Mistake Proofing Techniques

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
SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008
SSG06101ENUK - MP/Issue 1.1/ September 2008 1 ©The British Standards Institution 2008
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
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
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
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
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.
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.
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
10
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
11
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
12
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
13
Electrical (General)
• Shapes and colours extensively used to prevent equipment
being incorrectly connected
14
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
15
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
16
Using Shapes and Colours
17
Software Warnings and

Reminders
18
Using Dialogue Boxes and

Software Checks
19
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
20
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
21
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?
22
Using Lights, Sounds, Signs

and Barriers
23
Amsterdam Airport: Problem-Airport

Cleanliness
Target Practice?!
Error Proofing and FMEA –

Complimentary Techniques?
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
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
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
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?
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
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
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
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?
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
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
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
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
37
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
38
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
39
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.
40
Poka Yoke Workshop 1

Process: Tightening nuts Prevent Error/Detect Error
(Delete as appropriate)
Problem: Washers left out before tightening Shutdown/Control/Warn
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
41

Pprocess: Parts Transport Line Prevent Error/Detect Error
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
42

Process: Inspecting Cassette Tape Decks Prevent Error/Detect Error
Problem: Inspection Tapes out of Sequence shutdown/control/warn
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
43

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…!!!
44
45
46

• 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……..?
47
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)
Solutions
49

Process: Tightening Nuts Prevent Error/Detect Error
Problem: Washers left out before tightening Shutdown/Control/Warn
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
50

Process: Parts transport line Prevent Error/Detect Error
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
51

Process: Inspecting Cassette Tape Decks Prevent Error/Detect Error
Problem: Inspection tapes out of sequence Shutdown/Control/Warn
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
52

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…!!!
53
54
55

• 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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Lean Six Sigma Operational - Delegate Workbook

Mistake Proofing Techniques

SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008

History of Error Proofing

SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008

SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008

SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008

Functions of Poka Yoke

Predict Defect Control Process

SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008

ABC Fix Explanation Scenario

SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008

ABC Fix Explanation Scenario

Dilemma: Vehicles are alerted and have

Dilemma: None. Problem solved.

SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008

Original Box Cutter Spring loaded--

Guard protecting blade

Extra safety guards

SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008

SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008

Source BBC News

SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008

SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008

SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008

SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008

Low Brake Pad Warning

SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008

Using Shapes and Colours

SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008

Software Warnings and

SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008

Using Dialogue Boxes and

SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008

Using Switches and Automatic

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

SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008

2 Altimeter calibration (+50 Metres)

4 Hydraulic pressure (Min 30 bar Max 40

6 Backup generator functional

SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008

Visual Prevention Methods

SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008

Using Lights, Sounds, Signs

SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008

Amsterdam Airport: Problem-Airport

SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008

Error Proofing and FMEA –

SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008

FMEA Inputs and Outputs

SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008

SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008

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

How How How

What is wrong the 0 0 How are 0 0

SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008

Definition of Terms - Failure Mode

SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008

Definition of Terms - Effect

SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008

Definition of Terms - Cause

SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008

Definition of Terms - Current

• Which is more important to process: