PA - Problem Analysis

Use this app to perform KT Problem Analysis and find the cause of tough problems.

Problem Overview

Issue ID Issue Title Issue Owner

KTPA0565 mechanical fracture in slider subassembly tooling Alberto Catani
Background Information
The M1889 is a final assembly line of steering intermediate shafts for the automotive industry. The final assembly line is a flexible manufacturing system
FMS for high mix high volume high variation and has an O-form. 40 pallets/chucks are running automatically on a conveyor belt which joins about 20
operations (a.k.a. modules) depending on the product type. 20 products are produced in this final assembly line with a yearly volume of 3 million ishafts
with a shift model of 21 shifts per week. Averagely, 10 changeovers are done per week with a mean duration of about 90 minutes. All the modules in the
FMS wait for the downstreaming module before releasing the ishaft in service to the queue on the roller conveyor. Between module and module a
maximum of 3 pallets could pile up as WIP on the conveyor. Flow variation in one of the modules leads to starving and blocking the whole FMS due to the
strong coupling between the modules and the manual feed-in logics at the beginning of the line waiting for the last produced ishaft on the pallet. EOL
inspection is also done manually. Loading and unloading are therefore made manually and all the 20 modules are fully automated. Conveyor logics works
using stoppers below the conveyor and inductive presence sensors to trigger the signals to the downstreaming modules and generates motion to the
upstreaming modules. One of the core modules is the M2672 at the beginning of the assembly line which splines the seamless steel tubes into type-
depending profiles. The loading and undloading operations are done with two pick & place robots that grasps the steel tube an put it in the M2672 splining
station and take it back to the conveyor after splining. Poor spline profiles leads to scrap due to violation of critical to quality characteristics like sliding
assembly or torsional stiftness. This problem analysis aims at understanding why the tooling of this module M2672 cracked during apparently normal
operating conditions which make it unusable for further serial production.
Is There A Deviation? Is The Cause Unknown? Do We Need To Know Cause?

Further Description (if required)

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Capture Date Updated Date Closed Date
2019-09-25 2019-09-26 2019-09-30
Notes

Current Status

State the Problem

State the Problem

cracks in tooling of M2672 during serial production

Specify the Problem

State the Problem

cracks in tooling of M2672 during serial production

IS IS NOT
WHAT

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What Object? sicken slider with drawing number ZG-574752 and the rest of the tooling belonging to the slider
wear/sealing plate with ZG-565355 belonging to subassembly ZG-627418-000-A like: 8x screws
the slider subassembly ZG-627418-000-A. DIN912 M5x20, 2x screws DIN EN ISO8735 8x30-
A-St, 1x spacer sleeve with ZG-564984, 2x spacer
bolts with ZG-370284, 1x sealing plate splining
with ZG-333694, as well as the rest of the tooling
belonging to the beading insert ZG-854973-000
like: 4x corner sliders, 4x brace supports, 4x
shims, 4x beading stamps, 1x tube holder.
What Deviation? mechanical fracture. other geometrical surface imperfections based on
DIN-EN-ISO-8785 like groove, scratch, pore,
blowhole, shrinkage hole, crevice, wane, concave
buckle, dent, wart, blister, convex buckle, scale,
inclusion, burr, flash, deposits, crater, lap, scoring,
chip rest, skidding, erosion, corrosion, pitting,
crazing, patch, discoloration, streak, flaking,
WHERE
Where Geographically? integrated as components of the beading insert in the slider subassemby tooling related to the
ZG-854973-000 installed permanently in the beading inserts within the splining modules
splining module M2672 of the final assembly line M1449, M1611, M1957 belonging respectively to
M1889 installed at TKPM, in Puebla, Mexico. the other 3 final assembly lines known as M1419,
M1607, M2163 installed at TKPM in Puebla,
Mexico, as well as the splining operations of
similar final assembly lines in Eschen like the
Stiwa 1 (M2661) & Stiwa 2 (M2681).
Where On The Object? on the left side of both objects (aerial view): on the right and middle side of both objects
sicken slider ZG-574752 & wear/sealing plate with (aerial view): sicken slider ZG-574752 &
ZG-565355. wear/sealing plate with ZG-565355.

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WHEN
When First? in CW18/2019 --> 29.04.19, Monday, early shift 01.02.2013 up to 28.04.19 night shift
When Since? 3 more incidents: all the noon and night shifts from production runs
CW21/2019 --> Sa. 25.05.2019 at 8:49 am between 29.04.2019 noon shift and each of the
CW25/2019 --> Th. 20.06.2019 at 4:49 am other 3 incidences and after the last one on
CW31/2019 --> Th. 01.08.2019 at 6:23 am 01.08.2019 noon shift up to now.
early shifts, shift leader Leo López, product type:
Nissan
What Is The Pattern? Periodic All Other Patterns - Is Not only
When In The Life-Cycle? 6 years and 2 months after installation in 6 years and 2 months before production runs of
February 2013 during production runs of Nissan Nissan P42J & P71A in April 2019.
P42J & P71A in April 2019.
EXTENT
How Many Objects? 32 objects due to 8 components from each 56 objects due to 14 components from each
exchanged slider subassembly ZG-627418-000 (8 x exchanged slider subassembly ZG-627418-000 (4 x
4 = 32) 14 = 56): 8x screws DIN912 M5x20, 2x screws DIN
4x sicken sliders 574752, EN ISO8735 8x30-A-St, 1x spacer sleeve with ZG-
4x wear/sealing plates 565355 564984, 2x spacer bolts with ZG-370284, 1x
sealing plate splining with ZG-333694 = 1.

4x sicken sliders & 4x wear/sealing plates,

belonging to the 3x slider subassemblies from the
other 3 final assembly lines M1419, M1607 &
M2163.
How Many Objects - Trend? Stable All Other Trends - Is Not only
What Is The Size? wear/sealing plates 565355: 10mm width, 200mm wear/sealing plates 565355: 30mm width, 250mm
length length,

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 sicken sliders 574752: 10mm width, 170mm sicken sliders 574752: 50mm width, 250mm
length length
What Is The Size - Trend? Stable All Other Trends - Is Not only
How Many Deviations? 8 cracks in each of the used 4x slider 4 times the following:
subassemblies ZG-627418-000-A: 1x on each of 1 crack in each one of the 4 corner sliders = 4
the four beading sliders ZG-574752 and 1x on 1 crack in each one of the 4 brace support = 4
each of the four sealing plates 565355. 1 crack in each one of the 4 shims = 4
1 crack in each one of the 4 beading stamps = 4
1 crack in the tube holder = 1
1 crack in the rest of the beading insert = 1
1 crack on each of the 8x screws DIN912 M5x20 in
slider subassembly ZG-627418-000 = 8
1 crack on each of the 2x screws DIN EN ISO8735
8x30-A-St in slider subassembly ZG-627418-000 =
2
1 crack on each of the 1x spacer sleeve in slider
subassembly with ZG-564984 = 1
1 crack on each of the 2x spacer bolts in slider
subassembly with ZG-370284 = 2
1 crack on each of the 1x sealing plate splining in
slider subassembly with ZG-333694 = 1--> 4 x 32 =
128 cracks
How Many Deviations - Trend? Stable All Other Trends - Is Not only

What Object? What Deviation? Where Geographically? Where On The Object?

- - - -

Use Distinctions and Changes

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 IS IS NOT Distinctions Changes (include
date/time)
WHAT
What Object? sicken slider with drawing the rest of the tooling the beading insert ZG- new design of slider
number ZG-574752 and belonging to the slider 854973-000 and the rest of subassembly was created in
wear/sealing plate with ZG- subassembly ZG-627418- the components in the slider Eschen since 12.07.2017
565355 belonging to the 000-A like: 8x screws subassembly ZG-627418- with drawing ZG-911-971-
slider subassembly ZG- DIN912 M5x20, 2x screws 000-A were not affected by 000. The sealing plate and
627418-000-A. DIN EN ISO8735 8x30-A-St, the mechanical fractures. the beading slider are not
1x spacer sleeve with ZG- interchangeabel anymore in
564984, 2x spacer bolts with the new slider subassembly.
ZG-370284, 1x sealing plate
splining with ZG-333694, as
well as the rest of the
tooling belonging to the
beading insert ZG-854973-
000 like: 4x corner sliders,
4x brace supports, 4x shims,
4x beading stamps, 1x tube
holder.
What Deviation? mechanical fracture. other geometrical surface no other geometrical nothing.
imperfections based on DIN- surface imperfections
EN-ISO-8785 like groove, besides cracks are present in
scratch, pore, blowhole, the two affected objects.
shrinkage hole, crevice,
wane, concave buckle, dent,
wart, blister, convex buckle,
scale, inclusion, burr, flash,
deposits, crater, lap, scoring,

