scope:

Description of Driving Event:

A contractor reported that there had been some discrepancies with the shipment of the Robotic Work Stations (RWS). The preliminary discrepancies were lack of shock indicators, improper Electrostatic Discharge (ESD) packaging, and improper packaging of the shipment. A formal investigation was conducted to determine the root cause and corrective actions.

Root cause: The following root causes were identified by the investigation:

1. Packaging instructions for the RWS assemblies were not being followed, as noted through review of the documentation which showed the personnel handling RWS assemblies several times (to correct packaging discrepancies) prior to being accepted by customer. Specifically, the units were not disassembled into components and the cables were not properly coiled and secured. Adequate packaging interface data, information, and description of hardware was not provided in the packaging instructions. Packaging engineering was not informed of names of authorized personnel for coordinating the activities related to packaging engineering, plus the instructions from the vendor were not provided to the packaging engineer.

2. No formal process was established for the organization having custody of the hardware/ software to maintain the Acceptance Data Packages (ADP) for the contractor-furnished equipment (CFE) and government-furnished equipment (GFE) in its possession, although the data required to maintain the ADP was generated in this case.

3. The packaging instructions were subject to interpretation by the user. For example a contractor's receiving inspection documented that temperature monitoring equipment and shock recording equipment were not present upon opening the container. Per the contractor's packaging procedure, these items are not required in the shipping containers but were assumed by the contractor to be required since they are required per NHB 6000.1D for mission critical equipment.