Find the way to prevent the human error in industries as well as 16 types of human errors for better identification and generating solution for given identified errors

1. HUMAN ERROR PREVENTION

2. What is an Error ?
 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
Learn method 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 Number of “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 Human Error
Human Errors are
unavoidable
Then why 99.9% performance not acceptable

8. Effect of believing Errors 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 We Prevent Defect
Defects
Check &
FeedbackAction
Error
Action
Errors Check &
Feedback
Result

10. Drill miss
and
customer
complaint
raise
Detection of Defect
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 Approach to Error Proofing
Step 1 : Identifying improvement opportunities
Step 2 : Generating Solutions
Step 3 : Evaluating and selecting solutions

13. Tools for identification of 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 Failure Modes
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 Corresponding Human 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 Corresponding Human 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
Go to 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 using principles 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
Task Risks
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) Task Elimination
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)
Functions to 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 switch off 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 to be 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 in results
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 chain Redundancy
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.

27. Thank you