Green shift 170

Red shift 180

Yellow shift 170

Total no. pads missing at inspection

182

180

178

176
No. pads missing

174

172

170

168

166

164
Green shift Red shift Yellow shift

Shift

Pad 1 35
Pad 2 30
Pad 3 35
Pad 4 36
Green Pad 5 34
Pad 1 35
Pad 2 35
Pad 3 35
Pad 4 36 45
Red Pad 5 39
Pad 1 30 40
Pad 2 35 35
Pad 3 40
No. pads missing

30
Pad 4 31
Yellow Pad 5 34 25

20

15

10

0
Pad 1 Pad 2 Pad 3
0
Pad 1 Pad 2 Pad 3
Green
 Ames 0
Helium 0
Vision 0
Green Final assy 170
Ames 0
Helium 0
Vision 0
Red Final assy 180
Ames 0
Helium 0
Vision 0
Yellow Final assy 170

No. pads missing at each process

200
170
No. pads missing

150

100

50
0 0 0 0 0 0
0
Ames Helium Vision Final Ames Helium Vision
assy
Green Red
Process / Shift

Pads 1,2,3,4,5 found missing

Pad 3 Pad 4 Pad 5 Pad 1 Pad 2 Pad 3 Pad 4 Pad 5 Pad 1 Pad 2 Pad 3 Pad 4
Pad 3 Pad 4 Pad 5 Pad 1 Pad 2 Pad 3 Pad 4 Pad 5 Pad 1 Pad 2 Pad 3 Pad 4
Green Red Yellow

Pad no. / Shift

h process
180
170

0 0 0

Final Ames Helium Vision Final

assy assy
Yellow

Pad 5
Pad 5
 PLAN DO CHECK ACT
OVERALL
MILESTONES
12/1/08 12/1/08 12/1/08 19/1/08 1/1 PPS SCORE: %
PPS Tracking No.:

HONDA CRV WQ FUEL TANK - ALL VARIENTS - STICKY PADS NOT PRESENT ON TANK - FOUND AT END OF LINE & DURING
PROBLEM STATEMENT QA SPOT AUDIT OF FINISHED STILLAGES. 2/2 EU - DEE - 0001

1 PROBLEM DEFINITION

11 /11 CONCERN INFORMATION Standard Condition Actual defect part Condition

1/1 2/2 2/2
Date found: 1/12/2008
Shift found: RED SHIFT
Initial quantity found: ONE MISSING PAD(S)
ALL FIVE PADS VARIOUS
PRESENT LOCATIONS
Defect found by: DEAN HUMPHREY
SPOT AUDIT - FINISHED
where found:
STILLAGE

How was defect viewed by supplier or department?

On vehicle On part
Who viewed & when: N/A DEAN HUMPHREY Drawing standard All 5 pads present in indicated position and orientation.
Barcode / Control Plan 5 pads present, fully adhered to tank surface, correct
Part traceability info: Prodn date Operator no.
Serial No. Standard location & orientation.
11-Jan 2223 12345 Other standards Correct specification of sticky pad must be used.

8/8 2 CONTAINMENT ACTIONS TAKEN

Containment Process Other Containment Process Other

HOW? Audit: visual WHO? Despatch driver Production team members 2/2
Quality Alert: 100% visual & touch Quality Alert: 100% visual & touch & touch
2/2 Quality Technician

Containment Process All assembly processes Other Containment Containment

Process Other
WHERE? where the part is present (Ames, Vision, Final Finished stillage 2/2 WHEN? 12-Jan-08 12-Jan-08 12-Jan-08 2/2
Warehouse Inspection) (warehouse)

3 Grasp the situation & Clarify the problem

Total no. pads missing at inspection No. pads found missing at each process No. pads 1,2,3,4,5 found missing on each shift INITIAL CONCLUSIONS BASED ON STUDY OF FACTS:
180
Defect characteristics: 200
170 170 45
40 - NO CLEAR TREND PER SHIFT.
6.5/7 - MISSING PADS FOUND ONLY AT FINAL ASSEMBLY.
No. pads missing

No. pads missing

200 180 150 35
170 170
30
- NO TREND FOR WHICH PAD NUMBER IS MISSING. 3/3
No. pads missing

150 25
100
20
15
100
50 10
NOTE: NO MISSING PADS ON TANKS ARRIVING AT VISION
5 BENCH, HOWEVER FURTHER INVESTIGATION REQUIRED
50 0 0 0 0 0 0 0 0 0
0
0
Pad 1 Pad 2Pad 3 Pad 4 Pad 5 Pad 1 Pad 2 Pad 3 Pad 4 Pad 5 Pad 1 Pad 2Pad 3 Pad 4 Pad 5
TO CONFIRM WHAT HAPPENS AT AND BETWEEN VISION
Final assy
Final assy

