Tri State Final

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Describes a workshop developed using TWI principles to teach mistake-proofing

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Tri State Final

  1. 1. Overcoming Mistakes for Improved Quality Performance Presented by Sam Wagner for Quality Council February 3, 2009
  2. 2. What We Plan to Learn Today  Why overcoming mistakes is critical to achieving improved quality performance  Some common mistakes  Common beliefs about mistakes  How to ensure that mistakes won’t impact quality performance from the customer’s perspective.
  3. 3. Agenda  “Great” Quality Performance  Formula to Improved Quality Performance  Role of Overcoming Mistakes  Helping ensure mistakes don’t affect the customer
  4. 4. Quality Performance Measures  Defective Parts Per Million Used  Defective Parts Per Million Shipped  % Acceptable Lots  Lines Down events  Corrective Action Requests  Scrap rate  First Pass Yield.
  5. 5. Path to Quality Excellence System Planning Quality Quality Policy System Define Key Improvement Processes Process Define Part Planning Perform Quality FMEA Requirements Perform Perform Capability Gauge R&R Execution Study Study Use SPC Conduct Audits
  6. 6. Customer Reject History 10,000 9,000 8,000 = Oops! 7,000 6,000 Rejects 5,000 4,000 3,000 2,000 1,000 0 Jan-07 Feb-07 Mar-07 Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Opportunity Hits/Million Goal Benchmark YTD PPM Nine mistakes in twelve months is good human performance
  7. 7. Human performance issues Why existing tools are not enough Motorola findings: ...it became evident early in the project that achieving a Cp greater than 2 would go only part of the way. Mistake-proofing the design would also be required ... Mistake-proofing the design is an essential factor in achieving the [total number of defects per unit] goal. Smith, B. IEEE Spectrum 30(9) 43-47 Even with high process capability, mistakes happen
  8. 8. Achieving Great Quality Performance  “Good is the enemy of Great” – Jim Collins  Mistake-proofing the design isn’t enough  Error-proofing your processes is also required  This requires everyone’s involvement
  9. 9. Zero Defect Production But why?  Customer satisfaction and loyalty – Customers no longer have an “acceptable quality level” – they expect all parts to be good  Upholds company reputation  Good business; supports job security  Eliminates additional effort and frustration due to rework, scrap, paperwork  Key to lean manufacturing.
  10. 10. Mistake-proofing: A key element in the House of Lean House of Lean Pull/Kanban JIT Cellular/Flow TPM Mistake Proofing POUS Quick Changeover Standardized Work Batch Size Reduction Layout Change Value 5S System Visual Stream Management Mapping
  11. 11. Agenda  “Great” Quality Performance  Formula to Improved Quality Performance  Role of Overcoming Mistakes  Helping ensure mistakes don’t affect the customer
  12. 12. Job Quality Formula JQ = (ZQC + TWI) x ATTITUDE 2
  13. 13. Zero Quality Control  Zero Quality Control (ZQC) is Shigeo Shingo’s term for delivering product to customers with zero defects  Shigeo Shingo is one of the developers of the Toyota Production System (Lean Manufacturing)  The Shingo Prize for Manufacturing Excellence, sometimes referred to as the Nobel Prize of Manufacturing, is named after him.
