ROOT CAUSE ANALYSIS

Black Spot Contamination in Pellet

K, Hana, Ven, Spring – Lab Review, 01-13, 10-Sep2020

TROUBLE INFORMATION
What : Black spot contamination in pellet Lot: abc0001
Who? : Detector, operation members, Lab members
When? : 09-Sep, 2020 ~ 08h30
Where? : During production, bagging, pelletizer, final product?
How detect? : Metal detector, Visual check?
Frequency? : during start up, after shutdown, high/low, continuous/ intermittent, etc.?
Direct Cause? : The presence of contaminants in the plastics in production
TROUBLE INVESTIGATION
Internal process
External process (supplier, transport, etc. )

Where the contaminants come from? What are the root causes?
The contaminants are dusts, metal debris, burned materials.
Material: contaminations of raw materials? (Gases, catalysts, additives, packaging quality control)
Man: who detect/ involve? not follow procedure (checking, leaning, etc.), intentional or unintentional?
Machine: OK or not? Dirty, troubles, not maintenance.
Method: no procedure, proper procedures? i.e. cleaning, checking, training,etc.
Environment: dirty, messy, untidy, no layout, etc.,
 ROOT CAUSE ANALYSIS – FISHBONE DIAGRAM
Lack of materials
& condition for Not checking Dirty
cleaning before materials
s
an rial hi ne Ineffective
procedure
ate

traffi ective
M ac

g
Insufficient

nin
M Supplier M cleaning
clea less

quality
Ine
g

nt
nin

tam ve

ine
ma irty
ina
Not following
e

con dditi
Car

ch
diti e
on

D
g
Ineffective procedure

contorag
No procedure

sin
ces l
pro initia
training

A
for checking No
per ong
checking

S
re
Not
tem ng wr
atu

ina al
cleaning Process Lack

nt
tam teri
contamination maintenance No 
No
Setti

rus r
con w ma
procedure

ext filte
io n
procedure Powder Trouble

No
Ra
Storage... contaminant damage
Put wrong Pipeline
materials dirty Lack of
No checking
before input
parts
Black
Wrong
Spot
method
Inp Wro No checking Insufficient
ut, ng cleaning
Ine

out before input

arr
Me gem
p
ffe met

ut

an
cti ho

ssy ent
Dirty
ve d

No
Ine

Ineffective method Environment

Ch

layout
ffe met

for training
ec
cti ho

No No cleaning
kin

pro
ve d

trai Shorte

Sto ckag
rules
g

f
fro ession

pa
nin n
cle

rag ing
m 3 rd al g ti No 5S
Im cedu

an

me
Pr

e&
r
par aini
pr
o

ing

ty ng
op res

Forklift
er

En Crane
Me vir
tho Ineffective on
training me
d nt
 ROOT CAUSE ANALYSIS
Lack of materials
& condition for Not checking Dirty
cleaning before materials
s
an rial hi ne Ineffective
procedure
ate

traffi ective
M ac

g
Insufficient

nin
M Supplier M cleaning
clea less

quality
Ine
g

nt
nin

tam ve

ine
ma irty
ina
Not following
e

con dditi
Car

ch
diti e
on

D
g
Ineffective procedure

contorag
No procedure

sin
ces l
pro initia
training

A
for checking No
per ong
checking

S
re
Not
tem ng wr
atu

ina al
cleaning Process Lack

nt
tam teri
contamination maintenance No 
No
Setti

rus r
con ma
procedure

ext filte
io n
procedure Powder Trouble

Raw

No
Storage... contaminant damage
Put wrong Pipeline
materials dirty Lack of
No checking
before input
parts
Black
Wrong
Spot
method
Inp Wro No checking Insufficient
ut, ng cleaning
No met

before input
Solutions:
out

arr
Me gem
p
ut
Ch hod

an
ssy ent
• Training
ec

Dirty
operators of operation, inspection, etc. periodically
kin

No
No met

Ineffective method Environment

g

layout
•
cle hod

for training
Build mandatory procedures for each step (storage, convey & refill material;
an

No No cleaning
pro Sho

Sto ckag
ing

f train rte rules

fro essioncleaning,

pa
ing n etc.)

