape
4 Transfer 'ABCDE/Runner' to 'ABCDE/Runner/ABCDE' fixture on assembly machine
5 Load 'Runner' onto assembly machine
6 Start machine cycle for 'ABCDE/Runner' and 'Runner'
7 Get 'ABCDE' from WIP table
8 Load 'ABCDE' onto assembly machine
9 Get 'ABCDE' from WIP table
10 Load 'ABCDE' onto assembly machine
11 Start machine cycle for 'ABCDE/Runner/ABCDE' and 'ABCDE/Runner'
12 Get 'Runner' from cart
11 10 8 1 4 5 6
12 7
9
TOTAL MANUAL TIME: 45.78 sec 2 3
Tape
Rack
Standard Daily Routine ( Minutes per Shift)
Shift
Item Elements First Second Third
A Load/Unload machine AA-007 389 389 N/A
B Record production downtime/scrap 5 5 N/A
C Cart handling for 'Runners' 9 9 N/A
Required Personal Protective Equipment
Total Minutes Used: 403 403 0 Remember Safety 1st!

Total Utilization: 79% 79% 0%
Note: Operator will be relieved during two 23-minute breaks and one 30-minute lunch.
Effective Date:________________________________
Manufacturing General Supervisor Approval:________________________________

GROUP / TEAM TORQUE CONVERTER PROCESS NAME: PUMP-A & TURBINE-A
OPERATION
NAME / # OP. A PUMP VANE SETTER
QUALITY CHECK SAFETY ERGO IN PROCESS NO. OPERATOR
ELEMENT TIME
STOCK
WORK ELEMENTS DIAGRAM 24 A
HANDWORK MACHINE WALKING
1 LOAD VANES 2.8 34.0

0.6
2 SET VANES 7.1
0.7
3 SET INNER RING AND LOAD TAB ROLLER 8.3
2.9
4 LOAD / UNLOAD WASHER 3.5
2.9
5 SET PUMP TO SHIPPING RACK 1.2
5.6
PIERCE
FINISHED
Can you Improve PUMP

STOCK
WASHER
VANER
this work cell ? 5

4 3 2 1
A
TAKT TIME 41 Sec. TOTAL HANDWORK 22.9

CYCLE TIME 34 Sec. MACHINE CYCLE TIME 34.0
WALK TIME 12.7
4.9
OTHER ACTIVITIES
SAFETY
CONTROL BLOCK J.E.S. LOCATION: POSTED AT OPERATOR WORK STATION
AUDIT
VERIFY LIGHT CURTAINS AT BEGINNING OF SHIFT
QUALITY
PERFORM GAGING AS STATED IN THE CONTROL PLAN
ASSIGNED OPERATORS TRAINING DATE AUDIT
1ST SHIFT ROBERT ADAMS 1/12/04

SAFETY REQUIREMENTS W.P.O. PERFORM AUDIT AT BEGINNING OF SHIFT
MATERIAL PUSH FINISHED PRODUCT TO NEXT OPERATION EVERY 64 PARTS

2ND SHIFT SAM BATES SAFETY GLASSES HANDLING
DATA RECORD DOWNTIME, POST PERFORMANCE DATA TO
TEAMBOARD AT END OF SHIFT, RECORD SCRAP DATA
RECORDING
SUPPLEMENTAL EMPLOYEES TRAINING DATE KEVLAR GLOVES
1ST SHIFT Tom Smith 6/05/03 STEEL TOE SHOES
2ND SHIFT Patricia Knoles OTHER LOAD VANES TO VANER EVERY 40 CYCLES
1/12/04

(Example)
GROUP / TEAM TORQUE CONVERTER PROCESS NAME: PUMP-A & TURBINE-A
OPERATION
NAME / # OP. A PUMP VANE SETTER
QUALITY CHECK SAFETY ERGO IN PROCESS NO. OPERATOR
ELEMENT TIME
STOCK
WORK ELEMENTS DIAGRAM 24 A
HANDWORK MACHINE WALKING
1 LOAD VANES 2.8 34.0

0.6
2 SET VANES 7.1
0.7
3 SET INNER RING AND LOAD TAB ROLLER 8.3
0.9
4 LOAD / UNLOAD WASHER 3.5
0.9
5 SET PUMP TO SHIPPING RACK 1.2
1.8
WASHER
FINISHED
PUMP
STOCK
5 4
A
3
PIERCE
VANER
1 2
TAKT TIME 41 Sec. TOTAL HANDWORK 22.9

CYCLE TIME 34 Sec. MACHINE CYCLE TIME 34.0
WALK TIME 4.9
4.9
OTHER ACTIVITIES
SAFETY
CONTROL BLOCK J.E.S. LOCATION: POSTED AT OPERATOR WORK STATION
AUDIT
VERIFY LIGHT CURTAINS AT BEGINNING OF SHIFT
QUALITY
PERFORM GAGING AS STATED IN THE CONTROL PLAN
ASSIGNED OPERATORS TRAINING DATE AUDIT
1ST SHIFT ROBERT ADAMS 1/12/04

SAFETY REQUIREMENTS W.P.O. PERFORM AUDIT AT BEGINNING OF SHIFT
MATERIAL PUSH FINISHED PRODUCT TO NEXT OPERATION EVERY 64 PARTS

2ND SHIFT SAM BATES SAFETY GLASSES
1/12/04 HANDLING
DATA RECORD DOWNTIME, POST PERFORMANCE DATA TO

TEAMBOARD AT END OF SHIFT, RECORD SCRAP DATA
SUPPLEMENTAL EMPLOYEES TRAINING DATE KEVLAR GLOVES RECORDING
1ST SHIFT Tom Smith 6/05/03 STEEL TOE SHOES

2ND SHIFT Patricia Knoles 1/12/04 OTHER LOAD VANES TO VANER EVERY 40 CYCLES
Standardized Work provides a basis for effective

Operator Instructions.
OPERATOR INSTRUCTIONS
Where to use operator instructions?
Operator instructions are commonly available for:

• manufacturing and assembly
• inspection and data collection
• pack out
• laboratory
Often overlooked activities include:

• offline rework and containment
• set-up and change-over events
• prototype and engineering activities
• process labeling points
• material handling
• shipping and receiving
• maintenance/repair
• office
Best Practices Operator Instruction Format:
• Short descriptions of how to perform EVERY step necessary
to complete the required work (bullet format).
• Instructions for individual stations: minimal in length, specific and

concise.
• Photos or graphics which enhance and explain work requirements

to indicate:
- part orientation/nesting - critical characteristics

- cosmetic features - assembly detail
- inspection points on the part - gages
- all applicable labels - packaging
- machine settings and/or messages
- any required safety equipment
• Translations for any prominent language spoken by the operators .

Best Practices Operator Instructions Content :
• operator safety issues and required safety equipment.

• work elements and sequence of events performed by operator.
• start-up procedures.
• change-over procedures.
• shutdown procedures.
• quality checks and data collection points (SPC, etc.).
• inspection frequencies.
• standard work-in-process quantities (standard packs).
• reaction plans for common and special cause events.
• machine/equipment settings and messages.
Note: Where appropriate operator instructions can be linked to other

operator instructions such as labeling, inspection, gaging and
packaging.

Best Practices Operator Instructions:
• Operator Instructions shall, when appropriate, be updated as a

process or product change occurs.
• Operator Instructions should be:
 developed by multi-disciplinary teams.

 developed from Standardized Work Instructions*.
 used for Standardized Operator Training*.
 used as a template for new programs.
• Operator Instructions are an indicator of a world class organization.

