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Overcoming Mistakes
for Improved Quality
     Performance
  Presented by
  Sam Wagner
       for
 Quality Council
February 3, 2009
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.
Agenda
   “Great” Quality Performance
   Formula to Improved Quality Performance
   Role of Overcoming Mistakes
   Helping ensure mistakes don’t affect the
    customer
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.
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
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
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
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
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.
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
Agenda
   “Great” Quality Performance
   Formula to Improved Quality Performance
   Role of Overcoming Mistakes
   Helping ensure mistakes don’t affect the
    customer
Job Quality Formula

JQ = (ZQC + TWI)



  x ATTITUDE       2
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.
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
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
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
Agenda
   “Great” Quality Performance
   Formula to Improved Quality Performance
   Role of Overcoming Mistakes
   Helping ensure mistakes don’t affect the
    customer
The Foundation of KAIZEN


        Tools and Systems

            Concepts

           Principles
The Foundation of KAIZEN


               Tools and Systems

                   Concepts

 Process and                       Non-Judgmental/
                Total Systems
   Results                          Non-Blaming

                                     C-Store Fall Through Floor.mpg
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
Beliefs & Truths About Mistakes
1)   Mistakes are so infrequent, they don’t really matter



The truth: Mistakes are infrequent, but they do matter
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
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
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?
Mistake-proofing exercise


       Count the O’s
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
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?
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.
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?
“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.
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
“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.
“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.
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
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
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
Mistake-proofing exercise


        Count the O’s
    with a better process
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
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
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
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
“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.
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
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
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
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
To err is human;
Our goal must be to
 keep these errors
 from turning into
      defects
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
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.
Mistake-Proofing Exercise
Office Key    Office       Flash Drive           Car Key
             Security
               FOB




Problem: I forget the flash drive, either at home or at work
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
Identifying the Process
Sometimes my kids                         What
 need the car keys                       should
                      Need these to        I do
                     access the office    with
                                           the
                                          flash
                                         drive?
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.
Agenda
   “Great” Quality Performance
   Formula to Improved Quality Performance
   Role of Overcoming Mistakes
   Helping ensure mistakes don’t affect the
    customer
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
Mistake-proofing box counts
Complex Assy Mistake-proofing
Mistake-proofing an insert
Mistake-proofing Placement
Mistake-proofing a fixture
Back Room
Central System Monitor Thermolator Alarm
                                       29
Part Orientation Checking Device
                    Control System
                    Contact Method
Pink Ceiling Paint
             Most ceilings are
              white
             This pink paint
              dries white

           Warning System
           Fixed Value Method
Wireless Router
      Control System
      Motion-Step Method
Oil Change Mistake-proofing




Dipstick on the fender protector falls and
clatters if not put back before protector is
removed.
Medication Mistake-proofing

                  Patient died
                  from getting
                  undiluted
                  medication.
                  Now all
                  medication is
                  diluted
                  before being
                  stored.
Form Mistake-proofing




  Gray areas do not need signatures.
Bolt Mistake-proofing
Metric Blue
Mistake-proofing exercise


  Identify 2-3 different ways
       to mistake-proof:

     Buttoning your shirt
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.
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?
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?
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
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
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
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.
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
RR Crossing Potential Solutions


                                                  Bridge


                               Sign+Lights+arms
 Risk
  of
mistake




                 Sign+Lights
          Sign

                     Cost of device
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
Other Applications for Mistake-
   Proofing (beyond Quality)
 Safety

  – Accidents
  – Health care procedures
 Equipment   breakage
  – Mold damage
  – Fixture damage
  – Equipment damage
 Environmental   protection
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
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
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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Tri State Final

  • 1. Overcoming Mistakes for Improved Quality Performance Presented by Sam Wagner for Quality Council February 3, 2009
  • 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
  • 12. Job Quality Formula JQ = (ZQC + TWI) x ATTITUDE 2
  • 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
  • 18. The Foundation of KAIZEN Tools and Systems Concepts Principles
  • 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?
  • 25. Mistake-proofing exercise Count the O’s
  • 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
  • 37. Mistake-proofing exercise Count the O’s with a better process
  • 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.
  • 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. 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. 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. 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
  • 61. Back Room Central System Monitor Thermolator Alarm 29
  • 62. Part Orientation Checking Device Control System Contact Method
  • 63. Pink Ceiling Paint  Most ceilings are white  This pink paint dries white Warning System Fixed Value Method
  • 64. Wireless Router Control System Motion-Step Method
  • 65. Oil Change Mistake-proofing Dipstick on the fender protector falls and clatters if not put back before protector is removed.
  • 66. Medication Mistake-proofing Patient died from getting undiluted medication. Now all medication is diluted before being stored.
  • 67. Form Mistake-proofing Gray areas do not need signatures.
  • 69. Mistake-proofing exercise Identify 2-3 different ways to mistake-proof: Buttoning your shirt
  • 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
  • 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. 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