d-2391 held 41dd-2366 held 58dd-2402 failed 6dd-2118 excludedd-2287 held 33dd-2190 escalatedd-2044 modifiedd-1998 declinedd-1955 held 27dd-1902 held 12dd-1871 failed 9d
Constraints
sop-118 torque bandauthority: supervisorexpiry 18:00works council: task signals onlytask data onlylot traceabilitymaint window 21dce markingshift handover rulerelease gate: baselinerollback available
Incident
Site · lineNORD 04 · 3
Raised14:22, shift B
Pattern4th this quarter
Heldchangeover
Shift log
14:22 torque alarmMES
14:24 “sounds different since the lot change”operator
14:26 changeover heldline lead
Joint state
Precedents · group-wide
Process
Seal-head torque3.6 Nm ↓
Days since calibration14
Supplier lotK-7742
Quality variance+2.4 σ
Actor
Comparable cases1
Evidence already seenalarm + operator note
Authority
Shift supervisorApprove within SOP
D-2391 · NORD 04, recalibrated 3.9held 41d
D-2366 · OST 07, seal set replacedheld 58d
D-2402 · NORD 04, restart onlyfailed 6d
D-2118 · different geometryexcluded
Predicted consequence · 30 days
Holdp 0.71
Downtime
Scrap
Late
Recalibrate to 4.2 Nmp 0.78
Downtime
Scrap
Late
Replace seal setp 0.66
Downtime
Scrap
Late
Proposal · frozen 14:31
InterventionRecommend + show precedent
Recalibrate seal head to 4.2 Nm before the next changeover.
WithinSOP-118 rev 6
AuthorityShift supervisor
WindowBefore 18:00
Expected to hold30 to 50 days
Decision
Accepted with a change: 4.2 Nm, and bring the next calibration forward.