rag ing
m 3 al No 5S
Im cedu

tim
Pr

e&
rd
r
par aini e
pr

• Use
o

ty ng
modern equipment/tools to support people (cleaningForklift robot in hard-to-
op res
er

access position, auto refill, etc.) En Crane

Me vir
tho Ineffective on
training me
d nt
 ROOT CAUSE ANALYSIS
Lack of materials
& condition  for Not checking Dirty
cleaning before materials
s
an rial hi ne Ineffective
procedure
ate

traffi ective
M ac

g
Insufficient

nin
M Supplier M cleaning
clea less

quality
Ine
g

nt
nin

tam ve

ine
ma irty
ina
Not following
e

con dditi
Car

ch
diti e
on

D
g
Ineffective procedure

contorag
No procedure

sin
ces l
pro initia
training

A
for checking No
per ong
checking

S
re
Not
tem ng wr
atu

ina al
cleaning Process Lack

nt
tam teri
contamination maintenance No 
No
Setti

rus r
con ma
procedure

ext filte
io n
procedure Powder Trouble

Raw

No
Storage... contaminant damage
Put wrong Pipeline
materials dirty Lack of
No checking
before input
parts
Black
Wrong
Spot
method
Inp Wro No checking Insufficient
ut, ng cleaning
No met

before input
Solutions:
out

arr
Me gem
put
Ch hod

an
ssy ent
• Strictly
ec

Dirty
control
method quality of input materials (additive, gas, powder, etc.)
kin

No
No met

Ineffective Environment
g

layout
•
cle hod

for training
Control storage condition (residentNotime,
cleaning temp, dust, moisture, etc.)
an

No
pro Sho

Sto ckag
ing

t rules
fro e•ssion Processing:
f rain rte

pa
ing n checking initial process, main process, etc. corrosion,

rag ing
m 3 al No 5S
Im cedu

tim
Pr

e&
rd
r
par aini e
pr
o

remain
ty ng
material, for leak-in, breath hole, etc.
op res

Forklift
er

En Crane
Me vir
tho Ineffective on
training me
d nt
 ROOT CAUSE ANALYSIS
Lack of materials
& condition  for Not checking Dirty
cleaning before materials
s
an rial hi ne Ineffective
procedure
ate

traffi ective
M ac

g
Insufficient

nin
M Supplier M cleaning
clea less

quality
Ine
g

nt
nin

tam ve

ine
ma irty
ina
Not following
e

con dditi
Car

ch
diti e
on

D
g
Ineffective procedure

contorag
No procedure

sin
ces l
pro initia
training

A
for checking No
per ong
checking

S
re
Not
tem ng wr
atu

ina al
cleaning Process Lack

nt
tam teri
contamination maintenance No 
No
Setti

rus r
con ma
procedure

ext filte
io n
procedure Powder Trouble

Raw

No
Storage... contaminant damage
Put wrong Pipeline Lack of
materials dirty parts
No checking
before input
Black
Wrong
Spot
method
Inp Wro No checking Insufficient
ut, ng cleaning
No met

before input
Solutions:​
out

arr
Me gem
p
ut
Ch hod

an
ssy ent
• BuildIneffective
ec

Dirty
proper maintenance plan for each system.​
kin

No
No met

method Environment
g

layout
•
cle hod

for training
Optimize operation procedure (startup-shutdown, drain, flush, passivate, etc.)
an

No No cleaning
pro Sho

Sto ckag
ing

f train rte rules

fro ession to protect equipment

pa
ing n from corrosion, damage.​

rag ing
m 3 al No 5S
Im cedu

tim
Pr

e&
rd
r
par aini e
pr

• Use filter for
o

ty ng
removing foreign materials.​
op res

Forklift
er

• Use technology to manage machine's En condition.​ Crane

Me vir
tho Ineffective on
training me
d nt
 ROOT CAUSE ANALYSIS
Lack of materials
 Solution & condition  for
cleaning
Not checking
before
Dirty
materials
s
• anNeeds to check with method rialbefore processing. i ne Ineffective

ate ch procedure

traffi ective
M a

g
Insufficient
• Inspect the inputs of processing
nin
M Supplier M cleaning
clea less

quality
Ine
g

nt
nin

tam ve

ine
ma irty
• Review proceduresNoto

ina
Not following
e

be suitable with processing conditions.

con dditi
Car

ch
diti e
on

D
g
Ineffective procedure

contorag
procedure

sin
ces l
pro initia
training

A
for checking No
• Provide cleaning, checking procedure (if it’s not available)
per ong
checking

S
re
Not
tem ng wr
atu

ina al
• cleaning
Reject extraneous components Process
in the process
Lack

nt
tam teri
contamination maintenance No 
No
Setti

rus r
con ma
procedure

ext filte
io n
procedure
• Recommend training from the Powder
department, qualified 3rd Trouble
party

