Chapter 3: The Start Out – Everybody Heads Up!

A leader, who was embracing logic and critical thinking upon every decision made, was what the CRISIS team must have in order to navigate through this thunder storm upon a roaring sea.

A mission possible and a smart leader

It was a quarter to eight earlier in the morning Mr AA came out from the director’s office. He immediately rushed to his desk right behind me to check email and search for urgent messages. He was extremely earlier that day; I think he had to abandon his role sending his daughters to schools every school day for his commitment to his chief. I was intrigued yet convinced by my intuition about him, that his exhilarating behavior had something to do with the RED alert and his new role in the entire episode.

When I was about to ask for the details, he started to tell everything from the moment he received lots of midnight calls from the top officers asking for QC information related to the incident, his presentation about the Assembly Station Contamination Control project, to the moment earlier the head of the department had empowered he overseeing the CRISIS team progress.

The CRISIS team was a cross-functioned team consisted of technical staff from engineering departments. All we needed was a group of people who took an active part in the brainstorming, responded rationally and realistically when we found fault with their own area, and opened to others their work connecting the potential problematic area.

Earlier in that morning, the whole team brought along their gadgets swamped into the production room, tried to look for an illumination for the facts that produced the turmoil and brought down the entire production.

Mr AA had successfully convinced the top management and engineering departments that the problem would be entirely solved by implementing lessons learnt from the clean room overhauling projects.

A smart action plan

Just when we believed that the crisis would all be over in few months time, we did not know what it would be like to focus merely on the machine mechanical parts. The AS engineers were so eager to learn whether the outcome at the end resembling what they had accomplished earlier in their analysis report presenting to the top management.

Mr AA’s reports for recycling stations: Recycling station taken as a whole had severe cleanliness issues, dust and dirt could be found everywhere. The workers’ garments were dirty and most of the stations had failed the wipe test. The tooling fixtures had the potential adding contaminants to the cleaned parts. No proper inspection were performed on the parts before and after the cleaning process. No other significant issues were related to the problem were found during the audit.

AS engineers analysis report: Based on the top five defects from this particular part number, contamination issue was ranked 1st and further analysis on failed parts confirmed that the contaminants were unusual in normal assembly process and that matched the conditions in recycling center particularly the inefficient cleaning process. A relative enormous portion of the failed parts belonged to the same part number that was allowed to build using reused (recycled) materials.

Conclusion: The recycling center needs a full-scale revamp! A face-lift on the entire tidiness must be in place before the next customer’s audit.

Solution and action plan: In the recycling center, implement more regular and detailed station cleaning, ensure the fixtures design did not hinder the parts from the air sprays, and implement more stringent visual inspection on the parts.

An indisputable reveal

If we were to use the famous “Ishikawa Fish Bone Diagram” here, 5 core factors (4M1E) would significantly contribute to the problem; there are Method, Machine, Man, Measurement and Environment factor to be measured. How these factors impinged on the process, could be determined using Potential Failure Mode Effect Analysis (PFMEA).

I was one of the CRISIS team members during the audit, and the brainstorming session, I approached Mr AA and management with an entirely different point of view. Mr AA’s assumption and conclusion have committed severe logical flaws. In a nutshell, I could use any one of the common logical fallacies to explain the error he and the decision makers made in reasoning.

RED alert problem statement released by AS engineering along with quality and reliability engineering: The AAA product’s yield dropped from Z% to Y% attributable to functional failure that assumed caused by components’ Contamination issue.

• The decision made was hastily generated. The decision that based on one time sampling audit result was insufficient to warrant a reliable conclusion; the sample was too small to support an inductive generalization about a population (production performance over a longer period). The “crime” site had been falsified for the CRISIS team to audit, what we found during the audit was a speculative; it was not the problem that caused the product yields loss.
• The causation connections established that based on the team audit findings had not been proven, and no evidences were provided to support the assumption that the discrepancies found in the recycling centre had caused the contamination. Whether the contaminants found on the stations and worker’s garments matched the contaminants that caused the functional failure in HDD, no one has the answer for it.
• The audit findings had just revealed the effects of the problem, not the causes. There was another factor, may be a common cause that produced all these effects. Perhaps, it was a circular cause, or the process itself was a vicious cycle? If there were a “Chicken and Eggs” issue, then we had to apply a different approach to understand how these causes and effects related to each other.
• Mr AA had failed to recognize the complexity of the cause and effect. The effects could be caused by number of events, of which the cause identified was only a part. He claimed that the visual inspection was crucial to detect the problem before sending the dirty parts to the assembly stations; however, he had overlooked the possibility of cross contamination occurred after an effective visual inspection or during the transportation. I saw many parts staged near the assembly stations for days without appropriate treatment, not even they had a proper packaging to protect the parts from contamination and rough handling. It could be entirely possible that parts from recycling centre were cleaned initially, but later got contaminated at the assembly stations.
• It was a tradition and also a popular practice at the HDD assembly stations (laminar air flow system) to control the room air quality to class 100. However, the tactics did not seem to fit into recycling centre under a totally different environmental control (non laminar air flow system). Mr AA tried to apply something he practiced at the assembly stations on the recycling station without first studied the cause and the effect was a ridiculous act; it could be just another wasteful spending.
• Important evidence, which would undermine, an inductive argument has been excluded from consideration. Here, the statement about cross-contaminated from the base screw thread’s particles to the cleaned parts or may be to the failed HDD was not provided. The team only had evidence about cross-contaminations from the tools and the workstations to the cleaned parts. Another important question whether environmental factor had played a part in this issue was ignored.
• The clean room air flow in which essentially the entire body of air within a confined area was moved with uniform velocity along parallel flow lines. Turbulence did occur in the Compound room because adjacent room air flew out through the machine’s opening. Turbulence could cause particle movement, and this had violated the clean room protocol. As a consequence of this situation, the Compound room where the new machine had been installed was badly chosen for normal production process.
• The proper conclusion of an inductive argument was denied despite the evidence to the contrary. That “blinding sand storm” blew out from the machine felt by the workers was a decisive evidence that the machine design was incompetent, it somehow allowed contaminants released freely to the surrounding area. Further supported by the dirty tools, garments and stations observed during the audit; one common cause had produced all these effects.

A depressing finale

Months passed the product yields showed no sign of improvement with that plan. During the conversation with Mr AA, we discussed the factory ventilation system and role of subfloor. Apparently he did not have the confident to raise the environmental control issue to the management. In addition, the remedy could mean millions of ringgit revamping the entire, clean room system.

Apparently, it was a “too large to fail” problem, the company could not afford to compensate the failures. This was ridiculous, insane. The start out was extremely disappointed as the crisis team had to follow these irrational decisions.

The problematic areas had to be re-visited, re-investigated to find that missing puzzle. A leader, who was embracing logic and critical thinking upon every decision made, was what the CRISIS team must have in order to navigate through this thunder storm upon a roaring sea.

Perhaps a member who would play a fairly prominent role in putting forward her analytical thinking conquering this unfounded action plan was what we lacked. Not the shabby Glouchester fishermen in “Perfect Storm” who ignored warnings of a monster storm and kept looking for swordfish hoping to beat a streak of ill luck.

Worse still, the new high-tech machines were acceptable to continue cleaning the parts when overall safety measure had not been taken. More pressures forced towards the CRISIS team because it seemed no end to the disaster just started. At one side, the technical staff were convinced that the machines may be the cause, at the other side, the production folks were attempted to stick on their production schedule ignoring the “Stop Order” because no solid decision from the “Authority”.

Wai Ping Lee/ Mar 2011