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Lean Six Sigma Operational - Delegate Workbook

Mistake Proofing Techniques

Learning Objectives
At the end of this section delegates will be able to:
• Explain the role of Mistake Proofing within Lean Six Sigma
• Recognise that defects can be eliminated (100% of the
time)
• Understand that Mistake Proofing should be focused on
process steps that rely on operator vigilance and
concentration
• Recognise that simple, low cost devices can be the most
effective solutions
• Use a simple process for implementing a Mistake Proofing
system

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History of Error Proofing


• Dr Shigeo Shingo attributed with developing the methods
• Originally called Idiot Proofing but recognised that this label
could offend workers so changed to Mistake Proofing (Poka
Yoke in Japanese)
• Literally translated
• Yokeru: to avoid
• Poka: inadvertent errors
• Target of Zero Defects and elimination of QC Inspection

SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008

Human Error
• Humans make mistakes (errors) because of……
- Forgetfulness - Misunderstanding
- Lack of experience/skills - Lack of concentration
- Laziness - Lack of standards
- Rushing - Taking short cuts
- Malicious intent (deliberate action)
• Errors (can) lead to defects
• Defects are not inevitable and can be eliminated by the use
of simple, low cost methods – zero defects
• Mistake Proofing should take over repetitive tasks that
depend on vigilance or memory

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Types of Error
Four main types of error:
Processing
1. Omitted Processing - Step in process not carried out
Eg form not checked, discount not included, invoice not sent, hole not drilled,
part not cleaned
2. Processing Errors - step in process carried out incorrectly
Eg wrong discount included, invoice sent to wrong address, hole drilled in wrong
place
Materials
3. Missing materials/information
Eg form not filled out completely, order not complete, screw left out
4. Wrong materials/information
Eg wrong form filled out, wrong information supplied, wrong screw used

SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008

Functions of Poka Yoke


Shutdown Process

Predict Defect Control Process


(about to occur)

Warn Operator
Eliminate
Defects
Shutdown Process

Detect Defect
Control Flow
(occurred)

Warn Operator

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ABC Fix Explanation Scenario

The Problem:
Automobiles are crossing the
train tracks and getting hit by
a train.
The “ C” Fix:
Place flashing cross signs at
the crossing to alert vehicles.
Dilemma: Vehicles are alerted
of oncoming trains but can still
cross. Problem not solved.

SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008

ABC Fix Explanation Scenario


The “ B” Fix:
Place cross gates at crossing to further
deter crossing of vehicles.

Dilemma: Vehicles are alerted and have


limited crossing ability; however does
not prevent those who arbitrarily want to
cross. Problem deterred but not solved.
The “A” Fix:
Build overpass for vehicles to cross
train tracks without incident.

Dilemma: None. Problem solved.

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Safety Example
Rounded point

Original Box Cutter Spring loaded--


when operator
Sharp point lets go, the blade
goes back in
Blade can stay out
without operator
touching it

Guard protecting blade


only releases when
button is pushed

Extra safety guards


make it difficult to
accidentally contact blade

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Elevators
• Some common safety features are listed below:
 Doors sensors detect if an object/person is blocking
entrance, if so they automatically open
 2 separate braking systems used. The first is opened by
electrical current, if power is lost the brake closes under
high spring tension. The second is a centrifugal brake
governing the maximum speed
 A host of switches and sensors control the positioning of
the elevator
 Acceleration/deceleration alters with weight in carriage

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Medicine (Bottles)
• Up to one in five toddlers can
open medicine bottles and
chemical containers, even if they
have child-resistant tops
• Every year 25,000 under-fives are
taken to casualty, suspected of
swallowing substances ranging
from medicines to household
cleaning products
• One in five are admitted to
hospital for treatment
• Child-resistant tops are now
commonplace on most medicine
bottles and household chemicals -
but they are child-resistant, not
child-proof

Source BBC News

SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008

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Electrical (Household)
• RCD (Residual Current Device)
 Automatically cuts off power supply if a leakage current to ground is
detected
• Mains Socket
 Earth pin first to make and last to break contact
 Earth pin has to enter socket to move protective shields from Live and
NEUTRAL connections
 Shape prevents incorrect fitment
• 3 Pin Plug
 Only fits one way round
 Ergonomically designed so it is picked up by the case
 Insulation on Live and Neutral to prevent accidental touching of pins
 If wired correctly and plug pulled out by cable, Live first to pull out,
Neutral second, Earth last
 Fuse standard for plug no other fuses will fit. Maximum fuse size 13 amp
 If cover is not in place pins push back and cannot enter socket

