OpEx STEP # 3 - IMPLEMENT CONTAINMENT ACTIONS

A3 Report – PROBLEM SOVLING No. Containment Action Item Responsible Due Date
1 Impacted testing to be done IPT 9-Nov-19
Pinhole type damaged pouch - 11015MN1 2 check sharp edges on laminate path Tejas Immidiate
Leader: Area : Pouch Line 2 3
STEP # 1 - FORM A TEAM
4
Tejas, Pulkit, Mahipat, Nirav
5
6

STEP # 2 - DESCRIBE THE PROBLEM

On dated 09-nov-19, online leak observed in NDT machine which was a pinhole type
damaged pouch below horizontal seal area. Filler line 2, batch no 11015MN1, pediasure STEP # 4 - DETERMINE ROOT CAUSE(S) - SEE WORKSHEET ON BACK
upgrade chocolate 500gm.

Goal Statement STEP # 5 - CHOOSE CORRECTIVE ACTIONS

No. Corrective Action Item Responsible Due Date
There shhould be no leak, no damage pouch from filler
What is wrong or not working? Why should we do this? What is the benefit? What is the impact or consequence of the problem?
1 Reject laminate Tejas immidiate
2 Send SCNF to supplier 15-Nov-19
3
4
Current Condition 5
Specifically, what are we going to do and deliver? What are our improvement objectives and targets? How will success be
measures? Process Map, Check
What specific Sheets,
parameters Pareto
will Charts, Process Capability
be measured?
6
1. Line was running at 55PPM on Ped cho 500gm.
2. running laminate batch number was 5000085271. 7
3. laminate roll was changed at 12:38.
4. Operator followed all SOP, removed 20 empty pouches and start STEP # 6 - IMPLEMENT ACTIONS & EVALUATE RESULTS
machine. 5. Operator checked initially 3
pouches & continued production.
6. leak observed in online NDT machine at 12:42.
7. IPT operator inform filler
operator & filler FLL. 8. FLL & operator checked STEP # 7 - PREVENT REOCCURENCE
sharp edges on laminate path in filler with no observation found. 9. Replace
the laminate with new roll & reject the same laminate. Why? Who?
10. Give confirmation samples to IPT for NDT & line started after confirmation No.What? When?
Control Measure How Often? Who Checks?
done.
1
2

Is the solution
LESSONSimplemented? What control documentation was created to “help sustain the gains”? Has necessary training been performed? Were Visual
LEARNED/RECOMMENDATIONS/REPLICATION
Controls included as part of the control tools?
No. Replication Opportunities Areas Shared (Y/N)
1
2

What replication opportunities were identified from the project?

STEP # 8 - CELEBRATE SUCCESS AND CONGRATULATE TEAM

A3 Report 471658125.xlsx
 STEP # 4 - ROOT CAUSE ANALYSIS

A Fishbone Diagram

Serves as a discussion guide to assist in determining root cause People Method Machine

Step not followed as per FLU-I

Error in reactor
BMR

Wrong raw material chargd Error in reactor component

NA NA NA

NA NA NA

NA NA
Material was not isolated
in Batch FLU-20-I-0003
Raw material was not
Raw material was Out charged as per
of specification High Temp/RH
sequence

Improper laminate
NA NA
winding

NA NA NA

NA NA NA

Material Environment Measurements

5 Why's? Why did this occur? Ask "Why" 5 Times

Why? pin hole type leak found line 2 Why?

Why? Laminate quality issue Why?

Why? weak structure of laminate Why?

Why? Why?

Why? Why?

Action Action
SENF to be raised & sent to supplier

Why? Why?

Why? Why?

Why? Why?

Why? Why?

Why? Why?

Action Action

Fishbone Diagram 471658125.xlsx