Rev. Date: mm-dd-yy JOB ELEMENT SHEET Page: # of ##
Area/Cell/Department:
Control Operation Number:

Block
Process/Part Name:
(Example)
Label boxes for the pictures. Use to reference appropriate key point or step.
Space to add photographs, drawings or sketches.
SEQ - STEP (What) - SYM - KEY POINT (How) - REF - REASON (Why) -
THE " WHAT"IN THIS SECTION IS THE THE "HOW" PART OF THE DOCUMENT. IN THIS AREA WE EXPLAIN WHY A
LIST OF ALL THE MAJOR STEPS OF IS ASSOCIATED WITH THE STEPS AND IF KEYPOINT OR STEP IS IMPORTANT AND
THE OPERATION SEQUENTIALLY IN THERE IS SOMETHING THAT NEEDS TO BE WHAT HAPPENS IF THIS POINT IS
THE LEFT HAND COLUMN. EACH STEP EXPLAINED REGARDING IGNORED. IT ALSO MAKES THE JOB
SHOULD BE AN ACTION NECESSARY SAFETY/ERGONOMICS, QUALITY/KNACKS, MORE MEANINGFUL.
FOR ADVANCING THE ELEMENT TO THEY ARE EXPLAINED AND IDENTIFIED BY
ITS SUCCESSFUL COMPLETION. THE APPROPRIATE SYMBOL IN THE COLUMN.
KNACKS ARE KEY POINTS WHICH MAKE A

JOB PERFORMANCE EASIER (TRICKS,
PERCEPTIONS, SPECIAL KNOWLEDGE, ETC).
CRITICAL OPERATIONS SHALL BE

IDENTIFIED.
Symbol Legend (SYM): Safety Ergonomics Quality K Knack C Critical File/Ref:

Rev. Date: 5/15/03 JOB ELEMENT SHEET Page: 1of 1
Shift Team Leader Supervisor/Group Leader Date Area/Cell/Department: FINAL DRIVE
Control 1 Operation Number: N/A

Block 2
Process/Part Name: HEAVY DUTY/VOLVO UNLOAD
3
NO. 2A
(Example)
SEQ - STEP (What) - SYM - KEY POINT (How) - REF - REASON (Why) -
1 VISUALLY INSPECT DUNNAGE 1A USE BLUE VINYL GLOVES 1A CUSTOMER DEMAND
1B REMOVE ALL TAGS, STICKERS AND DEBRIS 1B PROPERLY IDENTIFIED ASSEMBLIES TO CUSTOMER
1C SET ASIDE DAMAGED OR DIRTY DUNNAGE 1C REDUCE SEDIMENT LEVELS
2 VISUALLY INSPECT ASSEMBLY AND WRITE 2A ENSURE CORRESPONDING INKJET INFORMATION 2A PROPERLY IDENTIFIED ASSEMBLIES TO CUSTOMER
CORRESPONDING STACK HEIGHT NUMBER IS CORRECT WITH STACK HEIGHT NUMBERS NUMBERS 3 THROUGH 9 ARE THE ONLY ONES
ON INTERNAL GEAR. ONLY #'s 3 THROUGH WRITTEN IN WHITE ON HEAVY DUTY, PINK ON ACCEPTED BY OUR CUSTOMER. OTHERS ARE TO
9 ARE TO BE USED VOLVO AND A YELLOW DOT ON VOLVO INTERNAL BE PUT INTO REJECT BUGGY
3 DEPRESS PARK LOCK PAWL INTO PARKING 3A ACKNOWLEDGE SPRING TENSION AND WINDOW 3A OBTAINS "PARK" STATUS IN AUTOMOBILE
GEAR CLEARANCE
4 INSERT SHORT END OF SHIPPING PIN INTO K 4A TURN INTERNAL GEAR WHILE DEPRESSING 4A ALLOWS FINAL DRIVE ASSEMBLY TO BE INSTALLED
INTERNAL GEAR PIN HOLE, LONG END LOCKING PARK LOCK PAWL UNTIL PARK LOCK PAWL INTO TRANSMISSION CASE AT ASSEMBLY PLANTS
PARK LOCK PAWL IN POSITION ADVANCES INTO FULL DEPTH
5 REMOVE ASSEMBLY FROM LINE AND LOAD 5A INSERT UNLOAD ASSIST DEVICE INTO THE SUN 5A REDUCES BODY STRAIN
INTO CORRESPONDING DUNNAGE GEAR SHAFT AND LIFT FINAL DRIVE ASSEMBLY
INTO THE BASKET USING THE "UP" AND "DOWN"
CONTROL LEVERS
5B LOWER ASSEMBLY CAREFULLY INTO DUNNAGE, 5B PREVENT BEARING FRACTURE
Symbol Legend (SYM): Safety Ergonomics Quality K Knack C Critical File/Ref:ES-705-FAHDVU

BENEFITS OF STANDARDIZED OPERATIONS
Workplace Organization:
• clean machines perform better.
• supports part cleanliness and improves quality.
• optimizes workspace flow and reclaims wasted floor space.
• improves employee's performance, attitude and focus on quality.
• reinforces organization's commitment to customer satisfaction.
Standardized Work:
• process improvements are easily identified.
• safety, quality and labeling points are included.
• operator training simplified and consistent.
• assures operator is following approved process (Layered Process
Audits)*.

BENEFITS OF STANDARDIZED OPERATIONS
Operator Instructions:
• promotes safety and quality consciousness.

• minimizes missed steps in the process.
- operations
- omitted or incorrect components
- quality checks
- labeling
• increases the operator's level of understanding.
• standardizes operator training process.

STANDARDIZED OPERATIONS SUMMARY
 utilize a systematic approach to implement and maintain Workplace
Organization.
 develop and implement Standardized Work Instructions using multi-
disciplinary teams.
 include work elements, operator movements and operation cycle time
in Standardized Work Instructions.
 train impacted and new employees in the use of Standardized Work
Instructions (Standardized Operator Training)*.
 post Standardized Work Instructions at all operations.
 utilize a systematic approach to develop Operator Instructions for all
work.
 verify, (Layered Process Audits)* maintain and update operator
instructions as processes/parts change.
STANDARDIZED OPERATOR
TRAINING
Was Operator training verified

and documented?

STANDARDIZED OPERATOR TRAINING
Standardized Operator Training shall be used to:
• define the minimum training content for each operation.

• identify who in the organization will conduct training.
• establish required documentation and tracking methods.
• Trainers shall monitor new operators’ activities and retrain if

necessary to assure Standardized Work Instructions are being
followed.
• Trainers shall instruct operators using the standard operation

training record.
• The trainer shall notify downstream operations of potential defects.

Operation Name and # ___________________
Standardized Operation - Training Record (Example)
Application: The following shall be completed with any new operator (for any given operation).
Review Complete
Safety/ Equipment Operation
Review operator job instructions/ Discuss critical points
Explain and demonstrate Standardized Work Instructions
Quality records to be filled out (eg. Check sheets)
Part (product) function
Demonstrate the operation and answer questions
Demonstrate gaging and answer questions
Have new employee run operation and answer questions
Teach past problems (eg. FMEA, Top Problems List)
Verify first units produced, coach as needed
Return within the shift, verify std work & product quality again
Return in approx. 1 day, verify std work & product quality again
Notify downstream operations of potential defects
Employee Signature _______________ Trainer Signature _______________

Standardized Operation - Training Record
Training Sign - Off Sheet
(Example) Workcell
Mold / Station #
Associate Name: Shift: Date:
Associate Trainer
Training Criteria Comments
Initials Initials
SAFETY
Fire Exits / Extinguisher Location
Safety Glass Policy
Personal Protective Equipment
MSDS Location
QUALITY
Gate trimming Technique
Visual Defects
Scrap Procedure
PAPERWORK
Production reporting
Scrap Reporting
Bar Code Scanning / Label Verification
OPERATIONS
Operator 1 Work Instructions - Min. 16 Hrs.
Operator 3 Work Instructions - Min. 16 Hrs.
Packaging Requirements (Regular / Service)
WORKCELL ORGANIZATION
5S Responsibilities
Supply Cabinet Location / Contents
Work Cell Board Review
Employee Signature Trainer Signature
Date: Date:
Form Ref: Rev.# Date:

REQUIREMENTS (continued):
• The trainer shall verify quality at a frequency determined necessary

to assure all standards are met. At a minimum the trainer shall
return within the shift and again within approximately one day.
• Operator training shall be tracked on “Trained Operator

Tracking Sheets”.
• Operator Tracking Sheets shall be posted at each

operation and verified through Layered Process Audits.
• Scheduling of refresher training for assigned operators is at

local site discretion.
• Supplemental employees shall not perform the job unless they

have been trained within the last three months.