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Electrical (General)
• Shapes and colours extensively used to prevent equipment
being incorrectly connected

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Appliances
• Microwave
 Will not work until the door is shut

• Washing machine
 Will not start until door is closed
 Will not allow door to be opened until cycle is
complete

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Low Brake Pad Warning


Indicators
• Brake pad wear indicators are fitted to
most modern cars. They are made up
of 2 insulated wires which fit in a hole
inside the brake pad
• As brake pads wear the insulated
cables become exposed and the
metal brake disk connects them like a
switch
• An electrical signal then lights up a
warning lamp on the cars dashboard
alerting the driver before the brakes
fail

SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008

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Using Shapes and Colours

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Software Warnings and


Reminders

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Using Dialogue Boxes and


Software Checks

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Using Switches and Automatic


Braking
• Safety switches need to be pressed and held before the start
levers will operate.
• Upon release of start lever, brakes automatically come on stopping
the cutting blades etc

• Safety interlocks or light beams used to automatically shut down or


stop processes

SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008

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Using Checklists

Pre-flight Checklist
1 Fuel level (min 1500 Max 2500)

2 Altimeter calibration (+50 Metres)

3 Ailerons functional

4 Hydraulic pressure (Min 30 bar Max 40


bar)
5 Generator voltage (Min 220v Max 250V)

6 Backup generator functional

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Visual Prevention Methods


• Some solutions are better Ladies Gents
than others
• Which signs would be the
most successful in
preventing different
nationalities entering the
incorrect toilet?

SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008

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Using Lights, Sounds, Signs


and Barriers

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Amsterdam Airport: Problem-Airport


Cleanliness

Target Practice?!

SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008

Error Proofing and FMEA –


Complimentary Techniques?

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History of FMEA
• First used in the 1960’s in the aerospace industry
during the Apollo missions
• In 1974, the US Navy developed MIL-STD-1629
regarding the use of FMEA
• In the late 1970’s, driven by product liability costs,
FMEA moved into U.S automotive applications

SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008

FMEA Inputs and Outputs


• Inputs
 Process map
 Process history
 Process technical procedures

• Outputs
 List of actions to prevent causes or to detect failure
modes
 History of actions taken

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FMEA Team
• Team approach is necessary
• Responsible black/green belt leads the team
• Recommended representatives:
 Operators/administrators/supervisors
 Design
 Engineering
 Operations
 Distribution
 Finance
 Information Technology
 Human Resources

SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008

Completing an FMEA

(1-10) (1-10) (1-10)

S O D R
Process Actions
Potential Failure Mode Potential Failure Effects E Potential Causes C Current Controls E P
Step/Input Recommended
V C T N

How How How


bad?
0 often?
0 well?
0 0
What
can go What is 0 0 0 0

What is wrong the 0 0 How are 0 0


the with effect What are these found What
input ? the on the 0
the causes? 0
or
0 0
can be
input? output? 0 0 prevented? 0 0 done?

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Definition of Terms - Failure Mode


• Definition
 The way a specific process input fails
 Will cause the effect to occur if not corrected or
removed
• Examples
 Temperature too high
 Incorrect PO number
 Surface contamination
 Dropped call (customer service)
 Paint too thin

SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008

Definition of Terms - Effect


• Definition
 Impact on customer requirements
 Generally an external customer focus, but can also include
downstream processes
• Examples
 Temperature too high: paint cracks
 Incorrect PO number: accounts receivable traceability errors
 Surface contamination: poor adhesion
 Dropped call: customer dissatisfaction
 Paint too thin: poor coverage

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Definition of Terms - Cause


• Definition
 Sources of process variation that cause the failure mode to
occur
 Identification of causes starts with failure modes associated
with the highest severity ratings
• Examples
 Temperature too high: thermocouple out of calibration
 Incorrect PO number: typographical error
 Surface contamination: overhead hoist systems
 Dropped call: insufficient number of CS representatives
 Paint too thin: high solvent content

SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008

Definition of Terms - Current


Controls
• Definition
 Systematised methods / devices in place to prevent or
detect failure modes or causes (before causing effects)
 Prevention consists of failsafing, automated control and
setup verifications
 Controls consist of audits, checklists, inspection,
laboratory testing, training, SOP’s, preventive
maintenance, etc

• Which is more important to process:


improvement, prevention or detection?

