Materials Receipt Controls

Significantly, your firm failed to perform identification testing for all incoming glycerin lots to verify identity and determine whether diethylene glycol (DEG) or ethylene glycol (EG) was present. Because you did not test each lot and container of glycerin using the USP identification test that detects these hazardous impurities, you failed to ensure the acceptability of component lots used in drug product manufacture. DEG contamination in pharmaceutical products has caused lethal poisoning incidents in humans worldwide.

 FDA Warning Letter of 02-Nov-2018 to Product Packaging West, Inc.

First of all, ouch. This brings to mind an old investigation that drew a lot of attention a few years back. It involved a tanker truck and a hurricane, but still, lots of memories.

This Warning Letter brings to mind questions about receipt of materials. So here are some top level thoughts.

Choosing tests should be a risk based approach evaluating what the material is, what it is used for, supplier qualification level and history of test results. A critical raw material with custom chemistry from a supplier that has had issues is a different matter than an off-the-shelf component that hasn’t had a problem in 10 years. But there always should some basic identity testing, especially if that is listed in an pharmacopeia. This should be done through a formal process, with periodic review.

Have a process in place for delivery of material to ensure that each container or grouping of containers of material are examined visually for correct labeling (including correlation between the name used by the supplier and the in-house name/code, if these are different), container damage, broken seals, and evidence of tampering or contamination. A good in-coming receipt inspection includes:

  • Each lot within a shipment of material or components is assigned a distinctive code and an unique internal number so material or component can be traced through manufacturing and distribution
  • A check to guarantee the origin of materials from approved manufacturers and approved distributors
  • Start inspection with visual examination of each shipping container for appropriate labelling, signs of damage, or contamination
  • Use a predefined checklist for inspection

Incoming material should be quarantined prior to approval for use. I recommend a separate quarantine area for incoming versus material segregated for investigations or issues.

Supplier qualification deserves a post of it’s own.

Evolved Expendable Launch Vehicle (EELV) Quality Management

We determined that ULA, SpaceX, and AR were not performing adequate quality assurance management for the EELV program as evidenced by the 181 nonconformities to the AS9100C at the EELV contractor production facilities. This inadequate quality assurance management could increase costs, delay launch schedules, and increase the risk of mission failure.

From ”

Evaluation of the Evolved Expendable Launch Vehicle Program Quality Management System DODIG-2018-045, Department of Defense Office of Inspector General

It is useful to read audit reports and inspection findings from multiple industries. From this we can see trends, make connections and learn.

I see a few things that stand out.

DOD findings

Risk Register

Our evaluation of the RIO database showed that 11 out of 26 risks related to either Atlas V or Delta IV launch vehicle were in “red” status, which indicates that risk mitigation was behind schedule.

It is not enough to identify risks (though that is a critical place to start). You just can’t track them (though again, if you don’t track it you don’t see it). You actually have to have clear plans to mitigate and eliminate the risks. And this is where the program seemed to fall short.

Not a surprise. I think a lot of companies are having these difficulties. In the pharma world the regulatory agencies have been signaling pretty strongly that this is an issue.

Make sure you identify risks, track them, and have plans that are actually carried out to remediate.

Configuration Management

SpaceX failed to comply with AS9100C, section 7.1.3, which requires it to “establish, implement, and maintain a configuration management process.” Configuration management is a controlled process to establish the baseline configuration of a product and any changes to that product. This process should occur during the entire life cycle of a product to provide visibility and control of its physical, functional, and performance attributes.

First rule of reading inspection reports: Things probably went bad if a section starts with standard review 101 material.

That said, hello change management my dear friend.

This was the gist of my ASQ WCQI workshop last May, every industry needs good change management and change control.

Material Management

ULA and AR failed to comply with AS9100C, section 8.3, which requires them to “ensure that product which does not conform to product requirements are identified and controlled to prevent its unintended use or delivery.”

At ULA, we found 18 expired limited-life material items that were between 32 and 992 days past their expiration dates, but available for use on EELV flight hardware. This material should have been impounded and dispositioned. The use of expired limited-life items, such as glues and bonding agents, could result in product that does not meet specifications and may require costly rework.

I find it hard to believe that these companies aren’t tracking inventory. If they are tracking inventory and┬áhave any sort of cycle count process then the mechanism exists to ensure expired material is removed from the possibility of use. And yet we still see these observations across the pharma industry as well.

Concluding Thoughts

Quality Management has it its core the same principles, no matter the industry. We use similar tools. Leverage the best practices out there. Read about stresses other companies are having, learn from them and remediate at your own organization.