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 chip rest, skidding, erosion,
corrosion, pitting, crazing,
patch, discoloration, streak,
flaking,
WHERE
Where Geographically? integrated as components in the slider subassemby old slider subassembly new slider subassembly
of the beading insert ZG- tooling related to the tooling with interchangeable tooling without having any
854973-000 installed beading inserts within the components with ZG- interchangeable
permanently in the splining splining modules M1449, 627418-000-A has been in components with ZG-911-
module M2672 of the final M1611, M1957 belonging used in Puebla since Feb 971-000 was redesigned in
assembly line M1889 respectively to the other 3 2013 without any design Eschen since July 2017 by
installed at TKPM, in Puebla, final assembly lines known changes from Eschen. Bertram Hartmann. This
Mexico. as M1419, M1607, M2163 new redesigned tooling is
installed at TKPM in Puebla, only used in the finala
Mexico, as well as the assembly lines at Eschen.
splining operations of
similar final assembly lines
in Eschen like the Stiwa 1
(M2661) & Stiwa 2 (M2681).
Where On The Object? on the left side of both on the right and middle side the mechanical fractures product type relocation
objects (aerial view): sicken of both objects (aerial view): always appear in the same from final assembly line
slider ZG-574752 & sicken slider ZG-574752 & left side of both M2163 to M1889 was done
wear/sealing plate with ZG- wear/sealing plate with ZG- components, which speaks in March 2019, which
565355. 565355. to a systematic cause of implies some adjustment of
variation. parameter data settings like
splining pressure & speed,
etc.
WHEN

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When First? in CW18/2019 --> 29.04.19, 01.02.2013 up to 28.04.19 the timeline of the first since March 2019, the
Monday, early shift night shift incidence correlates with production supervisor of all
strong organizational 4 final assembly lines
changes in production and changed the responsability
process engineering. and become line sheriff of
M2163 while delegating the
supervision of the other 3
final assembly lines to two
young, unexperienced
production supervisors. At
the same time, the process
einginerring department
was splitted off into 2
different teams focusing on
serial production and
integration of new products.
Both new managers of each
process engineering area
were unexperienced by
handling with resource
alocation and qualfication
matrix. The new
integrations managers does
not even speak the local
language (spanish).
When Since? 3 more incidents: all the noon and night shifts cracks incidence seems to the new, young,
CW21/2019 --> Sa. from production runs be high in early shifts with unexperienced production
25.05.2019 at 8:49 am between 29.04.2019 noon the same shift leader and supervisor assumed that
CW25/2019 --> Th. shift and each of the other 3 the same product family position only in early shifts
20.06.2019 at 4:49 am incidences and after the last Nissan (product types: P42J from March 2019 to mid
CW31/2019 --> Th. and P71A).

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 01.08.2019 at 6:23 am one on 01.08.2019 noon August 2019, where he left
early shifts, shift leader Leo shift up to now. the company.
López, product type: Nissan
What Is The Pattern? Periodic All Other Patterns the deviation incidence EPEI of the four final
appears about each 4 assembly lines is 4 since
weeks. 2106.
When In The Life-Cycle? 6 years and 2 months after 6 years and 2 months before no incidence in a relative a new process module
installation in February 2013 production runs of Nissan high time span longer than 6 known as HSO (high speed
during production runs of P42J & P71A in April 2019. years. First deviation in April oscilation) was integrated to
Nissan P42J & P71A in April 2019. the final assembly line
2019. M2163 in February 2019 for
core product families, which
led to product relocations
from M2163 to other final
assembly lines, including
M1889.
EXTENT
How Many Objects? 32 objects due to 8 56 objects due to 14 the cracks are only present product type relocation
components from each components from each in the final assembly line from M2163 to M1889 in
exchanged slider exchanged slider M1889. March 2019.
subassembly ZG-627418- subassembly ZG-627418-
000 (8 x 4 = 32) 000 (4 x 14 = 56): 8x screws the cracks are only present new slider subassembly
4x sicken sliders 574752, DIN912 M5x20, 2x screws in two interchangeable tooling without having any
4x wear/sealing plates DIN EN ISO8735 8x30-A-St, components of the slider interchangeable
565355 1x spacer sleeve with ZG- subassembly and not in all components with ZG-911-
564984, 2x spacer bolts with of them. 971-000 was redesigned in
ZG-370284, 1x sealing plate Eschen since July 2017 by
splining with ZG-333694 = 1. Bertram Hartmann. This
new redesigned tooling is
4x sicken sliders & 4x

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 wear/sealing plates, only used in the finala
belonging to the 3x slider assembly lines at Eschen.
subassemblies from the
other 3 final assembly lines
M1419, M1607 & M2163.
How Many Objects - Trend? Stable All Other Trends only two cracks nothing
What Is The Size? wear/sealing plates 565355: wear/sealing plates 565355: the cracks do not cross the nothing
10mm width, 200mm length 30mm width, 250mm whole components in length
sicken sliders 574752: length, and width, but about 80%.
10mm width, 170mm length sicken sliders 574752:
50mm width, 250mm length
What Is The Size - Trend? Stable All Other Trends the stability of the crack size nothing
speaks to a repeatable,
systematic, special cause of
variation.
How Many Deviations? 8 cracks in each of the used 4 times the following: the quantity of cracks nothing
4x slider subassemblies ZG- 1 crack in each one of the 4 preserved at 8 all the time.
627418-000-A: 1x on each corner sliders = 4
of the four beading sliders 1 crack in each one of the 4
ZG-574752 and 1x on each brace support = 4
of the four sealing plates 1 crack in each one of the 4
565355. shims = 4
1 crack in each one of the 4
beading stamps = 4
1 crack in the tube holder =
1
1 crack in the rest of the
beading insert = 1
1 crack on each of the 8x
screws DIN912 M5x20 in

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 slider subassembly ZG-
627418-000 = 8
1 crack on each of the 2x
screws DIN EN ISO8735
8x30-A-St in slider
subassembly ZG-627418-
000 = 2
1 crack on each of the 1x
spacer sleeve in slider
subassembly with ZG-
564984 = 1
1 crack on each of the 2x
spacer bolts in slider
subassembly with ZG-
370284 = 2
1 crack on each of the 1x
sealing plate splining in
slider subassembly with ZG-
333694 = 1--> 4 x 32 = 128
cracks
How Many Deviations - Stable All Other Trends the fact of having the same nothing.
Trend? counts of failures all the
time.

Identify Possible Causes

Possible Causes

Possible Cause A Possible Cause B Possible Cause C Possible Cause D

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Description obsolete design of slider strong organizational strong organizational a new process module
subassembly for splining change in the middle change in the middle known as HSO (high speed
operation. The slider management of production management of process oscilation) was integrated to
subassembly tooling under responsible for M1889 since engineering since March the final assembly line
scope was replaced by a February 2019 driven by 2019 driven by poor change M2163 mid of February
newest design ZG-911-971- poor change management management strategies. 2019, which led to a
000, it was created and strategies. Responsability of Process engineering for relocation from some
developed in Eschen by most experienced, senior serial production with new, product types running
Bertram Hartmann since production supervisor was unexperienced, technical initially at the M2163 to
12.07.2016. It was modified splitted to full focus on driven manager. Process alternative machines like
by maerob on 05.01.2018 to M2163 as line sheriff since engineering for integrations M1889. This relocation was
specify the planarity February 2019. The other 3 with new, unexperienced, done during March 2019,
tolerace on the drawing. final assembly lines were technical driven manager, whereas the integration of
delegated to 2 new 3c_process engineering the new product types was
unexperienced production manager does not speak the done by a new team of
supervisors. The production local language and the process engineers. The
supervisor of M1889 started subordinates have poor interaction of the new
in March 2019 as production english skills. Process parameter data settings
coach and then he left the engineers splitted into with competing mechanical
company mid August 2019. different teams and were parameters from other
realocated to machines serial products is not done
beyond their expertise by the same process
competences. Change engineer who integrated the
management topics due to product, but by the
the acceptance of the new production shift leader with
process engineering escalation to production
structure. supervisor and process
engineer for serial
production. Integration
process engineers are
leaded by manager A (non-
spanish speaking, lack of

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 management experience)
and serial production
engineers are leaded by
manager B (native speaker,
lack of management
experience).
Communication issues
between production and the
both new process
engineering teams could
lead to process or
mechanical parameter
incompatibility of new
projects with serial
products.

Test Possible Causes

Possible Cause A:
obsolete design of slider subassembly for splining operation. The slider subassembly tooling under scope was replaced by a newest design ZG-911-971-000,
it was created and developed in Eschen by Bertram Hartmann since 12.07.2016. It was modified by maerob on 05.01.2018 to specify the planarity tolerace
on the drawing.

IS IS NOT Evaluation Explain WHY?

