On August 7, 2026, the second-shift setup technician at Meridian Aerostructures left. Twelve days later, a setup on second shift ran 8 brackets with a superseded program. This is how the kit carried the situation from the failure to a covered shift, using the record numbers in the tools' own worked examples.
The failure and the retraining gate (G03)
August 19. K. Walsh, level 2 on 3-axis setup, setting up alone, loads program O5120 rev C instead of rev D. The first-piece CMM program, chosen the same way, passes the part. NCR-26-298; the same error as NCR-26-154 in April on first shift, whose corrective action (CAPA-26-026) had closed with 'operator retrained'. CAPA-26-026 reopens as an 8D.
August 20 to 24. The gate (RT-26-007). The nine questions show a level 4 setter made the same error in April; the setup sheet had no revision step; the machine folder held three revisions with near-identical names; second shift had nobody qualified to ask. Classification: method or instruction problem, with a skill gap and a staffing gap contributing. Retraining appropriate: partly, and only alongside changes to the job.
August 24 to September 11. The job changes. No setup alone below level 3 (L. Nguyen, August 24); superseded programs archived where machines cannot load them (J. Alvarez, August 28); traveler prints program revisions and the setup sheet adds a signed revision match (M. Okafor, September 4); CMM programs released against the drawing revision (September 11).
The matrix and the training plan (G01)
The new step becomes a skill. S07, setup revision check, goes on the Skills tab with a minimum of six. All seven setters on both shifts are trained by S. Haddad, September 8 to 18.
Coverage on October 31. Second shift: six people, one 3-axis setter (F. Osei), nobody who can set up Mill 7, release a first piece or stamp final inspection. Plant-wide: four skills held by one person (lathe setup, CMM programming, skin-panel countersinking, the certificate at the shipping desk); final inspection one short of its minimum.
The plan. K. Walsh to level 3 on 3-axis setup by November 30; F. Osei on first-piece release; D. Ruiz on CMM programming (management review action MRA-26-08); G. Park on certificates; N. Petrov on lathe setup (two months overdue: on the agenda); a contract inspector on second shift from November 2 (MRA-26-11) until the hire (MRA-26-03).
Authorization (G02), evaluation (G04) and awareness (G05)
October 28. Qualification QR-26-014. F. Osei qualified for first-piece release on Mills 4 and 6: five first pieces inspected alongside D. Ruiz, all 142 characteristics agreed, test 92 percent, evaluated by M. Okafor (not the trainer), vision exam October 6. Qualified with limits; stamp M-21 issued and logged. Second shift can now release its own setups.
The registers on October 31 show what else needs a decision: D. Ruiz's vision exam overdue since October 15; K. Ito's certificate authorization expired in August; E. Moreno's first-piece authority lapsed after six months unused; R. Chen's stamp due for requalification on November 4. The stamp of the setup technician who left (M-18) was recovered and logged on August 7.
October 27. Evaluation TE-26-006. The revision-check training evaluated on the job: 21 of 21 observed setups with the step signed; no mismatch reached a part in 124 setups; the step caught 4 mismatches before cutting. Effective so far; the corrective action's 90-day check continues. C. Lindqvist, hired in September, reached level 2 and is retrained (TE-26-012, not effective).
September 22. Briefing. A week after the short-thread escape at Customer A (example), F. Osei and R. Chen briefed second shift at Mill 6 with a sectioned fitting and both gauges: where the part goes, what happened, what changed, stop, tag, tell. On October 26 three people asked at their machines could answer all three questions (TE-26-007).
Management review: the resources input
At the Q3 management review on October 22, the coverage view and the authorization register were the evidence behind the resources input: four open positions including the second-shift inspector, Mill 7 overtime at 11 percent of hours, second shift carrying a third of the people and almost none of the authorizations. The outputs were the contract inspector (MRA-26-11), a weekend cell for Mill 7 (MRA-26-12) and the risk register entry for loss of second-shift setup capability (MRA-26-13).
What the example shows
The kit did not prevent the setup technician leaving. It turned his departure into a visible coverage gap, refused 'retrained' as the answer to the failure that followed, changed the job so the error could not recur on any shift, qualified a second-shift lead on evidence, showed the training worked, and gave the general manager the facts for the resource decisions.
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