Line 3 capper jam — double cap
Production · June 21, 2026 · Lead: Jamie R.
Problem
After a capper tool changeover, Line 3 ran ~7 minutes with the cap chute guard un fitted, producing double caps on ~40 units before the checkweigher caught the defect.
Fishbone
● verified · assumed · ◆ root cause · → handed to another team
Causal chain
Symptom
Double caps detected at checkweigher (~40 units on Line 3)
Contributing cause· verified
Capper chute guard not fitted after tool changeover
Maintenance log and shift handover confirm guard removed at 14:08, not refitted before run.
Contributing cause
Changeover checklist has no mandatory guard-fit verification step
Root cause· verified
Line 3 changeover SOP lacks guard-fit sign-off before run approval
SOP v4.2 reviewed — no guard verification gate before line release.
Contributing cause
Cap chute alignment drift after tool change (Maintenance scope)
Verified root cause
Line 3 changeover SOP lacks guard-fit sign-off before run approval
SOP v4.2 reviewed — no guard verification gate before line release.
Owned actions
Add guard-fit check to Line 3 changeover checklist with signed verification before run
Jamie R. · review by 2026-07-06 · Zero double-cap events for 30 days post-implementation
Daily pre-run guard inspection at capper station 3 (visual + tactile)
Jamie R. · review by 2026-06-29 · 100% completion on shift-start checklist for 2 weeks
Handoffs
- Training: Operators not trained on guard importance at changeover
Need refresher for all Line 3 operators — guard purpose and fit verification.