(Example)
LATEST Job Instructions Rev. Date
TRAINED OPERATOR TRACKING SOP- 3510 1/1/2004
QAL-23 9/23/2004
Operation Name/# CNC OPERATORS SOP- 3510 10/13/2004
LATEST TRAINING DATE AND TRAINER INITIALS

SOP-3510 QAL-23 SOP-3510
DEPT. ASSIGNED EMPLOYEE
Burns, J. 1/02/04 J.M. 9/23/04 K.T. 10/14/04 J.M
Smith, K. 1/02/04 J.M. 9/23/04 K.T.
Underwood, L. 1/02/04 J.M. 9/23/04 K.T. 10/14/04 J.M
Whithers, A. 1/02/04 J.M. 9/23/04 K.T. 10/14/04 J.M
SUPPLEMENTAL EMPLOYEE
Brown, L 1/02/04 J.M. 9/23/04 K.T.
Troy, P. 1/02/04 J.M. 9/23/04 K.T. 10/14/04 J.M

TRAINING / FLEXIBILITY CHART (Example)
Job % of
Author:
Number group that
# of 3/4
Group: reached
circle jobs Check
Job Name
jobs /
per person here if
person
to meet target is
target
rotation plan met
Issue (% of
Date boxes
Team # Name (Write Position if not T/M) Req'd Actual checked)
# of people at 3/4 circle per job to Plan Know s Steps - In Training

meet coverage requirements Actual Can perform w ithout supervision
Check here if target is met Can teach
% of group that reached coverage target Can teach and do repairs
%
(% of boxes checked)

BENEFITS:
• Assures all operators have adequate and similar training.
• Assures unqualified operators receive training prior to

operating equipment.
• Reduces sort, rework and containment activities.
• Communicates operator status to all stakeholders.

SUMMARY
 ensure operator training is being tracked on “Trained Operator

Tracking Sheets”.
 post operator Tracking Sheets at each operation.
 notify downstream operations of new operators.
 train Supplemental employees who have not performed the job

within the last three months.

RISK REDUCTION PROCESS
PROACTIVE
RPN REDUCTION PROCESS:
Reducing the risk of a
POTENTIAL QUALITY FAILURE
REACTIVE
ERROR PROOFING PAST
QUALITY FAILURES

PROCESS FAILURE MODE & EFFECTS
ANALYSIS
(PFMEA)
DEFINITION
• An analytical technique for each process step that identifies:

– ways a process may fail to meet requirements.
– consequences to the internal / external customer (severity).
– frequency the failure will/could happen (occurrence).
– effectiveness of current controls (prevention & detection).
– ranking of causes and effects (risk priority number).
• A structured procedure for identifying and eliminating process

related failure modes.

PROCESS FAILURE MODE & EFFECTS ANALYSIS
(Example)
What How does PO T EPOTENTIAL
N T IAL How likely are
can go it affect FAILURE
F AILURE M O DEMODE
AN D AND
E F FEFFECTS
E CT S ANANALYSIS
ALYSIS we to notice if
wrong? customer? (PRO (PROCESS
CE SS F M EFMEA)
A) this happens?
REV'D DATE :
15xxxxx MODEL YEAR / CARLINE : FMEA DATE : B/P Level: 001, 7-NOV-02
PRODUCTION PLANT : FMEA CONDUCTED BY :
C ACTION RESULTS
POTENTIAL CURRENT CONTROLS RESPONSIBILI
PROCES POTENTIAL L O D R
PROCESS POTENTIAL CAUSE(S)/ RECOMMENDED TY & TARGET
S NAME/ EFFECT(S) OF S A C E P S O D R
FUNCTION FAILURE MODE MECHANISM(S) ACTION(S) COMPLETION ACTIONS
NUMBER FAILURE E S C T N E C E P
S OF FAILURE PREVENTION DETECTION DATE TAKEN
V V C T N
10 Install Incorrect Misbuild: 7 Manual: 7 No No 10 490 Sensor to Shad, B. 3/1/02 7 7 4 146

pilot part part does incorrect prevention detection detect
bearing installed not part bearing
function. selected type
20 Correct Incorrect unable to 7 Machine 3 No In-line 6 126 New Laser NA 7 3 2 42

sub- or install Vision ID prevention Audits Station.
assy reversed Incorrect
sub-
assembly
How often does this How high is

cause happen? the risk?
(AIAG PFMEA Third Edition)

SEVERITY RANKINGS
Criteria: Severity of Effect Criteria: Severity of Effect
This ranking results when a potential failure mode results in a This ranking results when a potential failure mode
final customer and/or a manufacturing/assembly plant defect. results in a final customer and/or a
The final customer should always be considered first. If both manufacturing/assembly plant defect. The final
occur, use the higher of the two severities. customer should always be considered first. If both
Effect (Customer Effect) occur, use the higher of the two severities. Ranking
(Manufacturing/Assembly Effect)
Hazardous Very high severity ranking when a potential failure mode affects Or may endanger operator (machine or assembly) 10
without warning safe vehicle operation and/or involves noncompliance with without warning.
government regulation without warning.
Hazardous Very high severity ranking when a potential failure mode affects Or may endanger operator (machine or assembly) with 9
with warning safe vehicle operation and/or involves noncompliance with warning.
government regulation with warning.
Very High Vehicle/item inoperable (loss of primary function). Or 100% of product may have to be scrapped, or 8
vehicle/item repaired in repair department with a
repair time greater than one hour.
High Vehicle/item operable but at a reduced level of performance. Or product may have to be sorted and a portion (less 7
Customer very dissatisfied. than 100%) scrapped, or vehicle/item repaired in
repair department with a repair time between a half-
hour and an hour.
Moderate Vehicle/item operable but Comfort/Convenience item(s) Or a portion (less than 100%) of the product may have 6
inoperable. Customer Dissatisfied. to be scrapped with no sorting, or a vehicle/item
repaired in repair department with a repair time less
than a half-hour.
Low Vehicle/Item operable but Comfort/Convenience item(s) operable Or 100% of product may have to be reworked, or 5
but at a reduced level of performance. vehicle/item repaired off-line but does not go to repair
department.
Very Low Fit and Finish/Squeak and Rattle item does not conform. Defect Or the product may have to be sorted, with no scrap, 4
noticed by most customers (greater than 75%). and a portion (less than 100%) reworked.
Minor Fit and Finish/Squeak and Rattle item does not conform. Defect Or a portion (less than 100%) of the product may have 3
noticed by 50% of customers. to be reworked, with no scrap, on-line but out-of-
station.
Very Minor Fit and Finish/Squeak and Rattle item does not conform. Defect Or a portion (less than 100%) of the product may have 2
noticed by discriminating customers (less than 25%. to be reworked with no scrap, on-line but in-station.
None No discernible effect. Or slight inconvenience to operation or operator, or no 1
effect.

OCCURRENCE RANKING
Probability Likely Failure Rates PpK Ranking

Very High: Persistent Failures > 100 per Thousand Pieces < 0.55 10
50 per Thousand Pieces > 0.55 9
High: Frequent Failures 20 per Thousand Pieces > 0.78 8
Moderate: Occasional Failures 5 per Thousand Pieces > 0.94 6
Low: Relatively Few Failures 0.5 per Thousand Pieces > 1.20 3
0.1 per Thousand Pieces > 1.30 2
Remote: Failure is Unlikely < 0.01 per Thousand Pieces > 1.67 1

DETECTION
RANKINGS
Inspection
Proofed
Gauged
Manual
Rating
Detection Criteria Suggested range of detection methods
Error
Almost Absolute certainty of
10 Cannot detect or is not checked.
Impossible non-detection. X
Very Controls will
9 Control achieved with Indirect or random checks only.
Remote probably not detect. X
Controls have poor
8 Remote Control is achieved with visual inspection only.
chance of detection. X
Controls have poor
7 Very Low Control is achieved with double visual inspection only.
chance of detection. X
6 Low Controls may detect. X X Control is achieved with charting methods, such as SPC.
Control is based on variable gauging after parts have left
5 Moderate Controls may detect. the station, or go/no-go gauging performed on 100% of the
X parts after parts have left the station.
Controls have a Error detection in subsequent operations, OR gauging
Moderately
4 good chance to performed on set-up and first piece check (for set-up
High
detect. X X causes only).
Controls have a Error detection in station, OR error detection in subsequent
3 High good chance to operations by multiple layers of acceptance: Supply,
detect. X X select, install, verify. Cannot accept discrepant part.
Controls almost Error detection in-station (automatic gauging with
2 Very High
certain to detect. X automatic stop feature). Cannot pass discrepant part.
Controls certain to Discrepant parts cannot be made because item has been
1 Certain
detect. X error proofed by process/product design.