WHAT
What Object? sicken slider with drawing the rest of the tooling it does not explain the IS
number ZG-574752 and belonging to the slider NOT condition, since other
wear/sealing plate with ZG- subassembly ZG-627418- single components from the

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 565355 belonging to the 000-A like: 8x screws same obsolete design ZG-
slider subassembly ZG- DIN912 M5x20, 2x screws 627418-000-A did not break
627418-000-A. DIN EN ISO8735 8x30-A-St, during the same operating
1x spacer sleeve with ZG- conditions.
564984, 2x spacer bolts with
ZG-370284, 1x sealing plate
splining with ZG-333694, as
well as the rest of the
tooling belonging to the
beading insert ZG-854973-
000 like: 4x corner sliders,
4x brace supports, 4x shims,
4x beading stamps, 1x tube
holder.
What Deviation? mechanical fracture. other geometrical surface it could explain the IS and
imperfections based on DIN- the IS NOT conditions,
EN-ISO-8785 like groove, providing that the
scratch, pore, blowhole, interchangeability of the
shrinkage hole, crevice, components would play an
wane, concave buckle, dent, important role in the
wart, blister, convex buckle, mechanical properties of
scale, inclusion, burr, flash, the whole system under the
deposits, crater, lap, scoring, same operational conditions
chip rest, skidding, erosion, (torque) and parameter
corrosion, pitting, crazing, data settings.
patch, discoloration, streak,
flaking,
WHERE
Where Geographically? integrated as components in the slider subassemby it does not explain the IS
of the beading insert ZG- tooling related to the NOT condition, since the

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 854973-000 installed beading inserts within the other assembly lines also
permanently in the splining splining modules M1449, use the old design and the
module M2672 of the final M1611, M1957 belonging cracks are not given.
assembly line M1889 respectively to the other 3
installed at TKPM, in Puebla, final assembly lines known
Mexico. as M1419, M1607, M2163
installed at TKPM in Puebla,
Mexico, as well as the
splining operations of
similar final assembly lines
in Eschen like the Stiwa 1
(M2661) & Stiwa 2 (M2681).
Where On The Object? on the left side of both on the right and middle side it could explain the IS and
objects (aerial view): sicken of both objects (aerial view): the IS NOT conditions,
slider ZG-574752 & sicken slider ZG-574752 & providing a clockwise
wear/sealing plate with ZG- wear/sealing plate with ZG- clamping system while
565355. 565355. splining the tube.

WHEN
When First? in CW18/2019 --> 29.04.19, 01.02.2013 up to 28.04.19 it does not explain both IS
Monday, early shift night shift and IS NOT conditions, since
before and after the first
incident, the same old
design have been used all
the time.
When Since? 3 more incidents: all the noon and night shifts it does not explain both IS
CW21/2019 --> Sa. from production runs and IS NOT conditions, since
25.05.2019 at 8:49 am between 29.04.2019 noon before and after the second,
CW25/2019 --> Th. shift and each of the other 3 third to first incident, the
20.06.2019 at 4:49 am incidences and after the last

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 CW31/2019 --> Th. one on 01.08.2019 noon same old design have been
01.08.2019 at 6:23 am shift up to now. used all the time.
early shifts, shift leader Leo
López, product type: Nissan
What Is The Pattern? Periodic All Other Patterns it does not explain the IS
condition, since the same
old design have been used
all the time, including the
about 4 weeks period.
When In The Life-Cycle? 6 years and 2 months after 6 years and 2 months before it does not explain both IS
installation in February 2013 production runs of Nissan and IS NOT conditions, since
during production runs of P42J & P71A in April 2019. the same old design was
Nissan P42J & P71A in April used before and after April
2019. 2019 by producing the
Nissan family.
EXTENT
How Many Objects? 32 objects due to 8 56 objects due to 14 it does not explain the IS
components from each components from each NOT condition, since the
exchanged slider exchanged slider other assembly lines also
subassembly ZG-627418- subassembly ZG-627418- use the same old design and
000 (8 x 4 = 32) 000 (4 x 14 = 56): 8x screws no cracks have been
4x sicken sliders 574752, DIN912 M5x20, 2x screws reported.
4x wear/sealing plates DIN EN ISO8735 8x30-A-St,
565355 1x spacer sleeve with ZG-
564984, 2x spacer bolts with
ZG-370284, 1x sealing plate
splining with ZG-333694 = 1.

4x sicken sliders & 4x

wear/sealing plates,

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 belonging to the 3x slider
subassemblies from the
other 3 final assembly lines
M1419, M1607 & M2163.
How Many Objects - Trend? Stable All Other Trends it fully explains the IS and
the IS NOT conditions due to
the component's
interchangeability from the
old design. The same
geometrical shape would
lead to the same results,
even using the newest
tooling design would also
have an stable behavior
under the same operational
conditions.
What Is The Size? wear/sealing plates 565355: wear/sealing plates 565355: it fully explains the IS and
10mm width, 200mm length 30mm width, 250mm the IS NOT conditions due to
sicken sliders 574752: length, the component's
10mm width, 170mm length sicken sliders 574752: interchangeability from the
50mm width, 250mm length old design. The same
geometrical shape would
lead to the same results,
even using the newest
tooling design would also
have an stable behavior
under the same operational
conditions.
What Is The Size - Trend? Stable All Other Trends it does not explain the IS
NOT condition, since an

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 ascending or descending
trend of the crack size could
also be affected by changing
the parameter data settings
using the same obsolete
design.
How Many Deviations? 8 cracks in each of the used 4 times the following: it does not explain the IS
4x slider subassemblies ZG- 1 crack in each one of the 4 NOT condition, since other
627418-000-A: 1x on each corner sliders = 4 single components from the
of the four beading sliders 1 crack in each one of the 4 same obsolete design ZG-
ZG-574752 and 1x on each brace support = 4 627418-000-A did no have
of the four sealing plates 1 crack in each one of the 4 the any cracks during the
565355. shims = 4 same operating conditions.
1 crack in each one of the 4
beading stamps = 4
1 crack in the tube holder =
1
1 crack in the rest of the
beading insert = 1
1 crack on each of the 8x
screws DIN912 M5x20 in
slider subassembly ZG-
627418-000 = 8
1 crack on each of the 2x
screws DIN EN ISO8735
8x30-A-St in slider
subassembly ZG-627418-
000 = 2
1 crack on each of the 1x
spacer sleeve in slider
subassembly with ZG-

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 564984 = 1
1 crack on each of the 2x
spacer bolts in slider
subassembly with ZG-
370284 = 2
1 crack on each of the 1x
sealing plate splining in
slider subassembly with ZG-
333694 = 1--> 4 x 32 = 128
cracks
How Many Deviations - Stable All Other Trends it does not explain the IS
Trend? NOT condition, since other
single components from the
same obsolete design ZG-
627418-000-A did no have
the any cracks during the
same operating conditions.

Possible Cause B:
strong organizational change in the middle management of production responsible for M1889 since February 2019 driven by poor change management
strategies. Responsability of most experienced, senior production supervisor was splitted to full focus on M2163 as line sheriff since February 2019. The
other 3 final assembly lines were delegated to 2 new unexperienced production supervisors. The production supervisor of M1889 started in March 2019 as
production coach and then he left the company mid August 2019.

IS IS NOT Evaluation Explain WHY?

WHAT
What Object? sicken slider with drawing the rest of the tooling it could explain the IS and
number ZG-574752 and belonging to the slider the IS NOT conditions,
wear/sealing plate with ZG- subassembly ZG-627418- providing a poor onboarding

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 565355 belonging to the 000-A like: 8x screws and lack of guidance for
slider subassembly ZG- DIN912 M5x20, 2x screws mechanical adjustments and
627418-000-A. DIN EN ISO8735 8x30-A-St, control of relevant
1x spacer sleeve with ZG- parameter data settings due
564984, 2x spacer bolts with to a new, unexperienced
ZG-370284, 1x sealing plate production supervisor.
splining with ZG-333694, as
well as the rest of the
tooling belonging to the
beading insert ZG-854973-
000 like: 4x corner sliders,
4x brace supports, 4x shims,
4x beading stamps, 1x tube
holder.
What Deviation? mechanical fracture. other geometrical surface it could explain the IS and
imperfections based on DIN- the IS NOT conditions,
EN-ISO-8785 like groove, providing a poor onboarding
scratch, pore, blowhole, and lack of guidance for
shrinkage hole, crevice, mechanical adjustments and
wane, concave buckle, dent, control of relevant
wart, blister, convex buckle, parameter data settings due
scale, inclusion, burr, flash, to a new, unexperienced
deposits, crater, lap, scoring, production supervisor.
chip rest, skidding, erosion,
corrosion, pitting, crazing,
patch, discoloration, streak,
flaking,
WHERE
Where Geographically? integrated as components in the slider subassemby it fully explains the IS and
of the beading insert ZG- tooling related to the the IS NOT conditions, since