  14. 14. Four Basic Elements • Source inspection to catch errors before they become defects • 100% inspection to check all products, not just a sample • Short feedback loop that brings quick corrective action • Mistake-proofing devices on equipment carry out the checking functions
  15. 15. Training Within Industry  Training for those who direct the work of others (supervisor)  “The Foundation of Lean”  Three Key Elements or Skills – Job Relations: get results by gaining cooperation of others – Job Instruction: efficiently and effectively train others – Job Methods: generate & implement ideas for improving the work
  16. 16. Training Within Industry structure  Training in 2-hour blocks for 4-5 days  Small classes of 8-10 people  Demonstrate, then learn by doing – learn from each other  Identify and solve today’s real problems during the training  Focus on areas within your control  Learn how to implement your ideas – SAUC  Pocket-sized reminder card TWI is a proven method for identifying and solving problems
  17. 17. Agenda  “Great” Quality Performance  Formula to Improved Quality Performance  Role of Overcoming Mistakes  Helping ensure mistakes don’t affect the customer
  18. 18. The Foundation of KAIZEN Tools and Systems Concepts Principles
  19. 19. The Foundation of KAIZEN Tools and Systems Concepts Process and Non-Judgmental/ Total Systems Results Non-Blaming C-Store Fall Through Floor.mpg
  20. 20. Top Ten Beliefs About Mistakes 1) Mistakes are so infrequent, they don’t really matter 2) I don’t make mistakes – but others might 3) If we care about what we’re doing, we won’t make mistakes 4) If we only try harder and pay attention, we won’t make mistakes 5) If I make a mistake, it’s my own fault 6) If I catch a mistake, I should quickly fix it and keep it to myself 7) I can’t do anything about making mistakes 8) I don’t need mistake-proofing devices or procedures 9) We can’t possibly mistake-proof everything, so why try? 10) Mistake-proofing is too expensive for us 11) Mistake-proofing is for the engineers to do
  21. 21. Beliefs & Truths About Mistakes 1) Mistakes are so infrequent, they don’t really matter The truth: Mistakes are infrequent, but they do matter
  22. 22. Why study errors?  Individuallyerrors are rare. However, as a group they are a major cause of rejects  Parts and processes can be controlled in ways that dramatically reduce the occurrence of rejects due to mistakes. Gaining this control requires a change in mindset
  23. 23. Beliefs & Truths About Mistakes 1) Mistakes are so infrequent, they don’t really matter 2) I don’t make mistakes – but others might The truth: We all make mistakes
  24. 24. Common Human Mistakes  Forgetting  Putting things in the wrong place or in the wrong orientation  Doing one thing when we meant to do another  Doing something at the wrong time or in the wrong order Have you ever made a mistake?
  25. 25. Mistake-proofing exercise Count the O’s
  26. 26. Beliefs & Truths About Mistakes 1) Mistakes are so infrequent, they don’t really matter 2) I don’t make mistakes – but others might 3) If we care about what we’re doing, we won’t make mistakes 4) If we only try harder and pay attention, we won’t make mistakes The truth: We do care and we try to pay attention; trying harder is only a short-term solution as mistakes are part of the human condition
  27. 27. Common Misperceptions  “If they just paid attention to what they were doing……”  “If they cared about their work…….”  “If they just followed the procedures…….”  “Try harder next time”…….  “Just be more careful”……..  “Why didn’t the inspectors catch it”……. Do you come to work every day looking to make mistakes?
  28. 28. What About Accountability?  Mistake proofing is not a substitute for personal accountability  Blatant intentional disregard for procedures and policies cannot and should not be tolerated  But when multiple people have repeated difficulty with the same process, it’s usually not a personal accountability issue.
  29. 29. The Truth About Mistakes  Smartpeople make mistakes  We don’t know why  Some causes: – Complex work – Repetitive work – Poor work environment – Poor workplace design – Interruptions and distractions. So who’s to blame?
  30. 30. “Be more careful” is not effective  “The old way of dealing with human error… – scold people – retrain them – tell them to be more careful …  My view is that – you can’t do much to change human nature – people are going to make mistakes  If you can’t tolerate them ... you should remove the opportunities for error.” 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.
  31. 31. Beliefs & Truths About Mistakes 1) Mistakes are so infrequent, they don’t really matter 2) I don’t make mistakes – but others might 3) If we care about what we’re doing, we won’t make mistakes 4) If we only try harder and pay attention, we won’t make mistakes 5) If I make a mistake, it’s my own fault The truth: Many mistakes are due to poorly designed systems
  32. 32. “Be more careful” not effective  “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.” 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.
  33. 33. “Be more careful” not effective  “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.
