Problem solving

How to put your organization into escalation?

Many years ago, I continued my career as a customer quality engineer at a new company.

I wanted to show my abilities to the team to prove that I am a quality professional.

I did not have to wait too long. We received a new quality claim from the customer on Friday afternoon (as always).

⁃ Yes! I can do that! – that was my first thought.

The issue did not seem too complicated; one small part has not been properly fixed.

Among other containment actions, we immediately implemented some extra operations to make sure the parts are OK.

We discussed as a team; the defined actions were appropriate and safe.

Everyone thought we are finished until the claimed part arrived, and the root cause analysis can be continued.

But I raised the following question:

Is there a similar part for the customer where such an issue could happen?

⁃ Well, yes. – answered the process engineer. But that produced at a different line, that is another application, but the fixation method is similar.

⁃ Ok, in this case, the similar containment actions should be implemented as well. Let’s not wait until there would be the same type of claim from the customer. Use the lessons learned!

The team was not too happy, especially on Friday afternoon, but they accepted my decision.

Finally, all actions have been implemented for the other part number as well.

At the end of next week, the defected part arrived, root causes have been defined, corrective actions were scheduled, everything seemed to be normal.

Certainly, the containment actions remained in place till the final implementation and validation of the corrective actions.

Everything went smoothly till I have received an angry e-mail from the customer about a claim with the other application, but it affected more parts.

No, it was not the same improper fixation issue. That was a totally different function problem.

Due to that claim, we have received the escalation letter…

This happened in my first month, customer escalation, I had to start organizing my trip to present what happened.

Well, that was not the perfect opportunity for introducing myself, which I imagined before.” Warm” welcome could be expected.

I took that case very seriously. I organized 8D meetings by the line, involved all experts, including the operators, but we could not understand the root cause for occurrence.

Other containments were in place; therefore, the customer was protected from more failed parts, but it was not enough because we still found occasionally NOK parts.

Escape was clear, but how it occurred?

The team performed lots of experiments based on the fishbone analysis, but we did not get closer.

I addressed different operators from different shifts and spent enormous time on the shop floor, but still no success for weeks.

One day I got lucky.

I was on the shop floor again, chatting with the operator, but continuously watching what and how she was doing.

Suddenly, I recognized that one assembly tool got slipped while she was doing the extra operation I asked a long time before due to the different claim about the other part number.

The tool hit a sensitive part, and the set function was lost.


We did some trials, verified in the lab, and the failure has been successfully reproduced.

Now we could get out of the escalation after the risk has been eliminated by a robust action.

Several months later, I had to explain the whole story to the ISO/TS16949 auditor. We went to the line where he understood everything.

I will never forget what his comment was.

⁃ You did a good job. But I recommend that next time you use the PFMEA better.

What happened?

We introduced an action as a lesson learned to a different product without proper risk assessment.

The other product was smaller. There was less space for the assembly tool, which increased the risk of slipping the tool. The tool hit a sensitive part, and the already verified function got misadjusted.

Do not expect that one proven effective action will have the same efficiency on other products as well, even if they have many similarities. (And make sure the final test is really the final test.)

Lessons Learned?

You can make a mistake if you do not perform proper risk assessment while you implement lessons learned.

How can you even make a bigger mistake?

If you do not apply lessons learned at all.

As always, think in system with Pro Automotive.

If you are interested in reading articles about automotive quality management topics, best practices, case studies, follow Pro Automotive.

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