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 854973-000 installed beading inserts within the the other final assembly
permanently in the splining splining modules M1449, lines were coached by
module M2672 of the final M1611, M1957 belonging other, more experienced
assembly line M1889 respectively to the other 3 production supervisors,
installed at TKPM, in Puebla, final assembly lines known including the senior one
Mexico. as M1419, M1607, M2163 (line sheriff from M2163).
installed at TKPM in Puebla,
Mexico, as well as the
splining operations of
similar final assembly lines
in Eschen like the Stiwa 1
(M2661) & Stiwa 2 (M2681).
Where On The Object? on the left side of both on the right and middle side it could explain the IS and
objects (aerial view): sicken of both objects (aerial view): the IS NOT conditions,
slider ZG-574752 & sicken slider ZG-574752 & providing a poor onboarding
wear/sealing plate with ZG- wear/sealing plate with ZG- and lack of guidance for
565355. 565355. mechanical adjustments and
control of relevant
parameter data settings due
to a new, unexperienced
production supervisor.
WHEN
When First? in CW18/2019 --> 29.04.19, 01.02.2013 up to 28.04.19 it could potentially explain
Monday, early shift night shift the IS and the IS NOT
conditions, since the new,
unexperienced production
supervisor began his
position in the same period
up to mid August 2019,
providing a poor guidance

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 from the production
supervisor to his production
staff, responsible for making
mechanical adjustments.
When Since? 3 more incidents: all the noon and night shifts it could potentially explain
CW21/2019 --> Sa. from production runs the IS and the IS NOT
25.05.2019 at 8:49 am between 29.04.2019 noon conditions, since the new,
CW25/2019 --> Th. shift and each of the other 3 unexperienced production
20.06.2019 at 4:49 am incidences and after the last supervisor began his
CW31/2019 --> Th. one on 01.08.2019 noon position in the same period
01.08.2019 at 6:23 am shift up to now. up to mid August 2019,
early shifts, shift leader Leo providing a poor guidance
López, product type: Nissan from the production
supervisor to his production
staff, responsible for making
mechanical adjustments.
What Is The Pattern? Periodic All Other Patterns it could fully explains the IS
and the IS NOT conditions,
supposing that the new,
unexperienced supervisor
was not on the shopfloor
during production of the
Nissan family.
When In The Life-Cycle? 6 years and 2 months after 6 years and 2 months before it could fully explains the IS
installation in February 2013 production runs of Nissan and the IS NOT conditions,
during production runs of P42J & P71A in April 2019. providing that the
Nissan P42J & P71A in April integration of new product
2019. types affect in any form the
mechanical adjustment

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 during production of the
Nissan product family.
EXTENT
How Many Objects? 32 objects due to 8 56 objects due to 14 it fully explains the IS and
components from each components from each the IS NOT conditions, since
exchanged slider exchanged slider the same shift leader has
subassembly ZG-627418- subassembly ZG-627418- done the adjustments
000 (8 x 4 = 32) 000 (4 x 14 = 56): 8x screws during the same early shifts,
4x sicken sliders 574752, DIN912 M5x20, 2x screws which speaks for a
4x wear/sealing plates DIN EN ISO8735 8x30-A-St, systematic root cause during
565355 1x spacer sleeve with ZG- production of the Nissan
564984, 2x spacer bolts with product family.
ZG-370284, 1x sealing plate
splining with ZG-333694 = 1.

4x sicken sliders & 4x

wear/sealing plates,
belonging to the 3x slider
subassemblies from the
other 3 final assembly lines
M1419, M1607 & M2163.
How Many Objects - Trend? Stable All Other Trends it fully explains the IS and
the IS NOT conditions, since
the same shift leader has
done the adjustments
during the same early shifts,
which speaks for a
systematic root cause during
production of the Nissan
product family.

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What Is The Size? wear/sealing plates 565355: wear/sealing plates 565355: it fully explains the IS and
10mm width, 200mm length 30mm width, 250mm the IS NOT conditions, since
sicken sliders 574752: length, the same shift leader has
10mm width, 170mm length sicken sliders 574752: done the adjustments
50mm width, 250mm length during the same early shifts,
which speaks for a
systematic root cause during
production of the Nissan
product family.
What Is The Size - Trend? Stable All Other Trends it fully explains the IS and
the IS NOT conditions, since
the same shift leader has
done the adjustments
during the same early shifts,
which speaks for a
systematic root cause during
production of the Nissan
product family.
How Many Deviations? 8 cracks in each of the used 4 times the following: it fully explains the IS and
4x slider subassemblies ZG- 1 crack in each one of the 4 the IS NOT conditions, since
627418-000-A: 1x on each corner sliders = 4 the same shift leader has
of the four beading sliders 1 crack in each one of the 4 done the adjustments
ZG-574752 and 1x on each brace support = 4 during the same early shifts,
of the four sealing plates 1 crack in each one of the 4 which speaks for a
565355. shims = 4 systematic root cause during
1 crack in each one of the 4 production of the Nissan
beading stamps = 4 product family.
1 crack in the tube holder =
1
1 crack in the rest of the
beading insert = 1

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 1 crack on each of the 8x
screws DIN912 M5x20 in
slider subassembly ZG-
627418-000 = 8
1 crack on each of the 2x
screws DIN EN ISO8735
8x30-A-St in slider
subassembly ZG-627418-
000 = 2
1 crack on each of the 1x
spacer sleeve in slider
subassembly with ZG-
564984 = 1
1 crack on each of the 2x
spacer bolts in slider
subassembly with ZG-
370284 = 2
1 crack on each of the 1x
sealing plate splining in
slider subassembly with ZG-
333694 = 1--> 4 x 32 = 128
cracks
How Many Deviations - Stable All Other Trends it fully explains the IS and
Trend? the IS NOT conditions, since
the same shift leader has
done the adjustments
during the same early shifts,
which speaks for a
systematic root cause during
production of the Nissan
product family.

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Possible Cause C:
strong organizational change in the middle management of process engineering since March 2019 driven by poor change management strategies. Process
engineering for serial production with new, unexperienced, technical driven manager. Process engineering for integrations with new, unexperienced,
technical driven manager, 3c_process engineering manager does not speak the local language and the subordinates have poor english skills. Process
engineers splitted into different teams and were realocated to machines beyond their expertise competences. Change management topics due to the
acceptance of the new process engineering structure.

IS IS NOT Evaluation Explain WHY?

WHAT
What Object? sicken slider with drawing the rest of the tooling it could explain the IS and
number ZG-574752 and belonging to the slider the IS NOT conditions,
wear/sealing plate with ZG- subassembly ZG-627418- providing that some product
565355 belonging to the 000-A like: 8x screws integrations were done an
slider subassembly ZG- DIN912 M5x20, 2x screws the parameter data setting
627418-000-A. DIN EN ISO8735 8x30-A-St, in the machine by a new,
1x spacer sleeve with ZG- unexperienced process
564984, 2x spacer bolts with engineer without verifying
ZG-370284, 1x sealing plate the competing effects to
splining with ZG-333694, as mechanical parameter
well as the rest of the adjustments for the rest of
tooling belonging to the product types running at
beading insert ZG-854973- M1889.
000 like: 4x corner sliders,
4x brace supports, 4x shims,
4x beading stamps, 1x tube
holder.
What Deviation? mechanical fracture. other geometrical surface it could explain the IS and
imperfections based on DIN- the IS NOT conditions,
EN-ISO-8785 like groove, providing a lack of
scratch, pore, blowhole, transparency and

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 shrinkage hole, crevice, communication of
wane, concave buckle, dent, parameter data settings
wart, blister, convex buckle, between the two new
scale, inclusion, burr, flash, process engineering teams,
deposits, crater, lap, scoring, integrations and serial
chip rest, skidding, erosion, production, leaded by
corrosion, pitting, crazing, different unexperienced,
patch, discoloration, streak, high technically-driven
flaking, managers without any
previous experience about
staff responsability and
effective communication in
team.
WHERE
Where Geographically? integrated as components in the slider subassemby it could explain the IS and
of the beading insert ZG- tooling related to the the IS NOT conditions,
854973-000 installed beading inserts within the providing that some product
permanently in the splining splining modules M1449, integrations were done an
module M2672 of the final M1611, M1957 belonging the parameter data setting
assembly line M1889 respectively to the other 3 in the machine by a new,
installed at TKPM, in Puebla, final assembly lines known unexperienced process
Mexico. as M1419, M1607, M2163 engineer without verifying
installed at TKPM in Puebla, the competing effects to
Mexico, as well as the mechanical parameter
splining operations of adjustments for the rest of
similar final assembly lines product types running at
in Eschen like the Stiwa 1 M1889.
(M2661) & Stiwa 2 (M2681).
Where On The Object? on the left side of both on the right and middle side it could explain the IS and
objects (aerial view): sicken of both objects (aerial view): the IS NOT conditions,