RISK PRIORITY NUMBER (RPN)
• Risk Priority Number (RPN) is the result of Severity, Occurrence and

Detection rankings.
PO T E N T IAL
Severity x Occurrence x Detection =S AN
F AILURE M O DE AN D E F F E CT RPNALYSIS
(PRO CE SS F M E A)
REV'D DATE :
15xxxxx MODEL YEAR / CARLINE : FMEA DATE : (Example)
PRODUCTION PLANT : FMEA CONDUCTED BY :
C
POTENTIAL CURRENT CONTROLS
PROCESS POTENTIAL L O D R
PROCESS POTENTIAL CAUSE(S)/
NAME/ EFFECT(S) OF S A C E P
FUNCTION FAILURE MODE MECHANISM(S)
NUMBER FAILURE E S C T N
S OF FAILURE PREVENTION DETECTION
V
10 Install Incorrect Misbuilt, 7 Manual: 7 No No 10 490
pilot part part incorrect prevention detection
bearing installed doesn't part
function selected
20 Correct Incorrect Loss of 7 Machine 3 No In-line 6 126

Assy - Piston or Engine Vision ID prevention Audits
piston reversed Power; Incorrect
and
QSB rod piston
WORKSHOP REV. 062705 Engine 92
• PFMEA’s shall be completed for all manufacturing processes and
support functions as required by the Quality Management System.
 Support functions include: (receiving inspection, material

handling, labeling, shipping, repair, rework, etc…).
• PFMEA’s shall:
 conform to current AIAG guidelines and customer requirements.
 be updated on a regular basis (living documents).
 exist for all product lines / part numbers.
 include all processes and process steps.
 be utilized for Continual Improvement.
 have accurate Severity/Occurrence/Detection ratings.

• Multi-disciplinary teams shall perform periodic PFMEA Reviews.
• The frequency and/or number of PFMEA reviews shall be determined by

supplier leadership based on:
 customer expectations (PR/Rs, DDW, Launch activities, etc…)
 process capability (FTQ, SPC, etc…)
 changes to the process (Error proofing, Tier 2 changes, etc…)
• Criteria to prioritize which PFMEA to review include:

 product from an acquisition, tool move or change in supplier.
 PFMEA developed without adequate cross-functional involvement.
 PFMEA for part(s) with history of PR/R, Customer complaints,
Warranty or FTQ issues.
 Occurrence ratings (FTQ, scrap, etc…) have changed significantly.
 PFMEA with oldest revision dates.
• PFMEA Review shall include the following at a minimum:
 verification that all operations/processes are included and
accurate (paint, heat treat, material handling, labeling, etc…).
 all process controls are included.
 Detection ratings are accurate.
 Occurrence ratings are analyzed using data (SPC, FTQ, Quality
Gate, C.A.R.E.*, Scrap, Layered Process Audits* results, etc…).
 verification that the PFMEA meets customer requirements and
expectations (AIAG, PPAP, Launch, DDW, etc…).
• Upon completion of the review, a list of the highest (RPN) Risk

Reduction opportunities is established or revised based on the new data.
• An action plan or equivalent shall be utilized by the multi-disciplinary

team to track progress in reducing the RPN ratings.

RPN TRACKING CHART
(Proactive) (Example)
RPN Completion Revised

No. OP No. Function & Failure Mode Value Who Recommended Actions Date RPN
SENSOR TO DETECT
1 10 INCORRECT BEARING INSTALLED 490 B. SHAD BEARING TYPE 12/1/2004 112
INCORRECT OR REVERSED
2 20 SUBASSEMBLY 126 N. ADAMS INSTALL LASER STATION 12/31/2004 42
INSTALL POST ON ASSEMBLY

3 50 HOLE MISSING 168 S. BROWN FIXTURE 12/23/2004 42
4 60 INCORRECT LABEL 112 V. WAGNER IMPLEMENT SCANNER 1/30/2005 21
The number of RPN reduction opportunities on the list is dependent

on complexity of parts and process, size of plant, customer feedback, etc…

(Example: GM form1927-21)
(This is for reference only; check for latest revision)

REACTIVE RISK REDUCTION:
ERROR PROOFING PAST QUALITY FAILURES
• Multi-disciplinary team(s) shall be utilized to develop a list of the
past internal and external quality failures.
• Team(s) identify true PFMEA Severity, Occurrence and Detection

rating for each RPN using AIAG guidelines.
• Team(s) shall develop an action plan to Error Proof the failures.

 Recommended Actions are improvements that will prevent or
reduce the Failure Mode.
 When Error Proofing is not feasible, a plan to improve detection
shall be established.
 A team member shall be assigned responsibility for implementing
the recommended action.
 Reasonable target completion dates shall be established.
TOP FAILURES LIST
(Example)
QUALITY FAILURES
# of Last Cost Per

Issue # Proplem Discription Occurances Occurance Occurance
ICA-04-01 WRONG FITTINGS INSTALLED 21 9/23/2004 $940
CA-04-12 NUT LOOSE / UNDER TORQUED 10 11/4/2004 $950
CA-04-04 O'RING SEAL CUT/DAMAGED 8 11/11/2004 $1,165
ICA-04-09 SPRING OMITTED 8 10/30/2004 $457
ICA-04-15 ASSEMBLY DAMAGED BY IMPROPER HANDLING 5 12/31/2004 $1,500
CA-04-02 SEAL MISLOCATED, OMITTED OR EXTRA 5 12/4/2004 $864
CA-04-05 SENSOR DAMAGED / BROKEN 4 11/11/2004 $453
CA (EXTERNAL)
ICA (INTERNAL)

ERROR PROOFING PAST QUALITY FAILURES
• Error proofing shall be verified per the Error Proofing Verification*

process.
• When corrective actions have been implemented, teams shall
validate the new Occurrence and Detection rankings and resultant
RPN.
• Teams shall update PFMEA’s with all corrective action measures.

RISK REDUCTION
SITE LEADERSHIP:
• should review the need for PFMEA training at least once per year.
• shall support RPN reduction activities and provide necessary

resources.
• shall review the RPN reduction tracking charts.
• shall ensure that formal multi-disciplinary teams are

utilized in the preparation and ongoing review of PFMEA’s.

Risk Reduction
BENEFITS:
• Supports continual improvement as expected by TS16949.

• Allows leadership to allocate limited resources to critical areas.
• Provides a basis for effective error-proofing and problem solving.
• Core tool for APQP and PPAP requirements.
• Provides a Lessons Learned* archive.
• Promotes cross-functional teamwork.
• Meets customer expectations for “living documents”.

RISK REDUCTION SUMMARY
PROACTIVE
 Leadership shall support RPN reduction activities and provide

necessary resources.
 PFMEA’s shall undergo a complete review.
 A list of the highest (RPN) Risk Reduction opportunities shall be
established.
 An action plan or equivalent shall be utilized by the multi-disciplinary
team to track progress in reducing the RPN ratings.
REACTIVE
 A list of the past internal and external quality failures shall be
established.
 Team(s) shall develop an action plan to Error Proof the failures.

ERROR PROOFING
VERIFICATION
Was error proofing verified?