Final assy
Ames
Ames

Ames
Helium

Vision

Vision

Vision
Helium

Helium
0
Green Red Yellow
BENCH AND FINAL INSPECTION.
Green shift Red shift Yellow shift
Point of cause: Shift
Process / Shift Pad no. / Shift
Green Red Yellow

2.5/3

AMES
ASSEMBLY HELIUM LEAK FINAL FINISHED
WELDING LINE VISION BENCH
BENCH TESTER INSPECTION GOODS
(PADS FITTING PROCESS)

POINT OF CAUSE
UNCLEAR - FURTHER
INVESTIGATION
O O O ? REQUIRED.
X X

Other information: ITEMS TO CONFIRM AT VISION BENCH: METHOD OF VISION INSPECTION - RISK TO PADS; MANUAL HANDLING AFTER VISION BENCH TO FINAL INSPECTION. 1/1

4 "SMART" TARGET

1/1 ALL HONDA CRV WQ FUEL TANKS TO HAVE ALL 5 STICKY PADS PRESENT IN CORRECT LOCATION & ORIENTATION. ROOT CAUSE(S) TO BE IDENTIFIED & COUNTERMEASURE(S) IN PLACE WITHIN 10 DAYS (BY 22/1/08). 1/1

5 CAUSE INVESTIGATION

O Potential cause investigated & confirmed ok to standard or dismissed based on fact

10/10 1/1
T Potential cause investigated , confirmed as a contributor & followed on PFUS

Potential cause investigated & confirmed as direct cause

X 2/2

MAN METHOD 4/4

AMES O VISION O TEARING OF BACKING
PAPER
O
O NO CONFIRMATION APPLICATION PRESSURE
O NOT ENOUGH
OPERATOR NOT
O TRAINED OPERATOR NOT FOLLOWING
STANDARDISED WORK MANUAL HANDLING STORAGE ON LINE O
O KNOCKING PADS OFF
T
MARTIAN
INSTRUCTIONS O O
O UNCLEAR FINAL PADS WRONG LOCATION 1/1
O TEMPORARY INSPECTION T
MEMBER PADS WRONG ORIENTATION O
RANDOM STICKY PADS
TOO HOT O WET O MISSING FROM HONDA CRV
ENVIRONMENT WQ FUEL TANK - AT OR
BETWEEN VISION BENCH AND
TOO DARK DRY O FINAL INSPECTION.
TOO COLD T O OUTSIDE O
(RAIN)
NOT TO
O LIGHTING UNEVEN O O STORAGE SPECIFICATION X
ROTATION T
MISSING O
T
TOO FAST X
O JERKY CONDITION ADHESIVE
OF PADS
O O O
OPERATION OF CONVEYORS & NOT ENOUGH
X VISION BENCH O TOO COLD TEMPERATURE DIRTY
GUIDES ADHESIVE O
O WORN DROPPED ON
BROKEN TANK SURFACE TOO HOT O X FLOOR
O O O
WET/GREASY
PROGRAM T NOT VARIATION OF
DETECTING X O
NOT STICKY
DIMENSIONS O TANK ENOUGH X
MACHINE MATERIAL
EVALUATION
ITEM TI Standard Actual Judgement Priority Number / Symbol 2/2

WAREHOUSE DOORS TO BE DOORS BROKEN - MEMBERS HANDS H&S CONCERN - WORKING PFUS - Maintenance to fix doors by
TOO COLD IN PRODUCTION AREA
KEPT CLOSED COLD (NEARLY FORSTBITE!) TEMPERATURE NEEDS IMPROVEMENT 15/1/08

100% AUTO CHECK - ALL PADS 1 DIRECT CAUSE FOR WHY PARTS 'SHIPPED' TO
OPERATION OF VISION BENCH NOT DETECTING MISSING PADS NG
PRESENT FINISHED STILLAGE (IN WAREHOUSE)

TABLE SHOULD ROTATE WITHIN TABLE ROTATE SPEED NEEDS TO PFUS - Maintenance to adjust speed
ROTATIONAL SPEED OF VISION BENCH TABLE ROTATES WITHIN 3 SECS
5 SECONDS BE RETURNED TO SPEC. by 15/1/08

2
PADS SHOULD ADHERE TO
ADHESIVE - NOT 'STICKY' ENOUGH PADS FALLING OFF TANK NG DIRECT CAUSE FOR WHY PARTS 'MADE'
TANK

PADS ARE BLACK, TANK IS BLACK; MAN VISUAL INSPECTION NOT

OPERATOR ON FINAL INSPECTION NOT FOLLOWINT STANDARDISED WORK SHOULD CONFIRM ALL PADS ARE PRESENT SPOT AUDIT FOUND MISSING PAD AFTER INSPECTION PFUS - RUN 'RABBIT' ON WEEKLY BASIS FROM 16/1/08
100%

