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. Agenda
“Great” Quality Performance
Formula to Improved Quality Performance
Role of Overcoming Mistakes
Helping ensure mistakes don’t affect the
customer
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. 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. 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. 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. 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. 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. 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. Agenda
“Great” Quality Performance
Formula to Improved Quality Performance
Role of Overcoming Mistakes
Helping ensure mistakes don’t affect the
customer
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. 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. 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. 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. Agenda
“Great” Quality Performance
Formula to Improved Quality Performance
Role of Overcoming Mistakes
Helping ensure mistakes don’t affect the
customer
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. 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. Beliefs & Truths About Mistakes
1) Mistakes are so infrequent, they don’t really matter
The truth: Mistakes are infrequent, but they do matter
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. 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. 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?
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. 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. 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. 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. “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. 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. “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. “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. 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. 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. 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
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. 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. 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. 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. “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. 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. 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. 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. 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. To err is human;
Our goal must be to
keep these errors
from turning into
defects
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. 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.
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
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. Agenda
“Great” Quality Performance
Formula to Improved Quality Performance
Role of Overcoming Mistakes
Helping ensure mistakes don’t affect the
customer
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
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. 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. 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. 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. 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. 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. 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. 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. RR Crossing Potential Solutions
Bridge
Sign+Lights+arms
Risk
of
mistake
Sign+Lights
Sign
Cost of device
80. Other Applications for Mistake-
Proofing (beyond Quality)
Safety
– Accidents
– Health care procedures
Equipment breakage
– Mold damage
– Fixture damage
– Equipment damage
Environmental protection
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. 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. 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