NG BB 46 Mistake Proofing


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NG BB 46 Mistake Proofing

  1. 1. UNCLASSIFIED / FOUO National Guard Black Belt Training Module 46 Mistake Proofing (Poka Yoke) UNCLASSIFIED / FOUO
  2. 2. UNCLASSIFIED / FOUOCPI Roadmap – Improve 8-STEP PROCESS 6. See 1.Validate 2. Identify 3. Set 4. Determine 5. Develop 7. Confirm 8. Standardize Counter- the Performance Improvement Root Counter- Results Successful Measures Problem Gaps Targets Cause Measures & Process Processes Through Define Measure Analyze Improve Control TOOLS ACTIVITIES •Brainstorming • Develop Potential Solutions •Replenishment Pull/Kanban • Develop Evaluation Criteria •Stocking Strategy • Select Best Solutions •Process Flow Improvement • Develop Future State Process Map(s) •Process Balancing • Develop Pilot Plan •Standard Work • Pilot Solution •Quick Change Over • Develop Full Scale Action/ •Design of Experiments (DOE) Implementation Plan •Solution Selection Matrix • Complete Improve Gate •‘To-Be’ Process Mapping •Poka-Yoke •6S Visual Mgt •RIE Note: Activities and tools vary by project. Lists provided here are not necessarily all-inclusive. UNCLASSIFIED / FOUO 2
  3. 3. UNCLASSIFIED / FOUO Learning Objective  Use Lean techniques to improve the process  Understand and apply Mistake Proofing tools and techniques UNCLASSIFIED / FOUO 3
  4. 4. UNCLASSIFIED / FOUOClass Exercise - Inspection Purpose: To illustrate that inspection is not only Non-Value Added but also an ineffective means to achieve quality. Exercise: You have 60 seconds to count the letter “S” in the paragraph below. Document your answer below. Six Sigma Black Belts are assigned to Six Sigma projects. These projects are solved by identifying, measuring, analyzing, improving, and finally controlling the measure of interest. Six Sigma Champions help stomp out barriers to ensure success. Ad hoc teams lend their process and product skills. As the defect levels fall, so does the associated cost of poor quality. Six Sigma projects deliver measurable business results. The Black Belt resource ensures the program’s success. Answer: _________ UNCLASSIFIED / FOUO 4
  5. 5. UNCLASSIFIED / FOUO Mistake Proofing  A poka-yoke device is any mechanism that either prevents a mistake from being made or makes the mistake obvious at a glance  Simple example – applying brake to shift transmission from “park” UNCLASSIFIED / FOUO 5
  6. 6. UNCLASSIFIED / FOUO Old Process Assumptions “Defects are inevitable, but can be caught before leaving the organization or area (check points, multitude of inspectors, sampling tables, SPC)” “A disciplined, well-trained and highly motivated employee will not make mistakes” UNCLASSIFIED / FOUO 6
  7. 7. UNCLASSIFIED / FOUO Quality Goal - 99.9% Is this Good Enough? UNCLASSIFIED / FOUO 7
  8. 8. UNCLASSIFIED / FOUO Quality Goal - 99.9%  If the product were your heart, you would spend almost 9 hours a year in cardiac arrest  There would be 2 unsafe landings at Chicago a day  One hour of unsafe drinking water every 8 weeks  200,000 wrong prescriptions each year  15,000 newborn babies dropped each year  Nine missspelled words on evry page of every magazzine UNCLASSIFIED / FOUO 8
  9. 9. UNCLASSIFIED / FOUONew Assumption It is impossible to eliminate all errors from any task performed by humans. Indeed, inadvertent errors are both possible and inevitable Errors will not turn into defects if feedback and action takes place at the Error Stage UNCLASSIFIED / FOUO 9
  10. 10. UNCLASSIFIED / FOUO Poka Yoke: What Is It?  Poka (inadvertent errors) Yokeru (avoid)  Methods for preventing mistakes becoming defects  “Quality at Source” Can you think of an example of Poka Yoke? UNCLASSIFIED / FOUO 10
  11. 11. UNCLASSIFIED / FOUO Mistake-Proofing: Conserve Electricity Door key-card must be inserted in holder to activate electricity in room UNCLASSIFIED / FOUO 11
  12. 12. UNCLASSIFIED / FOUO Mistake-Proofing the Ketchup lid? Forget to shake the Ketchup? H.J. Heinz did their best to keep the watery liquid part of ketchup from soaking your bun. Their redesigned bottle lid had a little reservoir around the spout to catch the liquid. UNCLASSIFIED / FOUO 12
  13. 13. UNCLASSIFIED / FOUO Carry-on Luggage Mistake-Proofing Self-check to determine if the bag is going to fit UNCLASSIFIED / FOUO 13
  14. 14. UNCLASSIFIED / FOUO Mistake-Proofing the ATM?  New generation ATMs perform transactions without the card leaving your hand.  Chances of leaving your card in the machine remote or impossible UNCLASSIFIED / FOUO 14
  15. 15. UNCLASSIFIED / FOUO Uses of Mistake-Proofing  Enforce procedures or sequences  Signal or stop a process if a defect is created  Eliminate choices leading to incorrect actions  Prevent product or process damage  Prevent equipment damage  Prevent personal injury UNCLASSIFIED / FOUO 15