  34. 34. Beliefs & Truths About Mistakes 1) Mistakes are so infrequent, they don’t really matter 2) I don’t make mistakes – but others might 3) If we care about what we’re doing, we won’t make mistakes 4) If we only try harder and pay attention, we won’t make mistakes 5) If I make a mistake, it’s my own fault 6) If I catch a mistake, I should quickly fix it and keep it to myself 7) I can’t do anything about making mistakes The truth: If we make a mistake, we should identify it as a problem and get help to solve the problem
  35. 35. Oops – I Made a Mistake...  Don’t hide it!!! Why not?  If you made this mistake, the next operator doing this same job is likely to make the same mistake  If we don’t identify it as a problem, we won’t ever fix it – Do your best – Do not be afraid to ask for help – Treat others the way you want to be treated – Always work as a team
  36. 36. New Attitude: Preventing Errors  Make it more difficult to do things the wrong way  Make it possible to reverse actions —to “undo” them  Make it easier to discover the errors that occur  Make incorrect actions correct or OK. Mistake-proofing shows respect for the human condition
  37. 37. Mistake-proofing exercise Count the O’s with a better process
  38. 38. What can be done?  How do we remember to: – Replace the gas cap – Fill the car with the right fuel – Clear the way before shutting the garage door – Plug the cord in the right outlet – Turn off the lawnmower before leaving  Your examples See www.mistakeproofing.com for 70 examples
  39. 39. Beliefs & Truths About Mistakes 1) Mistakes are so infrequent, they don’t really matter 2) I don’t make mistakes – but others might 3) If we care about what we’re doing, we won’t make mistakes 4) If we only try harder and pay attention, we won’t make mistakes 5) If I make a mistake, it’s my own fault 6) If I catch a mistake, I should quickly fix it and keep it to myself 7) I can’t do anything about making mistakes 8) I don’t need mistake-proofing devices or procedures The truth: Because mistakes are a natural part of being human and our mistakes can cause business problems, we all need to use our mistake-proofing devices
  40. 40. Use & Improve Our Devices  We must overcome the temptation of not using our mistake-proofing devices  Mistake-proofing devices are normally put in place only when we’ve experienced similar mistakes that have caused problems  Our customers rely on us to use them properly, even when we think we don’t need them  Look for ways to make them easier to use and more effective, and propose your ideas
  41. 41. Results of Not Using Devices  Family mold labeling process – Large lot reject (500 pcs) to Diebold in January 2008 – Could have resulted in “Lines Down” situation (but didn’t – this time) – All this happened while we were on probation for ongoing quality issues – Our written plan to Diebold was that we would implement these types of mistake proofing processes – we did, but didn’t follow them  Assembly template – Reject from Honeywell in March 2008 because we didn’t follow the template Difficult to tell customers we don’t follow our procedures
  42. 42. “Getting Around” Our Devices  Mistake-proofing devices are put in place to help us overcome potential mistakes we could make – They are usually simple and low cost – They rely on us to use them properly, even when we think we don’t need them  Don’t fall to the temptation to “get around” using our mistake-proof devices  Follow standard procedure – It’s in our customers best interest – Therefore it’s in our best interest.