ERROR PROOFING / DETECTION DEVICE FUNCTIONING
Failure mode: Burr Cause: dull tool
Severity: Defect caught at GM Assembly Line (scrap): 5

Occurrence: Supplier process PpK > 1.10 4
Detection: Error detection device in process 3
RPN = 5 x 4 x 3 = 60
ERROR PROOFING / DETECTION DEVICE FAILS
Failure mode: Burr Cause: dull tool
Severity: Defect caught at GM Assembly Line (scrap): 5

Occurrence: Supplier process PpK > 1.10 4
Detection: Error detection device not functioning 10
RPN = 5 x 4 x 10 = 200
ERROR PROOFING VERIFICATION
All error proofing/detection devices with the potential to fail, wear,

misalign, or otherwise become out-of-adjustment shall be verified at a
minimum of once per day.
Note: This is not mastering a gage, (e.g. Setting gage to zero)

It is sending known good & bad parts through to confirm the
device is operating correctly.
.
DEFINITIONS:
Error Proofing Device – (CAN NOT MAKE) - Devices which prevent

the manufacture or assembly of nonconforming product.
Error Detection Device – (CAN NOT PASS or CAN NOT ACCEPT)

Devices which prevent the transfer of nonconforming product
(e.g. 100% in-line inspection equipment).
• Master Document of Error Proofing devices, with
ERROR PROOFING DEVICES SHALL BE
identification number and location
VERIFIED AND THEIR RESPECTIVE
• Verification frequency
LOCATIONS DOCUMENTED • Identify masters (Good/Bad) and defect being checked
• Clearly defined reaction plan if device fails to detect

REACTION PLANS SHALL BE DEVELOPED
• When/if shut down when device fails to detect bad part?
TO FOLLOW WHEN THE ERROR PROOFING • Containment plan? (100% Inspection, etc.)
DEVICES FAIL VERIFICATION • Are suspect parts rerun thru Error Proofing device?
• How/when is Error Proofing device repaired?
• Lot size of parts run between Error Proofing verification

ERROR PROOFING DEVICES SHALL BE • History of process to determine verification frequency
VERIFIED ONCE per DAY • How robust is the process?
• How easy is it to contain suspect product?
• Develop Log of Error Proof Verification failures

VERIFICATION RESULTS SHALL BE with reaction plan to nonconformities
RECORDED WITH IMMEDIATE RESPONSES • Develop form to notify of nonconformities and escalate
TO FAILURES reaction to nonconformities
• Document as Lessons Learned
VERIFICATION RESULTS SHALL BE • Method for getting information to management

REVIEWED BY SITE LEADERSHIP • Determine how information is to be displayed

(Example) SHIFT:
ERROR PROOFING VERIFICATION CHECKLIST DATE:

SNAP RING PRESENCE
op# THESE ITEMS ARE TO BE CHECKED DAILY Code YES NO
OP 30 4 OPERATE L&R SNAP RING INSTALLATION TOOL WITHOUT SNAP RING - IS PART REJECTED ? 4
OP 30 5 DID RED LIGHT ON LIGHT TREE TURN ON ? (L&R) 5
OP 30 6 DID REJECTED PART STAY IN STATION ? (L&R) 6
OP 30 7 DID ANDON ALARM SOUND? (L&R) 7
OP 40 8 OPERATE SMALL SNAP RING INSTALLATION TOOL WITHOUT SNAP RING - DID GAGE REJECT PART ? 8
9 DID RED LIGHT ON LIGHT TREE TURN ON ? (SMALL SNAP RING)? 9
10 DID REJECTED PART STAY IN STATION? (SMALL SNAP RING) 10
11 DID ANDON ALARM SOUND ? (SMALL SNAP RING)? 11
12 DOES PART STILL STAY IN STATION WHEN HAND VERIFICATION TOOL DISPLAYS A RED REJECT LIGHT? 182
13 IS SMALL SNAP RING VISUAL IN PLACE ? 15
14 IF SMALL SNAP RING TOOL IS DOWN, IS THE BACK-UP GAGE USED? 12
15 DOES BACK-UP GAGE REJECT PART IF NO SNAP RING IS PRESENT? 13
16 DOES THE LIGHT TURN RED? (SMALL SNAP RING BACK-UP)? 14
YES NO
SUPERVISOR:
TOTAL # OF X'S IN EACH COLUMN
AUDITOR:
ANY ITEM SHADED NOT WORKING PROPERLY, THE SUPERVISOR MUST BE NOTIFIED
IMMEDIATELY.
ANY ITEM OUT OF COMPLIANCE SHOULD BE REVIEWED WITH SUPERVISOR OR A COPY
OF THE AUDIT GIVEN TO SUPERVISOR.

(Example)
DEPT.____________ ERROR PROOFING VERIFICATION RESULTS
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
JAN FEB MAR APR MAY JUNE JUL AUG SEP OCT NOV DEC
% IN COMPLIANCE:
# OF ITEMS ON CHECKLIST:
# OF VERIFICATIONS
TOTAL # OF ITEMS VERIFIED:
# OF ITEMS IN COMPLIANCE:
ITEMS NOT IN COMPLIANCE NUMBER OF ITEMS NOT IN COMPLIANCE

BENEFITS:
• Assures error proof/detection devices are working as intended.
• Prevents nonconforming product from being made or transferred.
• Establishes a history for each device; indicates when preventative

maintenance or repair is needed.
• Instills discipline within the process.

SUMMARY
 Error proofing devices shall be verified at least once per day.
 Error Proofing device locations shall be documented.
 Reaction Plans to failures shall be developed.
 Verification results shall be recorded.
 Leadership shall review verification results.

LAYERED PROCESS
AUDITS
Were Leadership Layered
Audits Performed?

LAYERED PROCESS AUDITS
• Layered Process Audits provide a system to:

- verify compliance to the documented process.
- instill discipline.
- improve communication.
- improve overall quality.
• Layered Process Audits are becoming an industry standard.
• Layered Process Audits must be owned by manufacturing leadership.
• Quality and other functions will participate and support the Layered
Process Audits system.

• At a minimum of once per shift, Layered Process Audits shall be

conducted on high risk items throughout the manufacturing,
assembly,and associated processes.
• Frequency of Layered Process Audits is based on production volume

and the level of risk of the process and associated procedures.
• Layered Process Audits supplement ongoing control plan and job

instruction checks.

Develop a checklist:
• A list of high risk items to be verified during Layered Process
Audits shall be established.
• Possible elements to consider include:
Gages functioning and calibration confirmation
Stacking/packing techniques
Visual aids presence and content
Process parameters
Work instructions
Product identification
Torque monitoring (if applicable)
Documentation / record completion
Customer feedback
• Layered Process Audits shall verify appropriate Quality

documentation.
Develop a Checklist with Reaction Plan:
• Include repetitive nonconformance items from internal audits
(process, safety, housekeeping, management walk through, etc…)
on the Layered Process Audits checklist.
• Questions should be direct and simple in nature.
• Phrase questions so yes indicates conformance.
• Layered Process Audits results shall be recorded.

• Nonconformities shall be addressed immediately.
 Reaction plan(s) for nonconformities detected during
Layered Process Audits shall be documented and available
for use.
 Corrective actions shall be documented.

LAYERED PROCESS AUDIT CHECKLIST
(Example) DATE
SHIFT
LAYERED AUDIT REACTION PLAN
LAYERED AUDIT CHECKLIST
OPERATION
REACTION
CODE
REACT
op# ITEM # ITEMS TO BE CHECKED DAILY CODE YES NO Reaction Step
1 01
2 02
3 03
4 04
5 05
6 06
7 07
8
08
9
09
10
10
11
12 11
13 12
14 13
15 14
16 15
17 16
18 17
19
18
20
19
21
20
22
21
23
24 22
25 23
26 24
27 25
28 26
29 27
30 28
TOTAL NUMBER IN EACH COLUMN
29
30

LAYERED PROCESS AUDITS CHECKLIST
(Example)
LAYERED PROCESS AUDIT CHECKLIST
SHIFT: 1st
WEEK ENDING:
MON TUES WED THUR FRI SAT N/C

Op # 30 Assembly CODE
3 Y N N Y Y Y 2
Are the builders checking rotation and marking parts (touch point)?
Have the parts been inspected for presence of 8 holes and identified
3 N N Y Y Y Y 2
with orange marker?
Systemic CODE MON TUES WED THUR FRI SAT N/C
Are the operator verification sheets completed daily by all shifts ? 1 N N N N Y Y 4
Are the tagging procedures being followed? 1 Y Y Y Y Y Y 0

Are the posted Temporary Alert Notices current? 2 Y Y Y Y Y Y 0
MON TUES WED THUR FRI SAT WK TOT

TOTAL
RECORD ACTIONS TAKEN ON BACK OF SHEET NONCONFORMING 2 3 2 1 0 0 8
LIST ANY QUALITY OR MANUFACTURING CONCERNS ON ALL OPERATIONS.
AREA IS CONGESTED. HOUSEKEEPING INSTRUCTIONS ARE TOO GENERAL.