  16. 16. UNCLASSIFIED / FOUO Steps in Mistake-Proofing  Describe the defect (or abnormality)  Identify the location at which defect occurs  Detail current standard procedures  Identify mistakes or deviations from standards  Identify conditions that provoke mistakes  Identify root cause of defect condition  Mistake proofing is significantly easier if true root cause is known  Identify type of Mistake-Proofing device required  Create the device, test and standardize UNCLASSIFIED / FOUO 16
  17. 17. UNCLASSIFIED / FOUO Why Use Mistake-Proofing?  Why use mistake-proofing?  It works where other techniques don’t  There is lots of evidence of its effectiveness  The Poka Yoke devices tend to be inexpensive and very effective  Why is it important to CPI?  Defects are caused by errors in processes  Defects are waste and cause wasteful activities to deal with them  In a CPI operation, a defect disrupts the balance of work and the flow.  Immediate corrective action is taken to resolve the situation but, it is better to avoid this type of downtime by finding and eliminating the root cause. UNCLASSIFIED / FOUO 17
  18. 18. UNCLASSIFIED / FOUO To Err Is Human Have you ever done the following?  Driven to work and not remembered it?  Driven from work to home when you meant to stop at a store? It happens to workers too.  Workers finish the day and don’t remember what they have done  After building “green widgets” all morning, the workers put “green parts” on the “red widgets” in the afternoon UNCLASSIFIED / FOUO 18
  19. 19. UNCLASSIFIED / FOUOSources of Defects 10 Types of Human Error 10 Sources of Defects 1. Forgetfulness 1. Omitted process step 2. Misunderstanding 2. Processing errors 3. Misidentification 3. Errors in set up of parts 4. Lack of experience 4. Missing parts 5. Ignoring rules 5. Wrong parts 6. Inadvertent errors 6. Processed wrong part 7. Slowness 7. Mis-operation 8. Lack of standards 8. Adjustment error 9. Surprises 9. Errors in set up of equipment 10. Intentional errors 10. Design or preparation errors in tools, jigs and fixtures UNCLASSIFIED / FOUO 19
  20. 20. UNCLASSIFIED / FOUO Judgment Inspection  Involves sorting the defects out of the acceptable product, sometimes referred to as “inspecting in quality.”  The consensus in modern quality control is that “inspecting in quality” is not an effective quality management approach.  Judgment inspection does not improve process and should be used only in the short term. Inspection Description Techniques Assesses quality of production outputs or sorts out defects Judgment inspection from good product. (e.g. inspectors) Assesses process by inspecting outputs and using information Informative inspection gained to control the process (a feedback loop) (e.g. SPC). Assesses beforehand whether the conditions necessary for Source inspection high quality production to exist (e.g. Poka Yoke). UNCLASSIFIED / FOUO 20
  21. 21. UNCLASSIFIED / FOUO Source Inspection Exists at Source of Defect (Root Cause):  Checks for factors that cause errors, not the resulting defect 100% Inspection:  Uses inexpensive mistake proofing (poka-yoke) devices to inspect automatically for errors or defective operating conditions Immediate Action:  Operations are stopped instantly when a mistake is made and not resumed until it is rectified Never pass on a defect! UNCLASSIFIED / FOUO 21
  22. 22. UNCLASSIFIED / FOUO Blame the Process Not the Person  “The old way of dealing with human error was to scold people, retrain them, and tell them to be more careful … My view is that you can’t do much to change human nature, and people are going to make mistakes. If you can’t tolerate them ... you should remove the opportunities for error.”  “Training and motivation work best when the physical part of the system is well-designed. If you train people to use poorly designed systems, they’ll be OK for awhile. Eventually, they’ll go back to what they’re used to or what’s easy, instead of what’s safe.”  “You’re not going to become world class through just training, you have to improve the system so that the easy way to do a job is also the safe, right way. The potential for human error can be dramatically reduced.” Chappell, L. 1996. The Pokayoke Solution. Automotive News Insights, (August 5): 24i. LaBar, G. 1996. Can Ergonomics Cure ‘Human Error’? Occupational Hazards 58(4): 48-51. UNCLASSIFIED / FOUO 22
  23. 23. UNCLASSIFIED / FOUOSetting Functions The real question you need to ask:  How are you going to detect an error?  automatic, not dependent on human attention  fail in “detect” mode  simple & low cost if possible Setting function Description Physical Checks to insure the physical attributes of the product or (Shingo’s contact), process are correct and error-free (e.g. round hole). Sequencing Checks the precedence relationship of the process to insure (Shingo’s motion step), steps are conducted in the correct order (e.g. check list). Grouping or Counting Facilitate checking that matched sets of resources are available when needed or that the correct number of (Shingo’s fixed value methods), repetitions has occurred (e.g. egg tray). Information enhancement Determines and ensures that information required in the process is available at the correct time and place, and that it (Chase and Stewart) stands out against a noisy background. UNCLASSIFIED / FOUO 23