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Definition of Terms - Risk Priority


Number (RPN)
• Definition
 The output of an FMEA
 A calculated number based on information you provide, regarding:
• Potential failure modes,
• Effects, and
• Current ability of the process to detect the failures before reaching the
customer

 Calculated as the product of three quantitative ratings, each one


related to the effects, causes, and controls:

RPN = Severity X Occurrence X Detection


Effects
Effects Causes
Causes Controls
Controls

SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008

Risk Priority Number


• Risk Priority Number is not absolute
• Scaling for severity, occurrence and detection can
be locally developed
• Be aware of customer requirements
• Other categories can be added
 For example, one engineer added an impact score to
the RPN calculation to estimate the overall impact of the
failure mode on the process

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Definition of Terms
• Severity (of Effect) (1 = Not Severe, 10 = Very Severe)
 Importance of effect on customer requirements
 Could also be concerned with safety and other risks if failure occurs
• Occurrence (of Cause) (1 = Not Likely, 10 = Very Likely)
 Frequency with which a given cause occurs and creates failure
mode(s)
 Can sometimes refer to the frequency of a failure mode
• Detection (Capability of Current Controls) (1 = Likely to Detect,
10 = Not Likely at all to Detect)
 Ability of current control scheme to detect or prevent:
• The causes before creating failure mode
• The failure modes before causing effect

SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008

Example Rating Scale


Rating Severity of Effect Likelihood of Occurrence Ability to Detect

10 Hazardous without warning Cannot detect


Very high:
Failure is almost inevitable
9 Hazardous with warning Very remote chance of detection

8 Loss of primary function Remote chance of detection


High:
Reduced primary function Repeated failures
7 Very low chance of detection
performance

6 Loss of secondary function Low chance of detection


Moderate:
Reduced secondary function Occasional failures
5 Moderate chance of detection
performance
Minor defect noticed by most Moderately high chance of
4
customers detection
Minor defect noticed by some
3 High chance of detection
customers Low:
Minor defect noticed by Relatively few failures
2 Very high chance of detection
discriminating customers

1 No effect Remote: Failure is unlikely Almost certain detection

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A Well-Loved Process FMEA


Failure Modes -
Process Key Process Wha t ca n go Current
Step Input wrong? Effects Causes Controls
Pour into Waste d Bee r/
Be e r volume Ove rflow Drunk None
gla ss We t La p

Glass too sma ll Visua l

Not pa ying
None
a tte ntion
Ba d Ta ste /
Too much foa m Don't ge t as No tilt Visua l
drunk
Visua l and ope rator
Pouring too high
tra ining
Visua l and ope rator
Pouring too fa st
tra ining
No be e r
No Foa m mustache / Poor Fla t be e r Ex pira tion da te
ta ste

Tilte d glass Visua l

Slow Pour Opera tor tra ining

Empty gla ss No drink Too drunk None

Broke n Glass Visua l

Job / Proce ss
No Money Ex ce lle nce - big
bonus

No Frie nds Pe rsona lity

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FMEA Hints

• Keep it simple; not complex (no wall charts)


• Must involve a team, no “lone ranger”
development
• Update it as you move through the roadmap
• Make sure the FMEA is an action tool, not just a
document; use the right half of the tool

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POKA YOKE Connection to the FMEA

S O D R
Process Actions
Potential Failure Mode Potential Failure Effects E Potential Causes C Current Controls E P
Step/Input Recommended
V C T N

cusotmer?

or FM occur?

How well can you


How Severe is the
effect to the

detect cause or FM?


How often does cause
What is the In what ways does the Key What is the impact on the Key What causes the Key Input to What are the existing controls and What are the actions
process step/ Input go wrong? Output Variables (Customer go wrong? procedures (inspection and test) for reducing the
Input under Requirements) or internal that prevent eith the cause or the occurrance of the
investigation? requirements? Failure Mode? Should include an Cause, or improving
SOP number. detection? Should
have actions only on
high RPN's or easy
fixes.

Good POKA YOKE devices drive down


occurrence and detection rankings.

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Poka Yoke Workshop 1


Process: Tightening nuts Prevent Error/Detect Error
(Delete as appropriate)
Problem: Washers left out before tightening Shutdown/Control/Warn
(Delete as appropriate)

Solution:
Description of process: Operator adds washer and nut, then tightens using
an automatic nut driver.

