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A Poka-Yoke Primer:
Mistake-Proofing
and Error Reduction
Hosted by
Host: Mark Graban
Senior Advisor, KaiNexus
Mark@KaiNexus.com
Presenter: John Grout
Professor, Berry College
jgrout@berry.edu
4
KaiNexus.com
Book Giveaway Contest!
Our winners are…
Gina Cloutier
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About John Grout, Ph.D.
• Berry College (GA)
• Campbell School of
Business
• Professor, former Dean
• Ph.D. Management Science
• Penn State University
• Shingo Prize, “The Human
Side of Mistake-Proofing”
Mistake-Proofing/Poka-Yoke
Webinar
January 17, 2024
by John Grout
Objectives
• Build awareness of mistake-proofing
• Introduce a concise presentation format: “pecha kucha”
20 x 0:20 = 6:40
• What is mistake-proofing?
– Include lots of examples
• Why do people err?
• How can design eliminate errors?
• Next steps in implementation
Agenda
• Introduce Pecha Kucha
• Pecha Kucha 1: Introduce mistake-proofing
• Discuss examples & answer a few questions
• Pecha Kucha 2: Which errors does mistake-proofing work
on and how do I get started?
• Answer more questions about errors and mistake-
proofing
Pecha Kucha (ペチャクチャ)
• Pecha Kucha was devised in 2003 by architects Astrid Klein and
Mark Dytham in Tokyo, as a way to attract people to Super
Deluxe, their experimental event space.
• Pecha Kucha is a presentations having 20 slides, each shown for
exactly 20 seconds. The total presentation time was 6:40
seconds, that’s it.
• The format keeps presentations concise, fast-paced and
(hopefully) entertaining.
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Poka-Yoke
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Get a new
toothbrush
Use a metric
wrench
Your syrup is hot
Take the elevator to X-ray
MRI is this way Alcatraz kitchen: The convicts are
armed
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5 stories high
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Wear your scrubs
Leave me alone while I get these meds
Beware the magnet
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Time’s up!
Any questions?
Some common mistake-proofing devices:
•Guide Pins
•Blinking lights and alarms
•Limit switches
•Proximity switches
•Counters
•Checklists
Other examples
.
. .
.
Another Pecha Kucha is about
to begin
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James Reason
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Intent: Help visitors find their way
Execution: A little confusing
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Skill, Rule and Knowledge-based actions
• Skill-based action: action by autopilot.
• Rule-based action: we’ve seen it before and recall a rule
about what action is appropriate.
• Knowledge-based action: Truly novel circumstances
require careful thought and deliberation about what to do.
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Rule-based action
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Knowledge-based action
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1 minute 2 minutes 3 minutes 4 minutes 5 minutes
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Errors in knowledge-based action?
Don’t use mistake-proofing
Use human error prevention
strategies
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þ9
Errors in rule-based action?
Mistake-proofing may work well
Combine with human error
prevention strategies
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Errors in skill-based action?
Mistake-proofing is ideal
Perhaps best human
error prevention
strategy for these
actions
Root Cause Analysis
• Root Cause: a cause that can be acted upon
such that it meets our goals and objectives and
is within our control
• Look for actions AND conditions
Ignition source
Combustible material
Oxygen
Fire
1. Understand the problem
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Effects Caused
by
Causes
1. Injury Fall
2. Fall Wet surface
3. Wet surface Leaky valve
4. Leaky valve Seal failure
5. Seal failure Not maintained
1 2 3 4 5
A continuum of causes
1. Understand the problem
Cause and effect are same thing
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Cause and effect are same thing
• Toyota says ask why 5 times
• If it’s a continuum, why not more?
• Keep going until your answer to
why is:
• I don’t know
• I don’t care
Apollo Root Cause Analysis: A New Way of Thinking
by Dean L. Gano
1. Understand the problem
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2. Start brainstorming solutions
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Your 1st idea
A subsequent
improved
idea
Try-storming (w/full-sized cardboard mock-ups)
2. Start brainstorming solutions
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Boeing Moonshine
Shop
• No Money Spent = Creativity at a New
Level
• Scrounge for EVERYTHING!
EVERYWHERE!
• Fast and Inexpensive is the ONLY way to
Try-Storm
• A 50% solution actually implemented, beats
all hell out of a 100% perfect plan, created
by meetings
• Get out of Kansas! To think differently you
have to see and try different things –
LEAVE YOUR WORKSITE! Frequently
3. Learn quickly which ideas are mistakes
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3. Learn quickly which ideas are mistakes
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Day 1: Lots of mock-ups
Day 1.5: discard some ideas
consolidate others
Day 2: proof of concept
Day 2.75: prototype
Day 5: Finished tool
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Mistake-Proofing: When and How
Knowledge-based action?
Rule-based action? þ
Skill-based action?” þ
1. Find the root cause
2. Try-storm prevention strategies
3. Fail quickly and cheaply to find success
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Time’s up!
Any questions?
Design
(& details)
still matters
It’s there…
But can you
see it in
use?
Your errors
• What were they?
• Were they skill-, rule-, or knowledge-based?
• Any thoughts about how to prevent them?
– Make the error more obvious
– Create a failure that makes the error more benign
– Help people do things right by putting knowledge in the world
A proposal for action: Homework
• Do something meaningful
– Eliminate an error by mistake-proofing
– Create significant cost savings
• Do something you’ll be proud of
• Do something cool
– Brew some moonshine: do something with nothing
58
Thank you!
Register or get notified of future webinars: www.KaiNexus.com/webinars
NEXT WEBINAR:
"Apply Operations Science to
Accelerate Success Now”
February 6 — 1 pm ET
Ed Pound
Operations Science Institute
Author of Factory Physics for Managers
blog.kainexus.com
The KaiNexus Podcast
• www.KaiNexus.com/podcasts
• Subscribe via:
– Apple Podcasts
– Google Podcasts
– Overcast
– Spotify
– Other apps & services
Your Feedback Matters!
CLICK!
Q&A
• Web:
– www.kainexus.com
– blog.kainexus.com
– Webinars on Demand:
– www.kainexus.com/webinars
• Social Media:
– www.linkedin.com/company/kainexus
– www.facebook.com/kainexus
Host: Mark Graban
Senior Advisor, KaiNexus
Mark@KaiNexus.com
Presenter: John Grout
Professor, Berry College
jgrout@berry.edu

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