1. Flow of event 2. Cause & Consequence

3. Preventive action

i. To instruct inspectors to not doing manual allignment if unsure.ii. To instruct inspectors to not doing manual allignment/always run in auto if the part has jig.iii. To alter the cmm part program to include safety precautions -

- Safety distance before measurement-Automatically find holes for holes/diameter measuring- Operator comment for safety reminder.

iv. To make ready the guidelines/work instruction.v. To instruct inspectors to always start with low speed before the machine measures the first feature successfully . Prepared By : Checked By:

Manual allignment: Process to telling machine the location of the part by specifying a plane surface and two circles.

CMM2 have option to start the program by manual allignment first or just direct to auto measurement.

Inspector running the program in auto mode. Program stuck at circle

measurement.

Accident type: CollisionEquipment: CMM

Inspection part: Cylinder Head SZ OP10

Property damage: Probe 3mm/TP200

Inspector try to fix the stuck by doing the manual allignment.

Machine running in auto mode and full speed after manual allignment.

Machine inspect jig plan surface and collision occur

Collision occur while machine try to take the first point (1) to measure jig plane surface.

Obvious cause: Wrong manual allignment at plane surface

Plane should be taken atBut the inspector took at

1

23

4

Arrows shown the direction of probe movement. (Arrows are at the same vector and size)

A: Correct plane allignment. Probe move and tip just nicely at the jig surface.

B: Incorrect plane allignment: Machine has shift the position of jig surface. Movement of probe aim to new position resulting collision of probe with the jig

A

B