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4) Counters
5) Checklist
(jump to conclusions)
3) Errors in identification (view incorrectly...too far away) 4) Errors made by untrained workers 5) Willful errors (ignore rules) 6) Inadvertent errors (distraction, fatigue) 7) Errors due to slowness (delay in judgment) 8) Errors due to lack of standards (written & visual) 9) Surprise errors (machine not capable, malfunctions)
6) Wrong workpiece
7) Operations errors 8) Adjustment, measurement, dimensional errors 9) Error in equipment maintenance 10) Error in preparation of setup or tool adjustments
The Connection
Misidentification Forgetfulness No standards
Human Error Cause of Defect Omitted Processing Processing errors Error in setting up the workpiece Missing parts Inclusion of wrong part / item Wrong workpiece Operations errors Adjustment, measurement, dimensional errors Error in equipment maintenance Error in preparation of setup or tool adjustments
Misunderstanding
Inadvertent errors
Slowness
Amatures
X X # X X #
# X # # X X
# # #
# X # #
# X
X X X
# X #
# X # # X # # X
# X X
X X X #
X #
X #
# X
X Strongly Connected
# Connected
Surprise
# X #
Willful
The Basics
A mistake proof system exists in two states.
Prediction - Catch a defect that is about to occur. Detection - Catch a defect that has already occurred.
Control Devices
Removing the Defect from the system
DETECTION A fruit orchard that takes great pride in its oversized apples, assures only the biggest ones get to customers by passing all apples through a sizer. Those that dont make it are sent to the discount outlet.
PREVENTION At gas stations diesel pump nozzles and the hole for the tank are larger than the ones for gasoline.
Warning Devices
A signal to attract attention to defects.
Detection Prevention
Lights turn off after a few minutes without the owner having to turn them off.
The computer barks when the wrong command is entered
Shutdown
A restricting tool to stop the process when a defect occurs.