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 slider ZG-574752 & sicken slider ZG-574752 & providing that some product
wear/sealing plate with ZG- wear/sealing plate with ZG- integrations were done an
565355. 565355. the parameter data setting
in the machine by a new,
unexperienced process
engineer without verifying
the competing effects to
mechanical parameter
adjustments for the rest of
product types running at
M1889.
WHEN
When First? in CW18/2019 --> 29.04.19, 01.02.2013 up to 28.04.19 it fully explains the IS and
Monday, early shift night shift the IS NOT conditions, since
the process engineers for
this assembly line were
changed by March 2019 due
to an internal division of the
process engineering
department into two teams
supporting integration of
new products and support
of serial production. A poor
integration of new product
types is done by one
unexperienced process
engineer and the interacting
results with mechanical
parameters related to other
product families are
managed by the production

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 leader shift, production
supervisor or another
unexperienced process
engineer from the serial
production team.
When Since? 3 more incidents: all the noon and night shifts it fully explains the IS and
CW21/2019 --> Sa. from production runs the IS NOT conditions, since
25.05.2019 at 8:49 am between 29.04.2019 noon the process engineers for
CW25/2019 --> Th. shift and each of the other 3 this assembly line were
20.06.2019 at 4:49 am incidences and after the last changed by March 2019 due
CW31/2019 --> Th. one on 01.08.2019 noon to an internal division of the
01.08.2019 at 6:23 am shift up to now. process engineering
early shifts, shift leader Leo department into two teams
López, product type: Nissan supporting integration of
new products and support
of serial production. A poor
integration of new product
types is done by one
unexperienced process
engineer and the interacting
results with mechanical
parameters related to other
product families are
managed by the production
leader shift, production
supervisor or another
unexperienced process
engineer from the serial
production team.
What Is The Pattern? Periodic All Other Patterns it fully explains the IS and
the IS NOT conditions, since

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 the process engineers for
this assembly line were
changed by March 2019 due
to an internal division of the
process engineering
department into two teams
supporting integration of
new products and support
of serial production. A poor
integration of new product
types is done by one
unexperienced process
engineer and the interacting
results with mechanical
parameters related to other
product families are
managed by the production
leader shift, production
supervisor or another
unexperienced process
engineer from the serial
production team.
When In The Life-Cycle? 6 years and 2 months after 6 years and 2 months before it could potentially explain
installation in February 2013 production runs of Nissan the IS and the IS NOT
during production runs of P42J & P71A in April 2019. conditions, providing a lack
Nissan P42J & P71A in April of communication between
2019. the process engineers
responsible for integration
of new product types
(integrations coming from
M2163) and the ones for

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 serial production (Nissan
product family) since March
2019.
EXTENT
How Many Objects? 32 objects due to 8 56 objects due to 14 it fully explains the IS and
components from each components from each the IS NOT conditions, since
exchanged slider exchanged slider the process engineers for
subassembly ZG-627418- subassembly ZG-627418- this assembly line were
000 (8 x 4 = 32) 000 (4 x 14 = 56): 8x screws changed by March 2019 due
4x sicken sliders 574752, DIN912 M5x20, 2x screws to an internal division of the
4x wear/sealing plates DIN EN ISO8735 8x30-A-St, process engineering
565355 1x spacer sleeve with ZG- department into two teams
564984, 2x spacer bolts with supporting integration of
ZG-370284, 1x sealing plate new products and support
splining with ZG-333694 = 1. of serial production. A poor
integration of new product
4x sicken sliders & 4x types is done by one
wear/sealing plates, unexperienced process
belonging to the 3x slider engineer and the interacting
subassemblies from the results with mechanical
other 3 final assembly lines parameters related to other
M1419, M1607 & M2163. product families are
managed by the production
leader shift, production
supervisor or another
unexperienced process
engineer from the serial
production team.
How Many Objects - Trend? Stable All Other Trends it fully explains the IS and
the IS NOT conditions, since

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 the process engineers for
this assembly line were
changed by March 2019 due
to an internal division of the
process engineering
department into two teams
supporting integration of
new products and support
of serial production. A poor
integration of new product
types is done by one
unexperienced process
engineer and the interacting
results with mechanical
parameters related to other
product families are
managed by the production
leader shift, production
supervisor or another
unexperienced process
engineer from the serial
production team.
What Is The Size? wear/sealing plates 565355: wear/sealing plates 565355: it fully explains the IS and
10mm width, 200mm length 30mm width, 250mm the IS NOT conditions, since
sicken sliders 574752: length, the process engineers for
10mm width, 170mm length sicken sliders 574752: this assembly line were
50mm width, 250mm length changed by March 2019 due
to an internal division of the
process engineering
department into two teams
supporting integration of

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 new products and support
of serial production. A poor
integration of new product
types is done by one
unexperienced process
engineer and the interacting
results with mechanical
parameters related to other
product families are
managed by the production
leader shift, production
supervisor or another
unexperienced process
engineer from the serial
production team.
What Is The Size - Trend? Stable All Other Trends it fully explains the IS and
the IS NOT conditions, since
the process engineers for
this assembly line were
changed by March 2019 due
to an internal division of the
process engineering
department into two teams
supporting integration of
new products and support
of serial production. A poor
integration of new product
types is done by one
unexperienced process
engineer and the interacting
results with mechanical

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 parameters related to other
product families are
managed by the production
leader shift, production
supervisor or another
unexperienced process
engineer from the serial
production team.
How Many Deviations? 8 cracks in each of the used 4 times the following: it fully explains the IS and
4x slider subassemblies ZG- 1 crack in each one of the 4 the IS NOT conditions, since
627418-000-A: 1x on each corner sliders = 4 the process engineers for
of the four beading sliders 1 crack in each one of the 4 this assembly line were
ZG-574752 and 1x on each brace support = 4 changed by March 2019 due
of the four sealing plates 1 crack in each one of the 4 to an internal division of the
565355. shims = 4 process engineering
1 crack in each one of the 4 department into two teams
beading stamps = 4 supporting integration of
1 crack in the tube holder = new products and support
1 of serial production. A poor
1 crack in the rest of the integration of new product
beading insert = 1 types is done by one
1 crack on each of the 8x unexperienced process
screws DIN912 M5x20 in engineer and the interacting
slider subassembly ZG- results with mechanical
627418-000 = 8 parameters related to other
1 crack on each of the 2x product families are
screws DIN EN ISO8735 managed by the production
8x30-A-St in slider leader shift, production
subassembly ZG-627418- supervisor or another
000 = 2 unexperienced process
1 crack on each of the 1x

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 spacer sleeve in slider engineer from the serial
subassembly with ZG- production team.
564984 = 1
1 crack on each of the 2x
spacer bolts in slider
subassembly with ZG-
370284 = 2
1 crack on each of the 1x
sealing plate splining in
slider subassembly with ZG-
333694 = 1--> 4 x 32 = 128
cracks
How Many Deviations - Stable All Other Trends it fully explains the IS and
Trend? the IS NOT conditions, since
the process engineers for
this assembly line were
changed by March 2019 due
to an internal division of the
process engineering
department into two teams
supporting integration of
new products and support
of serial production. A poor
integration of new product
types is done by one
unexperienced process
engineer and the interacting
results with mechanical
parameters related to other
product families are
managed by the production

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 leader shift, production
supervisor or another
unexperienced process
engineer from the serial
production team.

Possible Cause D:
a new process module known as HSO (high speed oscilation) was integrated to the final assembly line M2163 mid of February 2019, which led to a
relocation from some product types running initially at the M2163 to alternative machines like M1889. This relocation was done during March 2019,
whereas the integration of the new product types was done by a new team of process engineers. The interaction of the new parameter data settings with
competing mechanical parameters from other serial products is not done by the same process engineer who integrated the product, but by the production
shift leader with escalation to production supervisor and process engineer for serial production. Integration process engineers are leaded by manager A
(non-spanish speaking, lack of management experience) and serial production engineers are leaded by manager B (native speaker, lack of management
experience). Communication issues between production and the both new process engineering teams could lead to process or mechanical parameter
incompatibility of new projects with serial products.

IS IS NOT Evaluation Explain WHY?

