>> I read 10+ years ago.
>>
>> Long story short we had a major cluster F in production -
>> 1. Incoming inspection missed a majorly obvious problem.
>> Several steps into the assembly it was finally noticed - undo the assemb=
ly
>> and send it back to supplier.
>> 2. Incoming inspection missed a second majorly obvious problem that they
>> should have seen in the first inspection.
>> Several plus one steps into the assembly the second problem was noticed =
 -
>> undo the assembly and send it back to supplier again.
>> 3. Incoming inspection missed a third majorly obvious problem caused by =
the
>> first "fix".
>> Several plus two steps into the assembly the third problem was noticed  =
-
>> this is where I get involved.
>>
>> The people involved are not professional engineers, there won't be a
>> "tribunal" or other such formal proceedings. But I'm sitting them all do=
wn
>> and doing the "after action review" tomorrow and was looking for some
>> sticks to beat them with.
>>     =20
This sounds like more of a breakdown in procedures. There should be a=20
testing/qualifying procedure in writing that is followed. (A checklist).=20
The various parties generate this list at design time, whether it be the=20
list of customer requirements as a start, and further developed to=20
encompass possible difficulties. This type of procedure comes under Lean=20
and Six Sigma tools areas.
http://en.wikipedia.org/wiki/Six_sigma

This shouldn't be a "Sticks to beat them", but educational session, on=20
how to improve. :)
--=20
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