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Human Error Prevention
The document discusses human error prevention, defining errors and introducing the concept of 'poka-yoke' as a method to avoid defects caused by mistakes. It outlines common human error types, their potential impact, and a structured approach to error proofing, which includes identifying issues, generating solutions, and implementing them. Additionally, it details various error modes and their corresponding human errors, emphasizing the importance of proactive measures in manufacturing and operations.
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Human Error Prevention
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- 2. What is anError ? It is an inadvertent, unplanned, accidental event that can leads to defect. It is event that occurs one off which we find very difficult to control/ Prevent. Some Common Human Errors - Missing Parts Wrong parts used Missed machine cycles
- 3. The First Poka-Yoke *The term “Poka-Yoke” was developed by Mr. Shigeo Shingo in 1960. Initially, it was called “Baka- Yoke” *Shingo eventually formalized the concept of Zero Quality Control (ZQC). He says that mistakes and defects go hand in hand. A mistake results in a defect if it is not prevented or detected.
- 4. Human Error Prevention Objectives Learnmethod to identify error.1 Learn Principles of error proofing to identify, control or prevent human errors. 2 Generating Solutions for Human Errors.3
- 5. 5 Why Operator Mistake? I Don’t Know. So I made Mistake ? I Know, BUT It’s Difficult. So I made Mistake ? I Know, It’s not difficult, BUT I Don’t Want To Do. I Know, It’s not difficult, I am willing, BUT I Forgot. So I made Mistake ? Educate Develop Skill OR Deskill the Operation Motivate Only - Human Error Prevention – “HEP”
- 6. Count the Numberof “F”s (both upper & lower case) Farming Fathers of Farmington! The Future Farmers of America needs your help. We need the help of all the fathers of every family farm in Farmington. Please fill your Family farms with four or five, maybe even fourteen or fifteen, children. Some of you fathers on family farms have fathered only one or two future farmers. For the future of farming in Farmington, we hope all of you family farmers find nothing but fertile fields in your future. No. of “F” = ??
- 7. Facts About HumanError Human Errors are unavoidable Then why 99.9% performance not acceptable
- 8. Effect of believingErrors are unavoidable Accepting 99.9% performance also means - • 1 defective car per 1000 car produced • 1 accident while every 1000 journey from Pune to Mumbai or to any place • Wrong amount dispensed one from ATM in 1000 withdrawal • Contamination in 1 pizza behind every 1000 produced.
- 9. How Can WePrevent Defect Defects Check & FeedbackAction Error Action Errors Check & Feedback Result
- 10. Drill miss and customer complaint raise Detection ofDefect Prevention of Defect Position of part dislocates & holes are drilled at incorrect positions Reference pin provided Locator pins provided
- 11. Error Proofing definition& Approach Improvement of work operations, including materials, machines and methods, with the aim of preventing problems due to human error Improve Human being to Fit Operations Improve Operations to Fit Human Beings Error Proofing
- 12. Three Step Approachto Error Proofing Step 1 : Identifying improvement opportunities Step 2 : Generating Solutions Step 3 : Evaluating and selecting solutions
- 13. Tools for identificationof human errors Identification of Human Error 16 Error Modes Brainstorming Past trouble database Process breakup at activity level Gemba – Gembutsu – Gengitsu (3G)
- 14. List of FailureModes Failure modes Corresponding Human Errors No. of error (1) Omission - Forgetting to take out or set parts/materials - Forgetting to operate buttons, valves, or switches 292 (28.1%) (2)Excessive/Insuffici ent Repetition - Re-executing the finished work - Excessively / Insufficiently repeating work 2 (0.2%) (3) Wrong order - Executing two sequential work operations in an inverted order 7 (0.7%) (4) Early / Late execution - Beginning work earlier/later than specified - Ending work earlier/later than specified 2(0.2%) (5) Execution of restricted work - Executing restricted work which is likely to cause poor quality, injuries or accidents 11(1.1%) (6) Incorrect Selection - Selecting the wrong parts/material - Using the wrong tools 176(17.6%)
- 15. Failure modes CorrespondingHuman Errors No. of error (7) Incorrect Counting - Supplying more material than specified. - Transporting less parts than ordered 9 (0.9%) (8) Misrecognition - Misreading work order sheets, meters or records - Failing to determine defective products 165 (16.5%) (9) Failing to sense danger - Failing to sense items not to be touched - Failing to sense areas not to be approached 17 (1.7%) (10) Incorrect holding - Holding a damageable part of materials/ parts - Holding tool the incorrect way 3 (0.3%) (11) Incorrect positioning - Setting parts in the wrong position - Transporting material to the wrong place 60 (60%) (12) Incorrect orientation - Setting materials / Parts the wrong way around - Bending materials to the wrong side 102 (10.2%) (13) Incorrect Motion - Bending material too much - Opening valve to fast 1 (0.1%)