LAYERED PROCESS AUDITS FREQUENCY
• Layered Process Audits frequency:
- High risk items shall be verified a minimum of once per shift.
- The manufacturing supervisor shall verify & audit (daily)

Quality documentation to ensure that it is being completed by
the operators.
- The manufacturing area manager shall verify & audit

(weekly) that supervisor verification is being completed.
- Leadership shall conduct Process Layered Audits

assessments periodically (monthly/quarterly).
Operator
Supervisor M T W T F M T W T F M T W T F
Manager
Site Leader
LAYERED PROCESS AUDITS STRUCTURE
(Example)
LAYERED AUDIT MATRIX
FREQUENCY SHIFT DAILY WEEKLY MONTHLY QUARTERLY
SUPERVISOR
OPERATIONS
CORPORATE
INSPECTOR
PRESIDENT
EXECUTIVE
OPERATOR
MANAGER
MANAGER
MANAGER
MANAGER
MANAGER
QUALITY
PLANT
PART/PRODUCT
ERROR PROOF VERIFICATION
FIRST PIECE APPROVAL
STANDARDIZED WORK INSTR.
OPERATOR TRAINING POSTED
SAFETY LIST COMPLETE
PROCESS
SET-UP SHEET COMPLETED
SPC COMPLIANCE
TOOL APPROVAL
QUALITY GATE DATA COMPLETE
SYSTEM
PREVENTATIVE MAINTENANCE
CALIBRATION COMPLIANCE
LOT TRACEABILITY
HOUSEKEEPING
VOICE OF THE CUSTOMER

6 PANEL POSTED
ACTION PLAN UP TO DATE
PRRs POSTED
C.A.R.E. DATA POSTED
QUALITY GATE BOARD CURRENT

• When appropriate, the Layered Process Audit nonconformance
shall be added to the Fast Response* system and/or the
C.A.R.E.* checklist.
• Layered Process Audit results shall be added to the Lessons

Learned* database when appropriate.
• Audit results shall be summarized and reviewed by the

manufacturing site leadership.

(Example)
DEPT._________________ LAYERED PROCESS AUDIT RESULTS
100% 47 50
90% 43 43 45
80% 40
70% 35
60% 27 30
23 24
50% 22 25
20 19
40%
16 16
20
14
30% 15
20% 10
10% 5
0% 0
% IN COMPLIANCE: 88% 68% 95% 96% 97% 84% 95% 95% 94% 95% 95% 89%
# OF ITEMS ON ASSESSMENT: 20 15 20 30 20 10 20 25 20 20 20 20
# OF ASSESSMENTS 20 9 28 15 20 10 20 20 20 20 20 20
TOTAL # OF ITEMS ASSESSED: 400 135 560 450 400 100 400 500 400 400 400 400
# OF ITEMS IN COMPLIANCE: 353 92 533 434 386 84 380 477 376 381 378 357
NON CONFORMANCES 47 43 27 16 14 16 20 23 24 19 22 43
NON CONFORMANCES NUMBER OF ITEMS NOT IN COMPLIANCE

Safety 10 8 5 2 1 1 1 1 1 1 1 1
Missed Audits 10 8 3 2 3 4 5 2 1 1 1 10
5S Related 2 7 7 3 2 2 2 2 2 2 3 2
Product 10 4 3 2 1 1 1 1 1 1 1 10
Voice of Customer 6 4 2 2 3 4 4 4 3 2 2 10
Systemic 9 7 1 2 2 2 2 2 2 2 2 2
Gage Calibration 5 6 3 2 2 5 6 7 2 2 2
Poke Yoke 5 7 8 10 6

LAYERED PROCESS AUDIT
SUMMARY
 Designate manufacturing to own and conduct Layered
Audits.
 Develop a check list of high risk items to be verified during
audit process.
 Establish frequency of audits. (High risk items to be

audited at a minimum of once per shift).
 Verify appropriate Quality documentation.
 Track and review the results of Layered Process Audits.

Quality Verification
QUALITY GATES
Data Driven Process Improvement
Stations
C.A.R.E.
CUSTOMER ACCEPTANCE REVIEW & EVALUATION
“PROTECTING THE CUSTOMER”

WHAT ARE QUALITY GATES?
A Quality Gate is a distinct station in the process:
– where 100% inspection is conducted.
– an accept/reject decision is made.
– data collected is utilized for continual improvement.
– Quality Gates require immediate escalation when gate
alarm is reached.
Operator (s) are assigned to Quality Gate stations and are responsible
for performing all quality functions as called out in the Operator
Instructions* and control plan.
NOTE: Operator Training Records Boundary
Samples, Safety Bulletins, and Run Rules should also
available to the operator at the Quality Gate.
Quality Gates use production process metrics in order to signal when
special causes occur.
‐ First Time Quality (FTQ)
‐ Parts per Hour
Why Do We Need Quality Gates?
• To provide a systemic approach to reduce process variation.
• To improve first time quality (FTQ) and process capability by:
- promptly identifying special cause variation.
- making decisions based on data.
- systematically reducing common cause variation.
• To alert operators of abnormalities.
Where to Place the Quality Gate?

• Points in the process or operation where there exists:
– high risk
– PRR
– high RPN
– low capability (Ppk, Cpk, FTQ) Any operation with a
Cpk or Ppk below 1.0 requires 100% inspection
• Between departments or distinct processes.

QUALITY GATE ROLES & RESPONSIBILITIES
Operator
• Performs quality checks.
• Reacts to nonconformance.
• Initiates escalation when alarm limits are reached.
Engineer, Supervisor, and Maintenance
• Reacts to identified discrepancies at the Quality Gate.
Quality Manager
• Facilitates the daily Quality Gate meeting.
• Manages the Quality Gate Problem Solving and follow-up.
Plant Manager (Director of Operations)

• Owns the Quality Gate.
• Develops and promotes problem solving and Error Proofing.
• Attends Quality Gate review – 1 per day.
SIX COMPONENTS OF
AN EFFECTIVE QUALITY GATE
• Tally Sheet with Alarm Limits

• Immediate Action Response Sheet
• Overall Defect Chart
• Top Defect Chart(s)
• Problem Solving Sheets
• Management Walk-Through/Daily Meeting (Layered Process
Audit)*

QUALITY GATE BOARD SETUP
(recommended display)
Overall Gate Performance
Top Defect Chart
Appropriate Chart For Each Defect Overall Pass Rate, by Shift
Run Chart Individuals or Run Chart (%)
p or np Chart
u or c Chart
Track by shift if appropriate
Pareto Analysis
Feedback Historical Information
C.A.R.E. Charts,
Functional Test, Tally Sheets,
PPM, Review Sheets,
Problem Solving Sheets
Warranty Lessons Learned
Cause and Effect Diagram,
Solution Tree, or
Common Problem Solving Run Review
Pareto
Document Response
Rules Sheet
Analysis
Sheet

Tally Sheet with Action Limits
The Tally Sheet:
• records the number of each type of problem by the hour.
• addresses special cause variation.
• alerts operator when alarm limit is reached.
• is located at or near the point of inspection. (Example)
1st Hour 2nd Hour 3rd Hour 4th Hour 5th Hour 6th Hour 7th Hour 8th Hour
# Defectives Gate Alarm 6:00-7:00 7:00-8:00 8:00-9:00 9:00-10:00 10:00-11:00 12:00-1:00 1:00-2:00 2:00-3:00 Total
4:00-5:00 5:00-6:00 6:00-7:00 7:00-8:00 8:00-9:00 11:00-12:00 12:00-1:00 1:00-2:00
0 Misc. 4 ll l ll 5
1 Bolt Reject 3 l lll Call an Alarm! 4
2 Lash Reject 3 ll l 3
3 Crank Torque 5 ll lll l 6
Do not call an Alarm
# Defects Per Hour 5 6 7 18

# of Assemblies Off Line

Immediate Action Response Sheet
• Documents response when Alarm Limit is reached.
• Records immediate actions taken by responders.
NOTE: This sheet is for communication and is

not intended to track the problem solving process.
(Example)
Immediate
System Who Called When Action Break Point Who Answered When
3/7/05 New Lot of Bolts 3/7/05
1 Bolts Breaking J. Smith 8:45 AM to Assembly RJ123456 M. Smith 9:00 AM

Overall Defect Chart
• Typically a First Time Quality Chart of percentage good vs. time.