WHAT
What Object? sicken slider with drawing the rest of the tooling it fully explains the IS and
number ZG-574752 and belonging to the slider the IS NOT conditions, since
wear/sealing plate with ZG- subassembly ZG-627418- a lack of communication
565355 belonging to the 000-A like: 8x screws between the unexperienced
slider subassembly ZG- DIN912 M5x20, 2x screws integration process
627418-000-A. DIN EN ISO8735 8x30-A-St, engineer, production shift
1x spacer sleeve with ZG- leader, unexperienced
564984, 2x spacer bolts with production supervisor,
ZG-370284, 1x sealing plate unexperienced process
splining with ZG-333694, as engineer of serial products
well as the rest of the and two brandnew
tooling belonging to the unexperienced managers

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 beading insert ZG-854973- leads to a pre-programmed
000 like: 4x corner sliders, competing process and
4x brace supports, 4x shims, mechanical parameters
4x beading stamps, 1x tube between new and serial
holder. products in the same
production line. The
creation of the two new
process engineering teams
catalyzes exponentially the
non-aligned parameter data
setting process between
process engineering and
production.
What Deviation? mechanical fracture. other geometrical surface it fully explains the IS and
imperfections based on DIN- the IS NOT conditions, since
EN-ISO-8785 like groove, a lack of communication
scratch, pore, blowhole, between the unexperienced
shrinkage hole, crevice, integration process
wane, concave buckle, dent, engineer, production shift
wart, blister, convex buckle, leader, unexperienced
scale, inclusion, burr, flash, production supervisor,
deposits, crater, lap, scoring, unexperienced process
chip rest, skidding, erosion, engineer of serial products
corrosion, pitting, crazing, and two brandnew
patch, discoloration, streak, unexperienced managers
flaking, leads to a pre-programmed
competing process and
mechanical parameters
between new and serial
products in the same
production line. The

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 creation of the two new
process engineering teams
catalyzes exponentially the
non-aligned parameter data
setting process between
process engineering and
production.
WHERE
Where Geographically? integrated as components in the slider subassemby it fully explains the IS and
of the beading insert ZG- tooling related to the the IS NOT conditions, since
854973-000 installed beading inserts within the a lack of communication
permanently in the splining splining modules M1449, between the unexperienced
module M2672 of the final M1611, M1957 belonging integration process
assembly line M1889 respectively to the other 3 engineer, production shift
installed at TKPM, in Puebla, final assembly lines known leader, unexperienced
Mexico. as M1419, M1607, M2163 production supervisor,
installed at TKPM in Puebla, unexperienced process
Mexico, as well as the engineer of serial products
splining operations of and two brandnew
similar final assembly lines unexperienced managers
in Eschen like the Stiwa 1 leads to a pre-programmed
(M2661) & Stiwa 2 (M2681). competing process and
mechanical parameters
between new and serial
products in the same
production line. The
creation of the two new
process engineering teams
catalyzes exponentially the
non-aligned parameter data
setting process between

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 process engineering and
production.
Where On The Object? on the left side of both on the right and middle side it fully explains the IS and
objects (aerial view): sicken of both objects (aerial view): the IS NOT conditions, since
slider ZG-574752 & sicken slider ZG-574752 & a lack of communication
wear/sealing plate with ZG- wear/sealing plate with ZG- between the unexperienced
565355. 565355. integration process
engineer, production shift
leader, unexperienced
production supervisor,
unexperienced process
engineer of serial products
and two brandnew
unexperienced managers
leads to a pre-programmed
competing process and
mechanical parameters
between new and serial
products in the same
production line. The
creation of the two new
process engineering teams
catalyzes exponentially the
non-aligned parameter data
setting process between
process engineering and
production.
WHEN
When First? in CW18/2019 --> 29.04.19, 01.02.2013 up to 28.04.19 it could potentially explain
Monday, early shift night shift the IS and the IS NOT

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 conditions, providing a lack
of communication and
alignment of policies for
process parameter setting
between process
engineering and production
by beginning of March 2019.
When Since? 3 more incidents: all the noon and night shifts it could potentially explain
CW21/2019 --> Sa. from production runs the IS and the IS NOT
25.05.2019 at 8:49 am between 29.04.2019 noon conditions, providing a lack
CW25/2019 --> Th. shift and each of the other 3 of communication and
20.06.2019 at 4:49 am incidences and after the last alignment of policies for
CW31/2019 --> Th. one on 01.08.2019 noon process parameter setting
01.08.2019 at 6:23 am shift up to now. between process
early shifts, shift leader Leo engineering and production
López, product type: Nissan by beginning of March 2019.
What Is The Pattern? Periodic All Other Patterns it could potentially explain
the IS and the IS NOT
conditions, providing a lack
of communication and
alignment of policies for
process parameter setting
between process
engineering and production
by beginning of March 2019.
When In The Life-Cycle? 6 years and 2 months after 6 years and 2 months before it could potentially explain
installation in February 2013 production runs of Nissan the IS and the IS NOT
during production runs of P42J & P71A in April 2019. conditions, providing a lack
Nissan P42J & P71A in April of communication and
2019. alignment of policies for

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 process parameter setting
between process
engineering and production
by beginning of March 2019.
EXTENT
How Many Objects? 32 objects due to 8 56 objects due to 14 it fully explains the IS and
components from each components from each the IS NOT conditions, since
exchanged slider exchanged slider a lack of communication
subassembly ZG-627418- subassembly ZG-627418- between the unexperienced
000 (8 x 4 = 32) 000 (4 x 14 = 56): 8x screws integration process
4x sicken sliders 574752, DIN912 M5x20, 2x screws engineer, production shift
4x wear/sealing plates DIN EN ISO8735 8x30-A-St, leader, unexperienced
565355 1x spacer sleeve with ZG- production supervisor,
564984, 2x spacer bolts with unexperienced process
ZG-370284, 1x sealing plate engineer of serial products
splining with ZG-333694 = 1. and two brandnew
unexperienced managers
4x sicken sliders & 4x leads to a pre-programmed
wear/sealing plates, competing process and
belonging to the 3x slider mechanical parameters
subassemblies from the between new and serial
other 3 final assembly lines products in the same
M1419, M1607 & M2163. production line. The
creation of the two new
process engineering teams
catalyzes exponentially the
non-aligned parameter data
setting process between
process engineering and
production.

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How Many Objects - Trend? Stable All Other Trends it fully explains the IS and
the IS NOT conditions, since
a lack of communication
between the unexperienced
integration process
engineer, production shift
leader, unexperienced
production supervisor,
unexperienced process
engineer of serial products
and two brandnew
unexperienced managers
leads to a pre-programmed
competing process and
mechanical parameters
between new and serial
products in the same
production line. The
creation of the two new
process engineering teams
catalyzes exponentially the
non-aligned parameter data
setting process between
process engineering and
production.
What Is The Size? wear/sealing plates 565355: wear/sealing plates 565355: it fully explains the IS and
10mm width, 200mm length 30mm width, 250mm the IS NOT conditions, since
sicken sliders 574752: length, a lack of communication
10mm width, 170mm length sicken sliders 574752: between the unexperienced
50mm width, 250mm length integration process
engineer, production shift

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 leader, unexperienced
production supervisor,
unexperienced process
engineer of serial products
and two brandnew
unexperienced managers
leads to a pre-programmed
competing process and
mechanical parameters
between new and serial
products in the same
production line. The
creation of the two new
process engineering teams
catalyzes exponentially the
non-aligned parameter data
setting process between
process engineering and
production.
What Is The Size - Trend? Stable All Other Trends it fully explains the IS and
the IS NOT conditions, since
a lack of communication
between the unexperienced
integration process
engineer, production shift
leader, unexperienced
production supervisor,
unexperienced process
engineer of serial products
and two brandnew
unexperienced managers

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 leads to a pre-programmed
competing process and
mechanical parameters
between new and serial
products in the same
production line. The
creation of the two new
process engineering teams
catalyzes exponentially the
non-aligned parameter data
setting process between
process engineering and
production.
How Many Deviations? 8 cracks in each of the used 4 times the following: it fully explains the IS and
4x slider subassemblies ZG- 1 crack in each one of the 4 the IS NOT conditions, since
627418-000-A: 1x on each corner sliders = 4 a lack of communication
of the four beading sliders 1 crack in each one of the 4 between the unexperienced
ZG-574752 and 1x on each brace support = 4 integration process
of the four sealing plates 1 crack in each one of the 4 engineer, production shift
565355. shims = 4 leader, unexperienced
1 crack in each one of the 4 production supervisor,
beading stamps = 4 unexperienced process
1 crack in the tube holder = engineer of serial products
1 and two brandnew
1 crack in the rest of the unexperienced managers
beading insert = 1 leads to a pre-programmed
1 crack on each of the 8x competing process and
screws DIN912 M5x20 in mechanical parameters
slider subassembly ZG- between new and serial
627418-000 = 8 products in the same
1 crack on each of the 2x production line. The

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 screws DIN EN ISO8735 creation of the two new
8x30-A-St in slider process engineering teams
subassembly ZG-627418- catalyzes exponentially the
000 = 2 non-aligned parameter data
1 crack on each of the 1x setting process between
spacer sleeve in slider process engineering and
subassembly with ZG- production.
564984 = 1
1 crack on each of the 2x
spacer bolts in slider
subassembly with ZG-
370284 = 2
1 crack on each of the 1x
sealing plate splining in
slider subassembly with ZG-
333694 = 1--> 4 x 32 = 128
cracks
How Many Deviations - Stable All Other Trends it fully explains the IS and
Trend? the IS NOT conditions, since
a lack of communication
between the unexperienced
integration process
engineer, production shift
leader, unexperienced
production supervisor,
unexperienced process
engineer of serial products
and two brandnew
unexperienced managers
leads to a pre-programmed
competing process and

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 mechanical parameters
between new and serial
products in the same
production line. The
creation of the two new
process engineering teams
catalyzes exponentially the
non-aligned parameter data
setting process between
process engineering and
production.