  24. 24. UNCLASSIFIED / FOUO Regulatory Function The real questions you need to ask:  How are you going to stop the process?  the worker needs to get the message?  By audible or visual warning  By prohibiting further processing  How are you going to eliminate the possibility of error?  The Contrapositive of Murphy’s Law  Simplicity  Symmetry UNCLASSIFIED / FOUO 24
  25. 25. UNCLASSIFIED / FOUO Regulatory Function Regulatory Description Function Warnings Signals mistake but allows process to continue. System shuts down. Gagging Some resetting action required to correct the mistake. Control Methods Action leads to no response. Non-response The process does not crash nor does it proceed. Process stops. Self-correct System proposes correction to mistake. Process seeks information about what was really Let’s talk about it intended. Process associates correct outcomes with incorrect Teach me actions. UNCLASSIFIED / FOUO 25
  26. 26. UNCLASSIFIED / FOUO Poka Yoke: Preventing Errors  “Hard” mistake-proofing: Designing processes and tasks to ensure error-free execution  Anticipating errors to make processes “fail-safe”  Allows for preventive actions to be part of process design  Initiating individual accountability to ensure quality work before handing off to another step in the process  “Soft” mistake-proofing: Creating alarm signals to catch defects as they occur and warn people  Andon: processes and tools to STOP the process when a problem or defect is encountered UNCLASSIFIED / FOUO 26
  27. 27. UNCLASSIFIED / FOUOFail Safe  Level 0 (No Control): Acceptance, Inspection  Level 1 (Mitigation): Minimize Damage Feedback should  Build into Inspection: for example be immediate!  Double signals (sound and visual)  Cross footing in financial forms  Level 2 (Detection): Feedback and Control  Build into Process  Checks etc.  Posting Sequence  Level 3 (Avoidance): – Build into Design  Wrong part or orientation, No fit  Forms design  Level 4 (Replacement): – Automation or Elimination UNCLASSIFIED / FOUO 27
  28. 28. UNCLASSIFIED / FOUO Fail Safe (Cont.)  Fail Safing means embedding a device or procedure in a process so that the process will never allow a nonconformity (error) to occur.  The idea of Fail Safing is to prevent inevitable mistakes from turning into a defect.  Fail Safing requires the ability to discriminate the good from the bad. Simple Fail Safing methods are the low cost way to parts per million error rate. Precise outcomes without precise knowledge or action? => provide clues about what to do:  Natural Mappings  Affordances  Visibility  Feedback  Constraints UNCLASSIFIED / FOUO 28
  29. 29. UNCLASSIFIED / FOUONatural Mappings Which dial turns on the burner? Stove A Stove B UNCLASSIFIED / FOUO 29
  30. 30. UNCLASSIFIED / FOUOAffordance How would you operate these doors? Push or pull? Left side or right? How do you know? A B C Visibility and feedback  Visibility means making relevant parts visible, and effectively displaying system status  Feedback means providing an immediate and obvious effect for each action taken. UNCLASSIFIED / FOUO 30
  31. 31. UNCLASSIFIED / FOUO Is Box Full or Empty? Compressed Air Before Improvement After Improvement • Some boxes were unfilled • Empty boxes blown off • Not found since box was conveyor opaque • Pinwheel indicates airstream functioning UNCLASSIFIED / FOUO 31
  32. 32. UNCLASSIFIED / FOUO Mistake-Proofing Examples Mistake-Proofing Illustrated  Redesign the process to eliminate or reduce the Fixture possibility of a particular failure Workpiece mode Chuck  A way to avoid mistakes Correct Position Wrong Position (can be loaded) (cannot be loaded)  Make the error impossible  If you cannot prevent the error, modify the process to make the error obvious (detection) UNCLASSIFIED / FOUO 32
  33. 33. UNCLASSIFIED / FOUO Everyday Mistake-Proofing Examples UNCLASSIFIED / FOUO 33
  34. 34. UNCLASSIFIED / FOUO Exercise: GGA Budgeting Recap  The Generic Government Agency (GGA) represents a government agency that is focused on obligating their budgeted dollars  GGA obligates funds by processing Budget Documents (BDs)  GGA’s ability to obtain all necessary products and services is directly related to the efficiency and effectiveness with which it processes Budget Documents UNCLASSIFIED / FOUO 34
  35. 35. UNCLASSIFIED / FOUO Exercise: GGA Budget Mistake-Proofing  As a CPI Belt you have been assigned the task of Mistake Proofing the GGA Budget Document.  Brainstorm ideas on how to Mistake-Proof the document for the Generic Government Agency (IT solutions are permitted)  Put the ideas into 2 categories:  Prevention  Control/Warning  Write the ideas on flip charts and be prepared to present back to the group 20 Minutes UNCLASSIFIED / FOUO 35
  36. 36. UNCLASSIFIED / FOUO Takeaways Source Inspection + Mistake-Proofing = Zero Defects UNCLASSIFIED / FOUO 36
  37. 37. UNCLASSIFIED / FOUO What other comments or questions do you have? UNCLASSIFIED / FOUO 37