Dr. Chr. Steudtner

European Quality Systems Manager Revision Level 2
Revision Date: 07.12.2007
 LEADER PRODUCTION QUALITY MAINTENANCE TRAINING LOGISTICS
Barry, Shift Andy & Rob, Harry Jones, Maintenance N/A Logistics 1 /1
IMPROVEMENT member
TEAM MEMBERS
Leader Line leaders Dean member 2/2
Humphrey

PPS STATUS
why shipped 6.5/8 why made 7/8

6A 5 WHY ANALYSIS TO IDENTIFY ROOT CAUSE

OPERATION OF VISION BENCH - ADHESIVE - NOT 'STICKY'

1 NOT DETECTING MISSING PADS 2 ENOUGH - PADS FALL OFF 3

WHY? Therefore WHY? Therefore WHY? Therefore WHY? Therefore

VISION CHECK TAKES PLACE AT START OF
DURING LAST OPERATION (AFTER PAD
CYCLE BEFORE BENCH & TANK ROTATE; IF
DETECTION BY VISION SYSTEM) BENCH / TANK ADHESIVE STRENGTH NOT STRONG ENOUGH.
PADS FALL OFF DURING ROTATION - TANK HAS
ROTATE - PADS FALL OFF.
ALREADY BEEN JUDGED OK.
WHY? Therefore WHY? Therefore WHY? Therefore WHY? Therefore

VISON CHECK NOT RECONFIRMING THAT PADS PADS PULL OFF FORCE EVALUATED AT <40Nm -
SEE 5 WHY FOR ADHESIVE 2
ARE STILL PRESENT AFTER BENCH ROTATION. OUT OF DRAWING SPECIFICATION.

WHY? Therefore WHY? Therefore WHY? Therefore WHY? Therefore

CURRENT BENCH SET-UP REQUIRES ONLY ONE ENGINEERING DRAWING STATES 50Nm PULL OFF
VISION CHECK FOR PADS PRESENT BEFORE FORCE; PIS STATES 35Nm PULL OFF FORCE -
ROTATION. DIFFERENCE.

WHY? Therefore WHY? Therefore WHY? Therefore WHY? Therefore

PIS STANDARD (35Nm) WAS FOR A SMALLER LIGHTER PAD USED
PRE-PRODUCTION / DEVELOPMENT ACTIVITY ON ANOTHER PROCESS; PIS WAS NOT CROSS CHECKED
FOR CORRECT SEQUENCE OF VISION CHECK ON AGAINST DRAWING DURING PRE-PRODUCTION; SUB-SUPPLIER
BENCH INSUFFICIENT. ISSUED WITH PIS STANDARD SO MADE PARTS TO INCORRECT
STANDARD.
WHY? Therefore WHY? Therefore WHY? Therefore WHY? Therefore

NEW PRODUCT LAUNCH TEAM FMEA DID NOT NO SYSTEMATIC CROSS-CHECK METHOD IN
EVALUATE ALL RISK AREAS FOR PRODUCING PLACE FOR DRAWING x PIS x PROCESS / PARTS
DEFECT PARTS. DURING PRE-PRODUCTION PHASE.

6B ROOT CAUSE why shipped 3/4 why made 3/4

NEW PRODUCT LAUNCH TEAM FMEA DID NO SYSTEMATIC CROSS-CHECK METHOD

IN PLACE FOR DRAWING x PIS x PROCESS /
NOT EVALUATE ALL RISK AREAS FOR PARTS DURING PRE-PRODUCTION PHASE.
1 2 3
PRODUCING DEFECT PARTS.

TEAM DID NOT CONSIDER / STUDY THE

ASSUMPTION MADE BY ENGINEERING TEAM
PROCESS DEEP ENOUGH TO FIND ALL POSSIBLE
THAT THE NEW PAD ADHESIVE PULL OFF FORCE
FAILURE MODES - LIMITED TRIALS TOOK PLACE
STANDARD WAS SAME AS THE SMALLER
WHICH WERE LED BY ENGINEERING WITH
LIGHTER PAD; THEREFORE PIS DEVELOPED
LIMITED INPUT FROM THE PRODUCTION
WITH INCORRECT SPECIFICATION.
MEMBERS.

12/
7 COUNTERMEASURE (S)
12

CHANGE STEPS OF VISION BENCH: WHO ? WHO ? WHO ? WHO ?