Determine Most Probable Cause

Most Probable Causes:

Cause A Cause B Cause C Cause D

Description obsolete design of slider strong organizational strong organizational a new process module
subassembly for splining change in the middle change in the middle known as HSO (high speed
operation. The slider management of production management of process oscilation) was integrated to
subassembly tooling under responsible for M1889 since engineering since March the final assembly line
scope was replaced by a February 2019 driven by 2019 driven by poor change M2163 mid of February
newest design ZG-911-971- poor change management management strategies. 2019, which led to a
000, it was created and strategies. Responsability of Process engineering for relocation from some
developed in Eschen by most experienced, senior serial production with new, product types running
Bertram Hartmann since production supervisor was unexperienced, technical initially at the M2163 to
12.07.2016. It was modified splitted to full focus on driven manager. Process alternative machines like
by maerob on 05.01.2018 to M2163 as line sheriff since engineering for integrations M1889. This relocation was
February 2019. The other 3 with new, unexperienced, done during March 2019,

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 specify the planarity final assembly lines were technical driven manager, whereas the integration of
tolerace on the drawing. delegated to 2 new 3c_process engineering the new product types was
unexperienced production manager does not speak the done by a new team of
supervisors. The production local language and the process engineers. The
supervisor of M1889 started subordinates have poor interaction of the new
in March 2019 as production english skills. Process parameter data settings
coach and then he left the engineers splitted into with competing mechanical
company mid August 2019. different teams and were parameters from other
realocated to machines serial products is not done
beyond their expertise by the same process
competences. Change engineer who integrated the
management topics due to product, but by the
the acceptance of the new production shift leader with
process engineering escalation to production
structure. supervisor and process
engineer for serial
production. Integration
process engineers are
leaded by manager A (non-
spanish speaking, lack of
management experience)
and serial production
engineers are leaded by
manager B (native speaker,
lack of management
experience).
Communication issues
between production and the
both new process
engineering teams could
lead to process or
mechanical parameter

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 incompatibility of new
projects with serial
products.
Most Probable Cause (MPC)

IS IS NOT Cause A Cause B Cause C Cause D

WHAT
What Object? sicken slider with the rest of the
drawing number tooling belonging
ZG-574752 and to the slider
wear/sealing plate subassembly ZG-
with ZG-565355 627418-000-A like:
belonging to the 8x screws DIN912
slider subassembly M5x20, 2x screws
ZG-627418-000-A. DIN EN ISO8735
8x30-A-St, 1x
spacer sleeve with
ZG-564984, 2x
spacer bolts with
ZG-370284, 1x
sealing plate
splining with ZG-
333694, as well as
the rest of the
tooling belonging
to the beading
insert ZG-854973-
000 like: 4x corner
sliders, 4x brace

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 supports, 4x shims,
4x beading stamps,
1x tube holder.
What Deviation? mechanical other geometrical
fracture. surface
imperfections
based on DIN-EN-
ISO-8785 like
groove, scratch,
pore, blowhole,
shrinkage hole,
crevice, wane,
concave buckle,
dent, wart, blister,
convex buckle,
scale, inclusion,
burr, flash,
deposits, crater,
lap, scoring, chip
rest, skidding,
erosion, corrosion,
pitting, crazing,
patch,
discoloration,
streak, flaking,
WHERE
Where integrated as in the slider
Geographically? components of the subassemby tooling
beading insert ZG- related to the
854973-000 beading inserts

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 installed within the splining
permanently in the modules M1449,
splining module M1611, M1957
M2672 of the final belonging
assembly line respectively to the
M1889 installed at other 3 final
TKPM, in Puebla, assembly lines
Mexico. known as M1419,
M1607, M2163
installed at TKPM in
Puebla, Mexico, as
well as the splining
operations of
similar final
assembly lines in
Eschen like the
Stiwa 1 (M2661) &
Stiwa 2 (M2681).
Where On The on the left side of on the right and
Object? both objects (aerial middle side of both
view): sicken slider objects (aerial
ZG-574752 & view): sicken slider
wear/sealing plate ZG-574752 &
with ZG-565355. wear/sealing plate
with ZG-565355.

WHEN
When First? in CW18/2019 --> 01.02.2013 up to
29.04.19, Monday, 28.04.19 night shift
early shift

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When Since? 3 more incidents: all the noon and
CW21/2019 --> Sa. night shifts from
25.05.2019 at 8:49 production runs
am between
CW25/2019 --> Th. 29.04.2019 noon
20.06.2019 at 4:49 shift and each of
am the other 3
CW31/2019 --> Th. incidences and
01.08.2019 at 6:23 after the last one
am on 01.08.2019
early shifts, shift noon shift up to
leader Leo López, now.
product type:
Nissan
What Is The Periodic Periodic
Pattern?
When In The Life- 6 years and 2 6 years and 2
Cycle? months after months before
installation in production runs of
February 2013 Nissan P42J & P71A
during production in April 2019.
runs of Nissan P42J
& P71A in April
2019.
EXTENT
How Many 32 objects due to 8 56 objects due to
Objects? components from 14 components
each exchanged from each
slider subassembly exchanged slider
ZG-627418-000 (8 x subassembly ZG-

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 4 = 32) 627418-000 (4 x 14
4x sicken sliders = 56): 8x screws
574752, DIN912 M5x20, 2x
4x wear/sealing screws DIN EN
plates 565355 ISO8735 8x30-A-St,
1x spacer sleeve
with ZG-564984, 2x
spacer bolts with
ZG-370284, 1x
sealing plate
splining with ZG-
333694 = 1.

4x sicken sliders &

4x wear/sealing
plates,
belonging to the 3x
slider
subassemblies
from the other 3
final assembly lines
M1419, M1607 &
M2163.
How Many Objects Stable All Other Trends
- Trend?
What Is The Size? wear/sealing plates wear/sealing plates
565355: 10mm 565355: 30mm
width, 200mm width, 250mm
length length,
sicken sliders sicken sliders
574752: 10mm 574752: 50mm

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 width, 170mm width, 250mm
length length
What Is The Size - Stable All Other Trends
Trend?
How Many 8 cracks in each of 4 times the
Deviations? the used 4x slider following:
subassemblies ZG- 1 crack in each one
627418-000-A: 1x of the 4 corner
on each of the four sliders = 4
beading sliders ZG- 1 crack in each one
574752 and 1x on of the 4 brace
each of the four support = 4
sealing plates 1 crack in each one
565355. of the 4 shims = 4
1 crack in each one
of the 4 beading
stamps = 4
1 crack in the tube
holder = 1
1 crack in the rest
of the beading
insert = 1
1 crack on each of
the 8x screws
DIN912 M5x20 in
slider subassembly
ZG-627418-000 = 8
1 crack on each of
the 2x screws DIN
EN ISO8735 8x30-
A-St in slider

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 subassembly ZG-
627418-000 = 2
1 crack on each of
the 1x spacer
sleeve in slider
subassembly with
ZG-564984 = 1
1 crack on each of
the 2x spacer bolts
in slider
subassembly with
ZG-370284 = 2
1 crack on each of
the 1x sealing plate
splining in slider
subassembly with
ZG-333694 = 1--> 4
x 32 = 128 cracks
How Many Stable All Other Trends
Deviations - Trend?