Before improvement: It is possible After Improvement:


to tighten the nuts even if washers
are missing.
Nut driver

Nut, tightened with


no washer

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Poka Yoke Workshop 2


Pprocess: Parts Transport Line Prevent Error/Detect Error
(Delete as appropriate)
Problem: Parts supplied upside down to
Shutdown/Control/Warn
automatic machinery (Delete as appropriate)

Solution:
Description of Process: A transportation chute feeds parts from a press into the next
process. in the next process parts are mounted in the same position as they arrive.

Before Improvement: Operators watch After Improvement:


incoming work pieces carefully and remove
upside down parts. some are always
overlooked.

Upside Down
Correct Work piece

SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008

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Poka Yoke Workshop 3


Process: Inspecting Cassette Tape Decks Prevent Error/Detect Error
(Delete as appropriate)
Problem: Inspection Tapes out of Sequence shutdown/control/warn
(Delete as appropriate)

Solution:
Description of Process: When a cassette deck is inspected, the inspector uses a series of cassettes
to check the performance of the unit. It is important that the tests are performed in the correct order and
that all tests are done.

Before Improvement: A slotted rack was After Improvement:


used to store tapes. If a tape was placed on
workbench or carried off then inspector could
lose track and make errors.

7
1 2 3 4 5 6

Storage Rack

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Poka Yoke Workshop 4


The inspectors found
medical notes were
confusing – written up
with the same “RR”
initials for women
needing a “routine recall”
and those needing a
“recall recall”, an urgent
reassessment…!!!

SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008

44

Poka Yoke Workshop 5

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Poka Yoke Workshop 6

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Poka Yoke Workshop 7


• City Trader buys $1000000000 worth of shares
instead of $10,000,000.00!
• Accounts pays supplier twice
• Failure to invoice customer for services provided
• Miscalculation in currency exchange
• Your experiences……..?

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Poka Yoke Summary


• Defects can be eliminated
• Target process steps that are repetitive and rely
on operator vigilance and checking
• Use simple, low cost devices
• Involve the operator in identifying, developing and
implementing devices
• Devices should be challenge tested by
introducing error (defect)

SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008

Solutions

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Poka Yoke Workshop 1


Process: Tightening Nuts Prevent Error/Detect Error
(Delete as appropriate)
Problem: Washers left out before tightening Shutdown/Control/Warn
(Delete as appropriate)

Solution:
Description of Process: Operator adds washer and nut, then tightens
using an automatic nut driver.

Before Improvement: It is possible After Improvement:


to tighten the nuts even if washers
are missing.
Nut driver Stopper Nut driver

Nut, tightened with Washer


no washer thickness

SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008

50

Poka Yoke Workshop 2


Process: Parts transport line Prevent Error/Detect Error
(Delete as appropriate)
Problem: Parts supplied upside down to
Shutdown/Control/Warn
automatic machinery (Delete as appropriate)

Solution:
Description of Process: A transportation chute feeds parts from a press into the next
process. In the next process parts are mounted in the same position as they arrive.

Before improvement: Operators watch After Improvement:


incoming work pieces carefully and remove
upside down parts. Some are always
overlooked.
Notch

Upside down
Correct Work piece

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Poka Yoke Workshop 3


Process: Inspecting Cassette Tape Decks Prevent Error/Detect Error
(Delete as appropriate)
Problem: Inspection tapes out of sequence Shutdown/Control/Warn
(Delete as appropriate)

Solution:
Description of Process: When a cassette deck is inspected, the inspector uses a series of cassettes
to check the performance of the unit. It is important that the tests are performed in the correct order and
that all tests are done.
Before Improvement: A slotted rack was After Improvement:
used to store tapes. If a tape was placed on
workbench or carried off then inspector could
lose track and make errors.

1 2 3 4 5 6 7

Storage rack

SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008

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Poka Yoke Workshop 4


The inspectors found
medical notes were
confusing – written up
with the same “RR”
initials for women
needing a “routine recall”
and those needing a
“recall recall”, an urgent
reassessment…!!!

SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008

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Poka Yoke Workshop 5

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Poka Yoke Workshop 6

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Poka Yoke Workshop 7


• City Trader buys $1000000000 worth of shares
instead of $10,000,000.00!
• Accounts pays supplier twice
• Failure to invoice customer for services provided
• Miscalculation in currency exchange
• Your experiences……..?

SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008

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