- 16. Failure modes CorrespondingHuman Errors No. of error (14) Improper Holding - Failing to ensure Material/part do not move - Dropping parts, products or tools 20 (2%) (15) Inaccurate Motion - Setting materials / parts in inaccurate positions - Tightening bolts to inaccurate torques 88 (8.8%) (16) Insufficient Avoidance - Knocking parts/tools into each other falling - Touching machine switches without intention 60 (6%)
- 17. Decomposition of Process Goto actual location / Gemba1 Take a video of operation / Process2 Observe video and break operation into elemental steps3 Brainstorm & Apply 16 error mode checklist to identify human error4
- 18. Identify solutions usingprinciples and sub-principles Error Proofing Prevention of Occurrence Minimization of Effects Elimination Task Elimination Risk Elimination Automation Support System Replacement Simplification Distinction Adjustment Facilitation Detection Record & Verify Motion Restrict Motions Verify Results Mitigation Redundancy Failsafe Protector
- 19. Error Proofing Principles TaskRisks Functions Required Error Abnorm alities Effects Error Proofing Detection Mitigation Minimization of effects LossesSmall Large Ensure that abnormalities caused by error are detected Equipment that detects worker’s motions and make an alarm Mitigate the effects of error Electric fuse that preventing equipment breaks Elimination Replacement Facilitation REMOVE WORK Susceptible to human error from the process. Make the error- prone operations unnecessary Replace the human operations with more reliable machines Automate operations Make the operations easier for workers to perform Distinguish parts boxes by color coding Prevention of Occurrence
- 20. 1. Elimination (A) TaskElimination Making Changes in the product of process design so as to eliminate the elemental task or complete operation in which errors are being occurred. Ex. (B) Elimination of risk Risk is the possibility / cause of harm to product or property. Elimination of risk is making changes to the product / process design so as to eliminate the risk. *Task or operation is not eliminated
- 21. 2. Replacement Replacement Memory Perception Motion Automation Support System (Checklist, reminders & guides) Functionsto be replaced Sub-principles Examples Error Error Proofing Misreading a work order sheet and installing the wrong parts in a sub assembly Sense the shape of the assembly product mechanically or electrically. Forgetting to do a part of operations Use a table showing the sequence & contents of operation, thus making it unnecessary for workers to memorize them.
- 22. Examples 1. Automatically switchoff the lamp in day 2. Automatically cost of product gets entered once bar code is shown in supermarket. 3. Car door automatically gets locked after few minutes of key removal. 4. Cooling fan starts when any electronic device gets heated. 5. Robotic painting 6. Auto lubrication of oil in machine Support System: Usage of guides, pins, stoppers, fixtures, templates, checklists, navigation Double click to view this video
- 23. 3. Facilitation Facilitation Memory Perception Motion Simplification Distinction Adjustment Functions tobe Facilitated Sub-principles Examples Error Error Proofing Selecting the wrong part Make a mark on each parts box consistent with a corresponding mark on the work order sheet Misunderstandi ng the types of parts Color coding of the parts and the arrangement of part boxes so as to keep away separate similar parts Misreading the work order sheet Making the symbols or characters which show the types of part bigger and clearer Decrease the no. of changes or differences, 5S
- 24. 4. Detection Detection Abnormalityinresults Abnormality inresults Negative Positive Record & verify motion & indicate abnormality Restrict Motion Verify result and abnormality Abnormalities to be detected Sub-principles Examples Error Error Proofing Misreading an operation order sheet and selecting the wrong parts Use photoelectric switches attached to the parts boxes to sense which part worker has picked & automatically suspend operation if wrong part picked Misreading an operation order sheet and selecting the wrong parts Change the shape of parts so that wrong part cannot be fitted into sub assembly product Misreading an operation order sheet and selecting the wrong parts Sensing the shape of the product on its way to the next process
- 25. 5. MitigationMitigation Malfunction chainRedundancy Malfunction unsafe state loss chain Unsafe state Loss Failsafe Protector Effects to be mitigated Sub-principles Examples Error Error Proofing Burning out the motor of a production machine by forgetting to switch off its power supply. Make it to the operators job to operate the switch on the machine itself and foreman’s job to operate the main workshop switch Burning out the motor of a production machine by forgetting to switch off its power supply. Fit the machine with the fuse which cuts off the power supply when the motor temp. reaches certain level. Knocking products Cover with shock absorbing materials
- 26. Locating pins &Guide pins1 Alarms and error detection system2 Limit switches3 Checklist4 Counters5 In the manufacturing industry, following poka-yoke devices are most often used.
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