Yes I agree that a full RCA is necessary. Base don the critical operation of the component and in general for hand soledered electrical connections and also due to the admission that the operators were "using up" known contaminated solder. This is a disaster waiting to happen.
The operators were told to "look out" for contaminated solder; what analysis tools were they given to assist them? What is the potential for other joint failures?
IMO the RCA should be conducted from purchasing to point of use.

Define the problem.

For example, ask how many times has this happened before? Then, what are the hazards and risks exposed to reputation, commercial viability, legal requirements (statutory & regulatory), and people? Use an Enterprise Risk Management approach (eg AS/NZS 4360 or ISO/DIS 31000).

Affinity Diagrams, Interrelationship Digraph type tools are useful to sort out real issues to spend investigation dollars on. Management always has the option to Do Nothing, Do a Quick Fix, or Do a Full RCA "appropriate to the effects of the nonconformities encountered" as it says in ISO 9001/8.5.2. Once you understand the problem and the exposure, then get into problem solving tools such as PDPC or FMEA or the Deming tools.

Basic assumption is that no-one comes to work to do a bad job, so an investigation needs to sort out where the system failed (not the operator). You need to understand what those involved understood at the time - see Prof Sydney Dekker "The Field Guide to Human Error" and Prof James Reason "Human Error".

And of course, there's the "WYMIWYG - YOGWYM" syndrome, "what you measure is what you get - you only get what you measure". If production is measured on units completed, completed units is what management will get; whether or not the units work is another parameter. Which is why any organisation that has any conflict at all between QA and production functions has totally lost the plot.

Hope this helps.

In light of the other more serious issues on this project, the costs associated with a full 3 day 5 person team to perform Root Cause Analysis may not be justified on this issue at this point. Having said that, as an executive, I would really want to know more details on how extensive this issue is before making any decision. I feel Jodi jumped the gun in authorizing the full blown investigation without more detailed backup.

If I understood the details in the case study, the contamination issue has already had an analysis performed that determined the existing stock of solder was at fault. If this was a "critical application", use of the potentially contaminated solder should have been immediately discontinued at that point in time. Instead, a decision was made (assumed to be by competent persons knowing the impact risk) to continue use of the existing solder until depleted.

Regardless of the criticality of the application, I would definately want to know why the company is still ordering a brand of solder having periodic contamination issues.

David Thuillier
Quality Manager
OASYS Technology, LLC
www.oasys-technology.com

I agree as well that a full RCA is necessary somewhat based on the fact that you invested the money and resources in some RCA training. Use it.
I also don't believe this would take anywhere near 3 days worth of analysis. And on the evidence of allowing the contaminated solder to be continued, how do you tell the operator to "watch out" for bad solder?. Get the solder of the floor immediately. And go back and review the environment the soldering is done in and what method was given to check bad solder.

I believe there is a much bigger problem than the bad solder. My theory is that Management is responsible for not knowingly putting suspect product on the production floor. Too many errors of man and method are just waiting to happen in this type of situation. It seems to me that we have failure of the purchasing process, the production process and the monitoring and measurement processes. There is a lot of additional information that I would want, but as a manager, I already see process failures that are likely affecting other products or processes. I would certainly want the RCA to take place.

The answer/comment is relatively easy: Constant tension between Production & Quality? Ineffective Solutions? Boardroom arguments? "Potential" benefits of finding solutions that prevent recurrence? A Production meeting decided to use up the current stock of suspect solder? Etc. Serious problems with the whole Quality System and serious lack of buy-in. Need to look at the whole (Hole?) system of Quality/Production/Commitment/Leadership NOW! I think that Kulshan is fortunate that the "bad" solder joint was found now - 3+ days of investigation now will, hopefully, forestall considerable grief (and much greater costs) later in the process, including the negative perception by their customer when they start receiving defective assemblies.

Jodi may have been "peaking" (lead-in article) at 10:25am, but I think the full article has it right - she was probably peeking... "Council" the worker? Maybe that's also right - maybe the workers should be heading up some of the councils that make the key decisions for Kulshan?

Not absolutely sure of who Brian Hughes works for - Appollo or Appolo or Apollo. According to the Web, he apparently works for Apollo Associated Industries, LLC.

Zenon

In this case the fault had been found on one small part it would be wrong to assume that all electrical contacts are at fault so a full root cause into a simple issue that could be found by 5 why or fishbone is more appropriate. If there was a trend appearing in the quality data that aligned to the fault that was found then yes more intensive root cause effect would be valued step.