  43. 43. Beliefs & Truths About Mistakes 1) Mistakes are so infrequent, they don’t really matter 2) I don’t make mistakes – but others might 3) If we care about what we’re doing, we won’t make mistakes 4) If we only try harder and pay attention, we won’t make mistakes 5) If I make a mistake, it’s my own fault 6) If I catch a mistake, I should quickly fix it and keep it to myself 7) I can’t do anything about making mistakes 8) I don’t need mistake-proofing devices or procedures 9) We can’t possibly mistake-proof everything, so why try? The truth: We need to start mistake-proofing those things that are affecting our business the most
  44. 44. Latest Customer Reject History 3,000 2,500 = Oops! 2,000 Rejects 1,500 1,000 500 0 Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Opportunity Hits/Million Goal Benchmark YTD PPM Three mistakes in ten months makes you an excellent supplier
  45. 45. Beliefs & Truths About Mistakes 1) Mistakes are so infrequent, they don’t really matter 2) I don’t make mistakes – but others might 3) If we care about what we’re doing, we won’t make mistakes 4) If we only try harder and pay attention, we won’t make mistakes 5) If I make a mistake, it’s my own fault 6) If I catch a mistake, I should quickly fix it and keep it to myself 7) I can’t do anything about making mistakes 8) I don’t need mistake-proofing devices or procedures 9) We can’t possibly mistake-proof everything, so why try? 10) Mistake-proofing is too expensive for us The truth: Much mistake-proofing can be inexpensive
  46. 46. Devices Tend to be Inexpensive Cost of Mistake-proofing Devices 1 0.9 0.8 0.7 Probability 0.6 Frequency of Occurrence 0.5 0.4 Cumulative Probability 0.3 0.2 0.1 0 $100 to$250 $250 to $1000 $25 to $100 $25 or less $1000 or more Cost Over half the devices cost under $100 to implement
  47. 47. To err is human; Our goal must be to keep these errors from turning into defects
  48. 48. Beliefs & Truths About Mistakes 1) Mistakes are so infrequent, they don’t really matter 2) I don’t make mistakes – but others might 3) If we care about what we’re doing, we won’t make mistakes 4) If we only try harder and pay attention, we won’t make mistakes 5) If I make a mistake, it’s my own fault 6) If I catch a mistake, I should quickly fix it and keep it to myself 7) I can’t do anything about making mistakes 8) I don’t need mistake-proofing devices or procedures 9) We can’t possibly mistake-proof everything, so why try? 10) Mistake-proofing is too expensive for us 11) Mistake-proofing is for the engineers to do The truth: Everyone has a role in mistake-proofing
  49. 49. Production Opportunities for Mistake-proofing  Mislabeling  Miscounting  Missing a component in a multi-part assembly  Placing a part in the wrong position  Forgetting to do a step in a process  Not noticing the defect during an inspection.
  50. 50. Mistake-Proofing Exercise Office Key Office Flash Drive Car Key Security FOB Problem: I forget the flash drive, either at home or at work
  51. 51. Current Method Sometimes my kids need the car keys I no longer forget the flash drive at home, but I now forget the office key & fob at work in my computer with the flash drive
  52. 52. Identifying the Process Sometimes my kids What need the car keys should Need these to I do access the office with the flash drive?
  53. 53. Mistake-Proofing Solution Now if I try to leave with the flash drive in my office computer, I can’t drive away, and I can still re-enter my office to retrieve it.
  54. 54. Agenda  “Great” Quality Performance  Formula to Improved Quality Performance  Role of Overcoming Mistakes  Helping ensure mistakes don’t affect the customer
  55. 55. Summary of Zero Defects Production Prevent errors from turning into defects  Source inspection  100% inspection  Short feedback loop and quick corrective action  Mistake-proof devices – Contact methods _ Warning – Fixed-value methods _ Control – Motion-step methods
  56. 56. Mistake-proofing box counts
  57. 57. Complex Assy Mistake-proofing
  58. 58. Mistake-proofing an insert
  59. 59. Mistake-proofing Placement
  60. 60. Mistake-proofing a fixture
  61. 61. Back Room Central System Monitor Thermolator Alarm 29
  62. 62. Part Orientation Checking Device Control System Contact Method
  63. 63. Pink Ceiling Paint  Most ceilings are white  This pink paint dries white Warning System Fixed Value Method
  64. 64. Wireless Router Control System Motion-Step Method
  65. 65. Oil Change Mistake-proofing Dipstick on the fender protector falls and clatters if not put back before protector is removed.
  66. 66. Medication Mistake-proofing Patient died from getting undiluted medication. Now all medication is diluted before being stored.
  67. 67. Form Mistake-proofing Gray areas do not need signatures.