Selected Most Probable Cause:

Cause A Cause B Cause C Cause D

Description obsolete design of slider strong organizational strong organizational a new process module
subassembly for splining change in the middle change in the middle known as HSO (high speed
operation. The slider management of production management of process oscilation) was integrated to
subassembly tooling under responsible for M1889 since engineering since March the final assembly line
scope was replaced by a February 2019 driven by 2019 driven by poor change M2163 mid of February
newest design ZG-911-971- poor change management management strategies. 2019, which led to a

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 000, it was created and strategies. Responsability of Process engineering for relocation from some
developed in Eschen by most experienced, senior serial production with new, product types running
Bertram Hartmann since production supervisor was unexperienced, technical initially at the M2163 to
12.07.2016. It was modified splitted to full focus on driven manager. Process alternative machines like
by maerob on 05.01.2018 to M2163 as line sheriff since engineering for integrations M1889. This relocation was
specify the planarity February 2019. The other 3 with new, unexperienced, done during March 2019,
tolerace on the drawing. final assembly lines were technical driven manager, whereas the integration of
delegated to 2 new 3c_process engineering the new product types was
unexperienced production manager does not speak the done by a new team of
supervisors. The production local language and the process engineers. The
supervisor of M1889 started subordinates have poor interaction of the new
in March 2019 as production english skills. Process parameter data settings
coach and then he left the engineers splitted into with competing mechanical
company mid August 2019. different teams and were parameters from other
realocated to machines serial products is not done
beyond their expertise by the same process
competences. Change engineer who integrated the
management topics due to product, but by the
the acceptance of the new production shift leader with
process engineering escalation to production
structure. supervisor and process
engineer for serial
production. Integration
process engineers are
leaded by manager A (non-
spanish speaking, lack of
management experience)
and serial production
engineers are leaded by
manager B (native speaker,
lack of management
experience).

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 Communication issues
between production and the
both new process
engineering teams could
lead to process or
mechanical parameter
incompatibility of new
projects with serial
products.
Most Probable Cause (MPC)

Confirm True Cause

Most Probable Cause

a new process module known as HSO (high speed oscilation) was integrated to the final assembly line M2163 mid of February 2019, which led to a
relocation from some product types running initially at the M2163 to alternative machines like M1889. This relocation was done during March 2019,
whereas the integration of the new product types was done by a new team of process engineers. The interaction of the new parameter data settings with
competing mechanical parameters from other serial products is not done by the same process engineer who integrated the product, but by the production
shift leader with escalation to production supervisor and process engineer for serial production. Integration process engineers are leaded by manager A
(non-spanish speaking, lack of management experience) and serial production engineers are leaded by manager B (native speaker, lack of management
experience). Communication issues between production and the both new process engineering teams could lead to process or mechanical parameter
incompatibility of new projects with serial products.

Actions to Confirm Responsibility/Timing

USE
Verify Assumptions creation of a list of products that were relocated line sheriff @ CW34/2019
from the final assembly line M2163 into M1889

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 between March and April 2019 to compare the
parameter data settings before the relocation
and after the relocation.
Observe create R&R matrix (roles and responsabilities) line sheriff @ CW45/2019
between process engineering and production for
integration of new product types and validation
of competing parameters in serial production.

Experiment reset all relevant process parameters of splining process engineer @ CW35/2019
operation in M2672 before the integrations
done by beginning March 2019 and verify the
results.
Try a Fix and Monitor reliability analysis to calculate the MTBF before maintenance engineer @ CW52/2019
and after the proposed fix.

Most Probable Cause Assumptions

it fully explains the IS and the IS NOT conditions, since a lack of communication between the unexperienced integration process engineer, production shift
leader, unexperienced production supervisor, unexperienced process engineer of serial products and two brandnew unexperienced managers leads to a
pre-programmed competing process and mechanical parameters between new and serial products in the same production line. The creation of the two
new process engineering teams catalyzes exponentially the non-aligned parameter data setting process between process engineering and production.
it fully explains the IS and the IS NOT conditions, since a lack of communication between the unexperienced integration process engineer, production shift
leader, unexperienced production supervisor, unexperienced process engineer of serial products and two brandnew unexperienced managers leads to a
pre-programmed competing process and mechanical parameters between new and serial products in the same production line. The creation of the two
new process engineering teams catalyzes exponentially the non-aligned parameter data setting process between process engineering and production.
it fully explains the IS and the IS NOT conditions, since a lack of communication between the unexperienced integration process engineer, production shift
leader, unexperienced production supervisor, unexperienced process engineer of serial products and two brandnew unexperienced managers leads to a
pre-programmed competing process and mechanical parameters between new and serial products in the same production line. The creation of the two
new process engineering teams catalyzes exponentially the non-aligned parameter data setting process between process engineering and production.
it fully explains the IS and the IS NOT conditions, since a lack of communication between the unexperienced integration process engineer, production shift
leader, unexperienced production supervisor, unexperienced process engineer of serial products and two brandnew unexperienced managers leads to a
pre-programmed competing process and mechanical parameters between new and serial products in the same production line. The creation of the two
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new process engineering teams catalyzes exponentially the non-aligned parameter data setting process between process engineering and production.
it could potentially explain the IS and the IS NOT conditions, providing a lack of communication and alignment of policies for process parameter setting
between process engineering and production by beginning of March 2019.
it could potentially explain the IS and the IS NOT conditions, providing a lack of communication and alignment of policies for process parameter setting
between process engineering and production by beginning of March 2019.
it could potentially explain the IS and the IS NOT conditions, providing a lack of communication and alignment of policies for process parameter setting
between process engineering and production by beginning of March 2019.
it could potentially explain the IS and the IS NOT conditions, providing a lack of communication and alignment of policies for process parameter setting
between process engineering and production by beginning of March 2019.
it fully explains the IS and the IS NOT conditions, since a lack of communication between the unexperienced integration process engineer, production shift
leader, unexperienced production supervisor, unexperienced process engineer of serial products and two brandnew unexperienced managers leads to a
pre-programmed competing process and mechanical parameters between new and serial products in the same production line. The creation of the two
new process engineering teams catalyzes exponentially the non-aligned parameter data setting process between process engineering and production.
it fully explains the IS and the IS NOT conditions, since a lack of communication between the unexperienced integration process engineer, production shift
leader, unexperienced production supervisor, unexperienced process engineer of serial products and two brandnew unexperienced managers leads to a
pre-programmed competing process and mechanical parameters between new and serial products in the same production line. The creation of the two
new process engineering teams catalyzes exponentially the non-aligned parameter data setting process between process engineering and production.
it fully explains the IS and the IS NOT conditions, since a lack of communication between the unexperienced integration process engineer, production shift
leader, unexperienced production supervisor, unexperienced process engineer of serial products and two brandnew unexperienced managers leads to a
pre-programmed competing process and mechanical parameters between new and serial products in the same production line. The creation of the two
new process engineering teams catalyzes exponentially the non-aligned parameter data setting process between process engineering and production.
it fully explains the IS and the IS NOT conditions, since a lack of communication between the unexperienced integration process engineer, production shift
leader, unexperienced production supervisor, unexperienced process engineer of serial products and two brandnew unexperienced managers leads to a
pre-programmed competing process and mechanical parameters between new and serial products in the same production line. The creation of the two
new process engineering teams catalyzes exponentially the non-aligned parameter data setting process between process engineering and production.
it fully explains the IS and the IS NOT conditions, since a lack of communication between the unexperienced integration process engineer, production shift
leader, unexperienced production supervisor, unexperienced process engineer of serial products and two brandnew unexperienced managers leads to a
pre-programmed competing process and mechanical parameters between new and serial products in the same production line. The creation of the two
new process engineering teams catalyzes exponentially the non-aligned parameter data setting process between process engineering and production.
it fully explains the IS and the IS NOT conditions, since a lack of communication between the unexperienced integration process engineer, production shift
leader, unexperienced production supervisor, unexperienced process engineer of serial products and two brandnew unexperienced managers leads to a
pre-programmed competing process and mechanical parameters between new and serial products in the same production line. The creation of the two

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new process engineering teams catalyzes exponentially the non-aligned parameter data setting process between process engineering and production.

Think Beyond The Fix

Extend the Cause

True Cause
a new process module known as HSO (high speed oscilation) was integrated to the final assembly line M2163 mid of February 2019, which led to a
relocation from some product types running initially at the M2163 to alternative machines like M1889. This relocation was done during March 2019,
whereas the integration of the new product types was done by a new team of process engineers. The interaction of the new parameter data settings with
competing mechanical parameters from other serial products is not done by the same process engineer who integrated the product, but by the production
shift leader with escalation to production supervisor and process engineer for serial production. Integration process engineers are leaded by manager A
(non-spanish speaking, lack of management experience) and serial production engineers are leaded by manager B (native speaker, lack of management
experience). Communication issues between production and the both new process engineering teams could lead to process or mechanical parameter
incompatibility of new projects with serial products.
What Other Damage Could This Cause Create?
robot crashes at M2672 in worst case
Where Else Could This Cause Create Problems?
in the splining operations from the other 3 final assembly lines: M1419, M1607 & M2163.
What Caused The Cause?
Lack of a clear change management strategy to tackle the resulting issues from demerging the process engineering department into 2 different misaligned
teams.

Extend the Fix

Proposed Fix

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change management workshop to generate the properly tactics and interventions needed for each core stakeholder
What Identical Things Need The Same Fix?
perform the same workshop for the production supervisors
What Problems Could This Fix Cause?
layers of resistance to change related to the problem, to the solution or to the implementation.

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