• Is a report card for the process that is being measured.
• Should be of greatest interest to the manager.
(Example)
First Time Quality - Assembly Process
95 Implementation of
Corrective Action
90
85
FTQ%
80
75
70 Implementation of
Quality Gate
65
60
May
May
Aug
Sep
Aug
Sep
Nov
Dec
Nov
Mar
Mar
Feb
Feb
Jun
Jan
Jun
Oct
Oct
Apr
Jul
Jul
Month

Top Defect Chart (s)
• Tracks progress of eliminating common cause variation.
• Perform a Pareto analysis and develop a control chart for
the top 1-5 defects.
Top Defect Chart
(Example)
6
5
Number of Defects
0
Crank Torque Misc. Bolt Reject Lash Reject
Defect Type

Problem Solving Sheets
Communicates the activities of the problem solving process.
• 8D form
• Internal corrective action request
• Drill Deep Analysis/ Worksheet
• Cause and Effect diagram
• Solution Tree
• Fast Response Tracking Board
• PRR Response

Management Walk-Through/Daily Meeting
• Management shall regularly Quality Gate Review For 3/8/2005
review the data and the action Title Signature
Plant Manager John Smith
items. Quality Manager Mary Jones
Engineering Manager Anne Miller
• Perform the daily meeting when Maintenance Manager Marty Morris
Ray Roberts
the gate or process is new. Area Supervisor
1. Review the First Time Quality Chart

Is it getting worse, better or staying the same?
• Once the Quality Gate process is

FTQ Chart is staying steady.
2. Review Alarms from Previous Day(s)

institutionalized (verified by Yes
Was the Immediate Action Response Sheet utilized?
Layered Process Audits)*, the What were the problem(s)?

Bolts were breaking
meeting can be held on a weekly Was the response timely?

Immediate Action completed within 15 minutes of the problem discovery
basis. Was the root cause identified?

Root Cause Analysis needs to be performed. - Mary Jones 3/10/05
3. Review the Pareto Chart of Top Defects

• Management Walk –Through shall What is the Top Defect?
Crank Torque defects
be done daily. 4. Review the Control Charts of Top Defects
Are they getting worse, better or staying the same?
• Sign off indicating presence at

All are staying the same.
5. Review the Problem Solving Documentation and Action Plans

Management Walk-Through/Daily No
Are there any road blocks that need to be removed?
Are there any resources that need to be re-assigned?

Meeting No

Quality Gate Information Board

ALARM LIMITS
• Alarm limits perform two very important functions:
– reveal special causes.
– provide concrete evidence that a process is stable/unstable.
• Alarm limits are:

– Absolute and real numbers, that give us a true reflection of the
process.
– Taken directly from measuring the process daily.
– Calculated from the actual variation in the process.
– A statistically valid number that triggers a reaction when

reached. When the number of defects found reaches
the alarm limit; escalation to initiate the problem solving
process begins.
REACTION PLAN
When the Alarm Limit is reached:

• Operator immediately initiates escalation.
• Engineering, Maintenance and Supervisor immediately responds to
identified discrepancies.
– Initiate containment or immediate action if possible.
– Establish breakpoint.
– Notify C.A.R.E.* if necessary. Note: Immediate Action
Response Sheet is the
documentation of the above
escalation process.
• Quality Manager initiates:
– Verification of Control of Non-Conforming Product.
– Problem Solving process as required.
– C.A.R.E.* if necessary.
– Follow-up activities such as report out at the Fast Response
Meeting.

COLLECT DATA: (Example)
Samples Defects Samples Defects
1 1 14 0
Calculation of Limit
2 0 15 0
3 1 16 1 Total Defects 14.00
4 2 17 0
5 0 18 2 Total Number of Samples 25.00
6 1 19 0
Average Number of Defects 0.56
7 0 20 0
8 0 21 0 Sq. Root of Avg. Defects 0.75
9 0 22 1
10 1 23 0 3 Times Square Root 2.24
11 2 24 0
Adding Avg. Defects + 3 times Sq. Root 2.80
12 1 25 1
13 0 Alarm Limit 3
Totals 25 14
SCOPE OF CHANGING ALARM LIMITS

Alarm limits are changed only if there is:
• an intentional, permanent change in the actual process.
or
• a special cause variation, where despite our best efforts to
discover the cause we are unable to make the correction.
QUALITY GATE MAINTENANCE
• After implementation is institutionalized (Layered Process Audits)*

discontinue daily Quality Gate Meetings and start weekly meetings.
• After Corrective Actions are in place recalculate alarm limits and

change if necessary.
• When defect rate at Quality Gate decreases, place another gate

upstream to further improve the process.
Note: If Quality Gates are called out in the control plan,

prior customer approval is required for removal or
relocation.

TYPES OF QUALITY GATES

QUALITY GATE DIAGRAM
OP 10 OP 20 QG
OP 40 QG OP 30
CARE GP12

C.A.R.E.
CUSTOMER ACCEPTANCE REVIEW & EVALUATION
• Protects your customer from non-conforming product, discrepancies

and labeling errors.
• Verifies that process controls are effective.
• Provides information for rapid corrective action.
• Supplements the approved control plan.
• Applies to customer satisfaction items that are part related.
• The Plant Manager & Quality Manager should facilitate activities.

Customer Satisfaction items shall be identified.
Customer Satisfaction Items can include:
- Pass-through items
- Customer/Assembly Plant Feedback
- Warranty Issues
- Customer used features
- Past PR/R issues
- High RPN Failure modes
- Labeling
- Supplier Management Concerns
(such as Tier II changes, tool moves)
When practical, Customer satisfaction items, part(s) and/or

lot will be marked, touched, gauged or scanned.

When a nonconforming part is found:
• The alarm limit for C.A.R.E. items is 1. Therefore, the Quality Gate
escalation process is initiated as soon as a nonconformance is found.
• Rework and inspect in the normal process flow (when practical)

rather than off-line to ensure specified requirements are met.
• Offline rework should be approved and included in the part control

plan.
• Rework requires standardized work instructions and inspection.
• Reworked material must be sent back through C.A.R.E.*
• Report nonconforming data to Fast Response* Meeting.

• Add the root cause corrective action to the Layered Process Audit*.

GP-12
• A process of documenting the organization’s efforts to
verify control of its processes during start-up, acceleration, and
process/part changes.
• Assures any quality issues that may arise are quickly

identified, contained and corrected at the organization’s location
and not at the customer’s receiving location.
• Identifies high risk operations providing opportunities for

continual improvement.
• A Quality Gate with an alarm limit of 1.
Note: Use GP-12 data and other information to

determine placement of other Quality Gates.

QUALITY GATES
BENEFITS:
• Protects internal/external customers from defects.
• Helps decrease common cause and special cause variation.
• Standardizes reaction to process variation.
• Verifies process controls are effective.
• Drives continual improvement.
• Focuses on customer satisfaction items.

QUALITY GATE SUMMARY
Organizations shall:
 Implement at least one Quality Gate.

Note: GMPT suppliers shall implement C.A.R.E.
 Institute 100% inspection.

 Take immediate action when alarm limit is reached.
 Place Information Board at point of Quality Gate.
 Implement corrective actions based on Quality Gate data.
 Conduct regular management walk-through/meetings at the
Quality Gate(s).

