In this case, an order came in which required that a machine undergo setup and the operator of that machine to modify his output for an afternoon. The supervisor made the operator aware of the situation, and the operator was left to find the set-up man (who was unavailable). Unable to find either the set-up man or the worker's supervisor (who was at a meeting), the worker took it upon himself to modify the machine as he had seen done in the past and proceed with the work. Because he thought he could improve the process, the worker modified the machine differently than the set-up man would have done, but was able to improve his output. When the parts checker checked the afternoon's work, there were not more defects than are typically acceptable.
The next morning, it was discovered that the work done after the parts checker approved the other work was highly defective, resulting in a large amount of rework. Upon examination, the set-up man determined that the problems were caused by the modifications that the worker had done to the machine: parts had come loose which were necessary for the work. At this point, the company must determine the appropriate action to take.
Several assumptions are made in the following analysis. It is assumed, for example, that the parts checker is not able to determine, by visual inspection, whether the machine was properly set up. Another assumption that is made is that special orders are, by their nature, not frequent occurrences and therefore represent a deviation from the typical workflow. It is also assumed that the company is interested in finding a resolution to the problem and prevent a similar event from happening in the future, rather than seeking to assign blame. Any disciplinary action that is taken would be done so for two primary reasons. The first reason would be to ensure that the parties involve understand the seriousness of the situation and find ways to avoid it in the fut...