Prasert, Kosit, Sutus
There is some discussion ongoing about the cleanliness of the loading tubes as a critical factor to avoid XLPE insulation issues at the CV line
I know the task force team has been working in several directions to address our problems, this note just have the purpose to make sure you have this information, and containment, correction and prevention actions are in place.
It seems that in 2006 similar issues occurred, and at that time some work was done to fix the problem. For some reason, it seems the practice was lost.
Don will be discussing with Khun Phichet and Khun Sompol about this and other practices that need to be recovered, so please follow up with him about next steps, to make sure we are fully aware of such practices and they are incorporated in the task force and process control plans you are working to put in place.
One important point to consider, is what needs to be done to make sure any correction defined in the past stays in place. This problem was solved in the past, and the solution implemented was lost. We need to understand why, and make sure the solution you implement or recreate are kept forever.
One of the most effective preventive solutions (additional to a permanent auditing process to detect issues) is to have some sort of visual control in place, meaning a very visual indicator that is seen by everyone so there is no excuse that instruction are not followed (similar to checklist in the bathroom doors). At least if the indication for control is in front of operators and supervisors, there will be no excuse for the people to say they are not informed about best practices.