SHORT TERM

1 1 2
L. KING QA ADHESIVE PULL OFF FORCE FOR
HARRY JONES 3
- TANKS ROTATES TO UNDERSIDE CHECK 1/HOUR UNDER BENCH. SUPPLIER SET AT 60Nm; PARTS MADE TO
- WORK UNDERSIDE WHEN? CONFIRM VISION SYSTEM WITH WHEN? THIS STANDARD. WHEN? WHEN?
- ROTATE TANK POKE YOKE OK / NG TANKS EVERY 13/1/08 INCOMING INSPECTION FOR 3 DELIVERIES 19/1/08
- WORK TOPSIDE (ADD PADS) SHIFT. (ONGOING AUDIT CHECK 1/MONTH).
- VISION CHECK & ON TO NEXT PROCESS
22/1/08 (L.KING)

WHO ? WHO ? WHO ? WHO ?

1 2
New Product New Product
LONG TERM

CHANGE FMEA PROCEDURE BY 3

Launch team CHANGE NEW PRODUCT LAUNCH Launch team
ADDING CONFIRMATION CHECK PROCEDURE BY ADDING CROSS
THAT ALL RELATED DEPARTMENTS CHECK BY QUALITY &
STUDY THE RISK AREAS FOR WHEN? WHEN? WHEN? WHEN?
MANUFACTURING THAT DRAWING =
MAKING DEFECT PARTS FOR THE By end May PIS = ACTUAL PROCESS / PARTS. By end May
CUSTOMER. 2008 2008

8 CONFIRM COUNTERMEASURE (S) 14/16

NO FALLEN PADS FOUND UNDER BENCH (FOR 6 WEEKS). NEW SEQUENCE IN PLACE & RUNNING - NO MISSING PADS FOUND AT FINAL INSPECTION / CONTAINMENT / SPOT AUDIT FOR 6 WEEKS.
1
QA AGREED CONTAINMENT CHECKS CAN BE REMOVED. POKA YOKE OK / NG PARTS CONFIRMED EACH SHIFT ON VISION SYSTEM.

FMEA PROCEDURE COMPLETED. ALL DEPARTMENTS BRIEFED AND TRAINED 12/5/08. LESSONS LEARNT UPDATED WITH HONDA 'STICKY' PADS CONCERN.

SUB-SUPPLIER OF STICKY PADS RECEIVED REVISIED PIS - ADHESIVE LEVELS CHANGED TO MEET 60Nm PULL OFF FORCE. DAILY CHECK OF ADHESIVE LAYER AT SUB -SUPPLIER TO CONFIRM
2 PROCESS PARAMETER SETTINGS.
INCOMING INSPECTION COMPLETED FIRST 3 DELIVERIES OF NEW SPEC. PADS - ALL PADS PASS REVISIED 60Nm PULL OFF FORCE REQUIREMENTS. ONCE PER MONTH AUDIT COMPLETE - PADS
WITHIN SPEC.
NEW PRODUCT LAUNCH PROCEDURE UPDATED WITH SECTION ADDED FOR CROSS CHECK : DRAWING x PIS x ACTUAL PROCESS / PARTS. ALL DEPARTM ENTS BRIEFED AND TRAINED 15/5/08.

FOLLOW UP DATE
6/1/2008

9 SHARE & STANDARDISATION

YOKOTEN (SHARE) 5.5/6 STANDARDISATION 4/5

ALL TI DEESIDE VISION BENCHES CHECKED (DURING FEBRUARY) FOR SIMILAR FAILURE MODES; 5 OTHER
BENCHES CHECKED ALL OK.

ALL ADHESIVE 'STICKY' PADS ON OTHER PRODUCTS CROSS CHECK DRAWING x PIS x ACTUAL PROCESS / FMEA PROCEDURE UPDATED FOR RISK ASSESSMENT OF HOW TO MAKE & SHIP DEFECT PARTS -
PARTS - 20 PARTS NUMBERS CONFIRMED ALL OK. COMPLETE 30/5/08.

5 TI EUROPEAN PLANTS INFORMED AT GENERAL MANAGERS MEETING 2/2/08. LESSONS LEARNT SHARED NEW PRODUCT LAUNCH PROCEDURE UPDATED FOR CROSS CHECK DRAWING x PIS x ACTUAL
WITH TI USA HEADOFFICE. PROCESS / PARTS - COMPLETED 28/5/08.

ALL RELATED MEMBERS / DEPARTMENTS BRIEFED AT MORNING MEETING (END JANUARY). SPECIFIC FMEA
TRAINING DURING JUNE PLANNED FOR RELEVANT MEMBERS.

Dr. Chr. Steudtner

European Quality Systems Manager Revision Level 2
Revision Date: 07.12.2007