LESSONS LEARNED
Capitalize on success…
minimize mistakes

LESSONS LEARNED
A Lessons Learned system:
• establishes a process for capturing information that will

support continual improvement to all operations/processes.
• prevents repeated mistakes allowing an organization to

capitalize on its successes.
• applies to all functions and responsibilities, therefore,

everyone in the organization should participate.
All documentation that will support continuous improvement

shall be entered into a Lessons Learned database.
A disciplined approach to problem prevention using Lessons

Learned shall be established.
Lessons Learned may be identified by anyone. Most activities within
an organization result in prevention of future problems or improving
performance. These activities build Lessons Learned.
Examples of activities to Identify Lessons Learned:
• GM Read Across Matrix

• Monthly “Q”-Charts
• Layered Process Audits
• Error Proofing Verification
• Internal Quality Issues
• Quality Gates (C.A.R.E.)
• APQP Process
• Continuous Improvement Teams
• Problem Solving (PR/Rs, Risk Reduction)
• Management Reviews
• Suggestion Programs

(example)
READ ACROSS MATRIX (Ref. GM 1927-69,PRR Read Across)
SYMBOL & STATUS KEY:
SUPPLIER: PQE/SQE: O Original Product line and location
Name: Name: X Product line and/or location with similar process
Location: Phone: R Repeat Issues
Duns: GM location / Provider N/A Not Applicable
Contact Name: Contact Phone: Completed & 3rd Party/GM verified
Contact Phone: E-mail: Completed & Supplier verified only
E-mail: Not Completed
Eight Week Period: Due Date:
A.P.Q.P. Duns #1/ Location Duns #2/ Location
Classification
Product /
Process
Customer Concern Defect on Part 5 Why Analysis PRR Number / Issue Corporate
Champion Symbols
Corrective Action
Containment
Technical Root Cause Identified

Customer Concern Defect on Part 5 Why Analysis PRR Number / Issue Corporate
Champion Symbols
Corrective Action
Containment
Technical Root Cause Identified
(This is for reference only; check for latest revision)

Lessons Learned shall be documented. Documentation may include:
• Lessons Learned Form
• APQP Checklist
• PFMEA
• Computer Form or Website, etc…
Lessons Learned must be communicated and kept available to all current

and potential users. Communication can be performed by:
• posting the lessons learned form
• including on a lessons learned website
• utilizing a company newspaper or closed circuit tv
• distribution of pocket cards, etc…
Leadership should review the Lessons Learned process to assure

Implementation.

LESSONS LEARNED
BENEFITS:
• Prevents repetitive mistakes and reduces waste of resources.
• Transfers knowledge to all stakeholders in an organization.
• Provides a history of activities.

LESSONS LEARNED SUMMARY
 empower everyone in the organization to participate in

Lessons Learned process.
 establish a process for capturing Lessons Learned.
 establish and institutionalize a system to document Lessons

Learned.
 establish a disciplined approach to problem prevention using
Lessons Learned.
 review the Lessons Learned process to assure
implementation.

KEY STRATEGIES
• Fast Response
• Control of Non-Conforming
Product (Identification)
No Major Disruptions
• Workplace Organization
No PRR’S
• Standard Operator Training
+ 0 PPM’S
• Risk (RPN) Reduction
= World Class Quality
• Error Proofing Verification
• Layered Process Audits
• Quality Gates (C.A.R.E.)
• Lessons Learned

Now that we have discussed QSB…
Educators Tell Us We Learn & Understand
• 10% of what we hear
• 15% of what we see
• 20% of what we both see & hear
• 40% of what we discuss with others
• 80% of what we experience directly or practice
• 90% of what we attempt to teach others

WORKSHOP

WORKSHOP AGENDA NOTES
Workshop time is valuable. Please refrain from spending group time
to work on other issues.
If the group needs outside resources (HR, IE, etc…,), contact those
who can help. Contact the Workshop Trainer or Supplier Champion.
Results will be delivered to the Top Management of the company

during the second day of training. Use this as an opportunity to
enhance the procedures already in place and meet all the
requirements for each strategy by presenting each team’s ideas.
The presentations are starting points and will need more

development by employees and management as they are
implemented.
Results that cannot be achieved by the closing meeting, must be

included in the QSB Action Plan.

DIVIDING INTO WORKSHOP TEAMS
Form teams of three to five people when possible. If there are not
enough people to form nine teams, assign two or three strategies to
each team. The following are suggestions on how to pair strategies
and assign personnel:
RISK REDUCTION Manufacturing Engineers,

ERROR PROOFING VERIFICATION Maintenance, Operators,
LESSONS LEARNED Supervisors, Auditors
OPERATOR TRAINING Supervisors, Operators,

STANDARDIZED OPERATIONS Training or Human Resources,
NONCONFORMING PRODUCT Manufacturing Engineering,
Quality Engineer
Layered Process Audits Operations Manager,

Quality Gates (C.A.R.E.) Quality Manager,
FAST RESPONSE Operators

WORKSHOP TEAM DELIVERABLES
Review the presentation and determine if all SHALLS are presently being met by
your systems.
– Is there a form? How is the requirement being documented?
– How is the requirement being tracked and analyzed?
– Is management reviewing the results?
– How are results communicated to the workforce? Are results posted? Are
results discussed in employee team meetings?
– Has the requirement been included in a QS 9000 procedure?
Develop suggestions for forms, tracking methods, management review timing

and communication responsibilities.
Develop a ‘To-do List’ or use the ‘Action Plan’ form to begin listing actions
required to implement strategy.
As a group decide how and who will present the team’s ideas.

WORKSHOP PRESENTATION AGENDA
• Introduce each team member.
• State the strategy to be presented.
• BRIEFLY describe the requirements and their status: being

met in all cases, partially met in some areas, not being met, etc...
• Present your suggestions: forms, tracking methods, etc…
• Present your ‘To-do List’ or ‘Action Items’.
• Ask for questions and comments.
NOTE: The presentation for each strategy should take approximately 10 minutes.


Fast Response Process: Standardized Rapid Reaction To Quality Issues

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FAST RESPONSE PROCESS

Standardized Rapid Reaction to

General Motors Corporation. All rights reserved.

A Problem is the GAP between the current

In 2005 Problem Report and Resolution (PRR), now

General Motors Corporation. All rights reserved.

Identify The Root

Implement Permanent Verify Effectiveness

General Motors Corporation. All rights reserved.

Define the Problem Part 1 represents what the customer

Containment Interim Actions (quick fix) that prevent the

D4 the problem. Use a systematic procedure to identify and

Histogram 5 Why’s Run Chart

Scatter Plot Control Chart Pictograph

General Motors Corporation. All rights reserved.

General Motors Corporation. All rights reserved.

• Initial investigation is done where the defect was found.

• If investigation determines the cause of the problem is upstream, then

• Statistical Engineering occurs when the manufacturing process does

General Motors Corporation. All rights reserved.

• Does the workstation layout allow the operator

General Motors Corporation. All rights reserved.

Quality Systems is responsible for determining if

General Motors Corporation. All rights reserved.

Date: ______________ Initiated by: _________________

Problem Description: Referred to: ________________________ (Red X, 5B)

Assigned to ___________________ Date ______________

Completed by _____________________ Date ______________

General Motors Corporation. All rights reserved.

Problem Description: Sketch:

Problem Definition (Real Problem):

Point Of Cause (where problem is first occurring):

Quality Breakdown Others

General Motors Corporation. All rights reserved.

Long-Term Countermeasures WHO DATE STATUS

Any Similar Areas where this might apply:

Follow-Up and Evaluation:

General Motors Corporation. All rights reserved.

Prevent – Why did the

Effects of Failure Mode:

Cause of Failure Mode:

5 Whys Corrective Action Owner Due Date

Protect – Why did the Quality

process not protect the customer

(GM) from the defect?

Predict – Why did the planning

process not predict the failure?

5 Whys – Ask “WHY” until actual

General Motors Corporation. All rights reserved.

Verify Effectiveness of Action Verification takes place in

Prevent Recurrence (Institutionalize) Preventing recurrence

Congratulate Your Team Recognize the contributions of

General Motors Corporation. All rights reserved.

General Motors Corporation. All rights reserved.

Part Name & GM Assy. N/C or CS

Part Name & GM Assy. N/C or CS

Prevent Corrective Action

Read Across - analysis of opportunities of system deficiencies and corrective actions

General Motors Corporation. All rights reserved.

Standardized Rapid Reaction to

Communication and Ownership

General Motors Corporation. All rights reserved.

General Motors Corporation. All rights reserved.

Date: Initiated by: ___

Assigned to _____ Date

Completed by _______ Date

Continue Fast Consider for Quality Gates/C.A.R.E.