  68. 68. Bolt Mistake-proofing Metric Blue
  69. 69. Mistake-proofing exercise Identify 2-3 different ways to mistake-proof: Buttoning your shirt
  70. 70. Mistake-proofing Process 1. Describe what goes wrong – Pick an actual workplace problem (Quality rejects, Safety incidents, Equipment breakage) – Was it caused by a mistake? 2. Identify the root cause 3. Develop the solution – Consider the risk & cost to implement 4. Apply the solution.
  71. 71. 1. Define what goes wrong  Identify the type of mistake – Forget? _ Wrong task – Wrong place/orientation _ Wrong order  Review our defect experience  Look at similar jobs or parts  Analyze the risk – Frequency – Lines down, large qty or high cost?
  72. 72. 2. Identify the Root Cause  Use 5-why tool to determine why defect was not caught  Use 5-why tool to determine why defect was made  Evaluate each major step of the process and consider: – Is the workplace clean, well lit & organized? – Is the process simplified (using JM)? – Is the current way the easy and safe way? – Is the process standardized? – Are instructions clear and complete? – Are key points identified and taught (using JI)? – Is feedback immediate if anything goes wrong?
  73. 73. 3. Develop the solution  Select type of mistake-proof device – Contact methods _ Warning system – Fixed-value methods _ Control system – Motion-step methods  Brainstorm alternative solutions  Select the best solution – Consider the cost versus risk – Consider unintended consequences  Identify how to test the device in production
  74. 74. Cost Considerations  Acquisition cost  Implementation cost  Effectiveness of the solution  Speed of implementation  Cost of using the device or technique  Potential for use on other parts or processes
  75. 75. Evaluating Risk  Consider the frequency with which the mistake could happen – This part or process – Similar parts or processes  Consider the consequence of the mistake not being caught – Lines down – Quality performance / reputation – Cost of replacement parts or rework – Cost of damage
  76. 76. 4. Apply the solution  Sell the new method – Boss – Operators  Get Approvals – Boss – Other departments  Use the new method – Make sure device is being used properly  Give credit for assistance.
  77. 77. RR Crossing Example 1. What can go wrong? – Driver enters crossing with train approaching – Automobile brakes malfunction – Driver hits the accelerator instead of brakes 2. What is the root cause? – Driver doesn’t see/hear train approaching – Why? Driver doesn’t see railroad crossing Why? Driver is human
  78. 78. RR Crossing Potential Solutions Bridge Sign+Lights+arms Risk of mistake Sign+Lights Sign Cost of device
  79. 79. Evaluating Solutions – RR Xing Solution Effectiveness Cost/speed Stop sign Warning Low/fast Multiple signs Warning Low/fast Sign + flashing lights Warning Low/mod Rumble strip Warning Low/mod Stop arm Control Mod/mod Bridge Control High/slow
  80. 80. Other Applications for Mistake- Proofing (beyond Quality)  Safety – Accidents – Health care procedures  Equipment breakage – Mold damage – Fixture damage – Equipment damage  Environmental protection
  81. 81. How to Identify Mistake-Proofing Opportunities  On which jobs do we continue to have internal and/or external rejects?  What part of our job is difficult to get right all the time?  What tasks do we sometimes do wrong?  What tasks do we sometimes have to re-do?  What tasks sometimes require re-work?  What tasks are frustrating to do?  What about our job does the external customer complain about?  What would our internal customers like to see us improve?  What seems wasteful?  What gets damaged occasionally?  What types of accidents have occurred?  About which tasks do we hear: – Be more careful – Pay attention – Try harder
  82. 82. Summary  Mistake-proofing is necessary to move your quality performance from good to great  A change in mindset is a pre- requisite  Everyone needs to be involved  A mistake-proofing methodology based on TWI and ZQC can help drive this improvement
  83. 83. What it’s really all about...  Believe in something bigger than ourselves  Believe in the company, its leadership, values, vision and mission; and our products & services  Eliminating motivational inhibitors – like making mistakes True Compensation

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