Raw

No
Storage... contaminant damage
Put wrong Pipeline
materials dirty Lack of
No checking
before input
parts
Black
Wrong
Spot
method
Inp Wro No checking Insufficient
ut, ng cleaning
Ine

out before input

arr
Me gem
p
ffe met

ut

an
cti ho

ssy ent
Dirty
ve d

No
Ine

Ineffective method Environment

Ch

layout
ffe met

for training
ec
cti ho

No No cleaning
kin

pro
ve d

trai Shorte

Sto ckag
rules
g

f
fro ession

pa
nin n
cle

rag ing
m 3 rd al g ti No 5S
Im cedu

an

me
Pr

e&
r
par aini
pr
o

ing

ty ng
op res

Forklift
er

En Crane
Me vir
tho Ineffective on
training me
d nt
 ROOT CAUSE ANALYSIS
Lack of materials
& condition  for Not checking Dirty
cleaning before materials
 nSolution i als i ne Ineffective
a r
te ventilation system ch procedure

traffi ective
•M Periodic maintenance ofMathe a

g
Insufficient

nin
Supplier M cleaning
clea less

quality
Ine
g

• Recommended optimal cleaning methods

nt
nin

tam ve

ine
ma irty
ina
Not following
e

con dditi
Car

ch
diti e
on

D
g
Ineffective procedure

contorag
No procedure

sin
ces l
pro initia
• 5S application into forsystem
training

A
checking processing production No
per ong
checking

S
re
Not
• Set
tem ng wr
atu

up the dust filter system

ina al
cleaning Process Lack

nt
tam teri
contamination maintenance No 
No
Setti

rus r
con ma
• Installation of automatic cargo transportation procedure

ext filte
io n
procedure Powder system Trouble

Raw

No
Storage... contaminant damage
Put wrong Pipeline
materials dirty Lack of
No checking
before input
parts
Black
Wrong
Spot
t
method c ieng
Inp Wro uffi in
ut, ng No checking Badation Insclean
Ine

out before input til

ven

arr
Me gem
p
ffe met

ut

an
cti ho

ssy ent
Dirty
ve d

No
Ine

Ineffective method Environment

Ch

layout
ffe met

for training
ec
cti ho

No No cleaning
kin

pro
ve d

trai Shorte

Sto ckag
rules
g

f
fro ession

pa
nin n
cle

rag ing
m 3 rd al g ti No 5S
Im cedu

an

me
Pr

e&
r
par aini
pr
o

ing

ty ng
op res

Forklift
er

En Crane
Me vir
tho Ineffective on
training me
d nt
ANALYSIS OF DEFECT FACTORS
Percentage of factors that cause black spot
Main causes for each main factor

Carelessness Manpower Improper Method

Environment in inspecting procedure
15% Raw material
28%

Man Power
20%

Method
Machine 19%
18%

Material Machine Environment

Ventilation
Contamination Dirty
system

Aust. J. Basic & Appl. Sci., 3(4): 3825-3835, 2009 Main causes for each main factor
COUNTERMEASURES
Main Detail Root Cause Countermeasure
Factor
o Set & update the specification standard for each
• Contamination materials. material
Material • Material uncheck. o Carefully check the COA as well as real quality of
• Supplier quality material before input to storage
o Evaluation & selection supplier regularly

• No procedure. o Establish & review procedures by all functional

Method • Improper procedure (different with actual) Departments
• Ineffective training.

• Operator not following procedure (no o Training operators of operation standard & inspection
Man checking or cleaning)
standard & their awareness in inspection
• Training not effective.

o Proper cleaning of machines periodically

• Equipment Cleanliness o Install the filtration system to remove contaminants.
Machine

• Equipment Degradation o Make the checklist & plan of maintenance periodically

o Set up the factory layout clearly

• Dirty o 5S the production environment regularly
Environment • Messy
o Setup & monitor the ventilation system to filter the
• Bad ventilation dusty environment
ANALYSIS METHODS
To find the root cause of where the contaminants come from?

1. Magnet to check whether iron is present.

– If Fe is present  highly likely that it is caused by debris in equipment or pipeline.
–  More cleaning is needed.

2. Microscope to measure the size of the contaminants.

3. X-ray method to analyze qualitatively what contaminants are present in the pellet.
4. FT-IR method to analyze functional groups.

• Other methods (XRD, XPS, SEM, etc.)

 THANK YOU
FOR YOUR ATTENTION