Mistake Proofing

Mistake Proofing

Mistake Proofing Control Kaizen Facilitation Objectives Review top causes of errors and the importance of mistake-proofing Learn 3 functions of a mistake-proofing measure: Shutout Control Warn Recall the steps to mistake-proofing Explore examples 2

Approaches Inspection / Judgment Discovers defects after they have happened A person or piece of equipment inspects/compares product or service with a standard, discovers items dont conform and rejects them Focus on alerting defect producing process about the problem Statistical Process Control (SPC) Process Behavior Charts Self-check of each output Successive checks of each output At The Source [Focus of Mistake-Proofing Measure] Catches errors before they cause defects

Uses devices (methods) to shutout (or shut-down), control, or warn of an improper process 3 Inspection/ Judgment Method Exercise Read the sentence below and count the number of times the letter f appears. When you are asked to stop, note the number of fs you have counted. Finished files are the result of much effort of many people effectively filing the materials of many other persons. Number: ____

4 Top 10 Causes of Errors Processing omissions: leaving out one or more process steps Processing errors: process operation not performed according to the standard Error in setting up: using wrong tooling or incorrect setting/ adjustment Missing parts: not all parts are included in assembly/ process

Improper part/ item: wrong part installed in assembly 5 Top 10 Causes of Errors (continued ) Processing wrong work piece: wrong part machined/ processed Operations errors: incorrect revision or specification sheet Errors in equipment, maintenance or repair: Defects caused by incorrect repairs or component replacement Error in preparation of inspection equipment, fixtures or tools: Damaged inspection tooling; poorly designed fixtures or wrong tools; mis-measurement 6

Errors and Defects Errors Defects Errors are the actions that cause defects 7 When to Focus on Mistake-proofing

When a process step has been identified where human error can cause mistakes or defects to occur, especially in processes that rely on the workers attention, skill or experience In a service process, where the customer can make an error which affects the output At a hand-off step in a process, when output or (for service processes) the customer is transferred to another worker When a minor error early in the process causes major problems later in the process When the consequences of an error are expensive or dangerous 8 Detection or Prevention People make errors & errors can lead to mistakes However

Mistakes can be eliminated through the use of mistake proofing devices (poka-yoke) that are used to either detect or prevent defects from occurring in the first place 9 Functions Basic mistake proofing functions to use against defects: Shutout / shutdowns machine, process or operation Control a process or operation Warn that a defect has occurred (or is about to)

10 Determine Process Condition Incorrect Process Process Not Followed Following process produces defects Change process, defects go away Generally, easiest to change

Process hard to follow consistently Process problem, not people problem 11 Definition A poka-yoke or mistake proofing device eliminates defects by preventing errors. What does it mean?

poka error (foolish action); yoke to avoid Replaces earlier version baka yoke (fool proofing) a more negative connotation 12 Poka-yoke Reduces Window of Waste Potential Error No power for laptop back at the Hotel 1) Drive to Hotel 2) Check-In Hotel 3) Plug-in Computer

T ime Mistakes happening within several windows Consider several Interventions (measures) 1) Attach Car Keys on Power cord 2) Hotel Key(s) in Wallet / on Lanyard or Belt Loop 3) Extra power cord in Computer Bag (redundancy) It is good to do it right the first time: it is even better to make it impossible to do it wrong the first time. 13 Mistake-proofing Steps

Step 1: Identify and Describe the defect/ red flag condition Step 2: Determine root cause (where the defect is discovered or where it is made) Step 3: Detail the sequence of events in the standard procedure Step 4: Review the steps that differ from the standard (deviations) (identify contributing conditions or potential failure modes) Step 5: Identify the mistake-proof device type required (S,C,W) Step 6: Create device(s) and test for effectiveness (incorporate into Standard Work practices) 14 Examples Garage door sensor (Shutout)

Microwave Oven (Shutout) 15 Examples Fuel Gage w/ indication light (Warn) Automatic MPG calculation (Control)

16 Examples Tethered Gas Cap (Control) Gas Cap Eliminated 17 Examples RR Crossing (Warn)

RR Crossing Eliminated 18 Examples No skateboarding allowed (Warn) Decorative Metal tabs (Shutout) 19

Examples Uniform Signage On Terminal 20 Examples Standardized Vessel Labor Start-up / Line-up

Routine 21 Guidelines 1. Try not to spend. 2. Simpler is better. 3. Dont make them optional. 4. Dont confuse gages (process checks / verification) with mistake proofing. 5. Eliminate decision making.(Done only one way!) 22 Red Flag Conditions

1. Adjustments 1. Multiple handoffs 2. Unclear or no instructions 2.

Hand processing 3. Undefined process 3. Rapid repetition 4. Many units/mixed units

4. 5. Multiple steps High volume demand or deadline pressures 5. Environmental conditions 6.

Infrequent production 7. Ineffective or lack of standards 23 Review Use an inspection approach for preventing defects (mistake proofing at the source) by applying prevention methods at the point in the process where the defects originate Always validate 100% (process check / step verification)

Provide for immediate feed-back for corrective action when errors or defects are detected Because humans are not infallible, use mistake-proofing measures to prevent mistake causing errors or at least to warn that a defect or error has occurred Strive for Shut-out 24

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