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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

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Human Error
Humans make mistakes (errors) because of
- Forgetfulness - Lack of experience/skills - Laziness - Rushing - Misunderstanding - Lack of concentration - Lack of standards - 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 Wrong materials/information Eg wrong form filled out, wrong information supplied, wrong screw used

4.

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Functions of Poka Yoke


Shutdown Process Predict Defect (about to occur) Eliminate Defects Control Process Warn Operator

Shutdown Process Detect Defect (occurred) Control Flow 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.

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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
Original Box Cutter Sharp point

Rounded point
Spring loaded-when operator 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
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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

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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

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Using Checklists
Pre-flight Checklist
1 2 3 4 5 6 Fuel level (min 1500 Max 2500) Altimeter calibration (+50 Metres) Ailerons functional Hydraulic pressure (Min 30 bar Max 40 bar) Generator voltage (Min 220v Max 250V) Backup generator functional

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Visual Prevention Methods


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

Ladies

Gents

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Using Lights, Sounds, Signs and Barriers

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Amsterdam Airport: Problem-Airport Cleanliness

Target Practice?!

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Error Proofing and FMEA Complimentary Techniques?

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History of FMEA
First used in the 1960s 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 1970s, driven by product liability costs, FMEA moved into U.S automotive applications

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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

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Completing an FMEA
(1-10)
Process Step/Input Potential Failure Mode Potential Failure Effects S E V Potential Causes

(1-10)
O C C Current Controls

(1-10)
D E T R P N Actions Recommended

What is the input ?

What can go wrong with the input?

How 0 bad? What is the effect on the output?


0

How 0 often?
0

How 0 0 well?
0 0

What are the causes?

How are these found or prevented?

What can be 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

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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

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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, SOPs, 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 Causes Controls Effects Causes Controls

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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

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Example Rating Scale


Rating 10 9 8 7 6 5 4 3 2 1 Severity of Effect Hazardous without warning Hazardous with warning Loss of primary function Reduced primary function performance Loss of secondary function Reduced secondary function performance Minor defect noticed by most customers Minor defect noticed by some customers Minor defect noticed by discriminating customers No effect Low: Relatively few failures Likelihood of Occurrence Very high: Failure is almost inevitable Ability to Detect Cannot detect Very remote chance of detection Remote chance of detection Very low chance of detection Low chance of detection Moderate chance of detection Moderately high chance of detection High chance of detection Very high chance of detection Almost certain detection

High: Repeated failures

Moderate: Occasional failures

Remote: Failure is unlikely

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A Well-Loved Process FMEA


Process Step
Pour into gla ss

Key Process Input


Be e r volume

Failure Modes Wha t ca n go wrong? Ove rflow

Effects
Waste d Bee r/ We t La p

Causes
Drunk Glass too sma ll Not pa ying a tte ntion

Current Controls
None Visua l None

Too much foa m

Ba d Ta ste / Don't ge t as drunk

No tilt

Visua l Visua l and ope rator tra ining Visua l and ope rator tra ining Ex pira tion da te

Pouring too high Pouring too fa st No be e r mustache / Poor ta ste

No Foa m

Fla t be e r

Tilte d glass Slow Pour Empty gla ss No drink Too drunk Broke n Glass

Visua l Opera tor tra ining None Visua l Job / Proce ss Ex ce lle nce - big bonus Pe rsona lity

No Money

No Frie nds

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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


Process Step/Input What is the process step/ Input under investigation? Potential Failure Mode Potential Failure Effects S E V How Severe is the effect to the cusotmer? Potential Causes O C C How often does cause or FM occur? Current Controls D E T How well can you detect cause or FM? R P N Actions Recommended What are the actions for reducing the occurrance of the Cause, or improving detection? Should have actions only on high RPN's or easy fixes. 0

In what ways does the Key What is the impact on the Key Input go wrong? Output Variables (Customer Requirements) or internal requirements?

What causes the Key Input to go wrong?

What are the existing controls and procedures (inspection and test) that prevent eith the cause or the Failure Mode? Should include an SOP number.

Good POKA YOKE devices drive down occurrence and detection rankings.

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Poka Yoke Workshop 1


Process: Tightening nuts Problem: Washers left out before tightening Solution: Description of process: Operator adds washer and nut, then tightens using an automatic nut driver. Before improvement: It is possible to tighten the nuts even if washers are missing. Nut driver After Improvement: Prevent Error/Detect Error
(Delete as appropriate)

Shutdown/Control/Warn
(Delete as appropriate)

Nut, tightened with no washer

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Poka Yoke Workshop 2


Pprocess: Parts Transport Line Problem: Parts supplied upside down to automatic machinery 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.

Prevent Error/Detect Error


(Delete as appropriate)

Shutdown/Control/Warn
(Delete as appropriate)

Before Improvement: Operators watch


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

After Improvement:

Correct

Upside Down Work piece

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Poka Yoke Workshop 3


Process: Inspecting Cassette Tape Decks Problem: Inspection Tapes out of Sequence 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. After Improvement: Before Improvement: A slotted rack was 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

Prevent Error/Detect Error


(Delete as appropriate)

shutdown/control/warn
(Delete as appropriate)

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!!!

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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..?

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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)

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Solutions

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Poka Yoke Workshop 1


Process: Tightening Nuts Problem: Washers left out before tightening Solution: Description of Process: Operator adds washer and nut, then tightens using an automatic nut driver. Before Improvement: It is possible to tighten the nuts even if washers are missing. Nut driver After Improvement: Prevent Error/Detect Error
(Delete as appropriate)

Shutdown/Control/Warn
(Delete as appropriate)

Stopper

Nut driver Washer thickness

Nut, tightened with no washer

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Poka Yoke Workshop 2


Process: Parts transport line Problem: Parts supplied upside down to automatic machinery 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.

Prevent Error/Detect Error


(Delete as appropriate)

Shutdown/Control/Warn
(Delete as appropriate)

Before improvement: Operators watch


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

After Improvement:

Notch
Upside down Work piece

Correct

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Poka Yoke Workshop 3


Process: Inspecting Cassette Tape Decks Problem: Inspection tapes out of sequence 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. After Improvement: Before Improvement: A slotted rack was 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

Prevent Error/Detect Error


(Delete as appropriate)

Shutdown/Control/Warn
(Delete as appropriate)

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!!!

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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..?

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