1

Who has a

safety contact/tip?

Let’s band together forSafety, Quality, Speed of Execution

A ship is safe in harbor, but that's not what ships are for

2

We’re all in the same boat -

The Problem with Poka-Yoke

Hopefully, not this one !

Improvement? Bah, Hum Bug !!

We gotta Improve our process !

And - - - it has to be “mistake proofed” to

boot!

5

SMILE !!

It’s Contagious!

Our objective:Take away one mistake proofing idea and go implement it!And … we’ll ask for one at end of the presentation.

Sustain the Gain

Where in the World are Poka-yoke?

They exist in the world around us…

(they’re out there)

Where in the World are Poka-yoke?

Let’s brainstorm!

1st, some… Classic Brainstorming Ground Rules

• Everyone participates• No judgments or teasing• No body language• Play off each others ideas• Write so others can see• Promote a “Can do, won’t fail” attitude• Start with “Open” questions…

– “What would we do to fix?”– “What are some ways we could…”– “If anything were possible, what…”

Now, where have you seen one?

• Describe a poka-yoke you have experienced…(a mistake-proofing thingy)

What Are Guidelines for Poka-Yoke ?

In general, the approach of Poka-Yoke should meet the following guidelines:

Inexpensive

Based on common sense and obvious to the person involved in the process

It MUST eliminate Occurrence and Detection of the problem at the root cause

BTW: Don’t Do Fake Poka-Yoke!

Almost !!

Almost !!

Almost !!

Almost !!

Almost !!

(Sure looks like a trash can …)

Almost !!

Cheaper than a plumber!

Almost !!

Easier to make a sign, then call tech support!

Almost !!

Do …Careful pedestrians need to stop??

Almost !!

2Partsto this one…

Notice how far away sign is from hospital bed

Almost !!

“falls program…”

Really ??!??!!

Almost !!

So many signs!

Maybe the pit fell in the void after catching fire??

Almost !!

Another!

Almost !!

At least they had a little fun with this one!

Almost !!

Who keeps leaving the coffee pot on? Hint: the cleaning crew …

Almost !!

Why did you “pop” open the trunk to gas up?

Almost !!

Which one turns on the fan? Gold tassel for light (golden rays of sunshine??…)

Almost !!

Almost !!

Where’s the flusher?

Almost !!

Where’s the flusher?

Almost !!

How do you turn on the shower?

towards their goals, but there are two big ones to look out for:Remove And Combine FunctionsFirst, most websites have way too many things that are clickable. Try to eliminate unnecessary functionality, and if you can’t get rid of it, try combining it with something else if it makes sense to do so. For example, many shows will combine temperature and water pressure into 1 knob. This eliminates the user’s ability to create a “hot-but-low-pressure” shower, but most people wouldn’t want that anyway. Minimizing functionality and clickable elements might seem obvious, but if your website is old and has suffered from some feature creep, it might be time to do some spring cleaning with a fresh perspective.Avoid Failure StatesSecond, don’t allow the user to do things that could result in a failure state. I’ve seen way too many forms that let me type in lots of invalid input before submitting. It’s only after I click the button I find out that “usernames must be 8 characters long” or that I mistyped my email address or something else stupid (can you sense the frustration?).

Almost !!

http://blog.teamtreehouse.com/poka-yoke-the-quest-for-mistake-proof-designs

What is the Purpose of Poka-yoke?

Prevent a foolish action through 3 functions:

SHUT DOWN a process, machine or operation

CONTROL a process, machine or operation

WARN that a defect (is about to occur or) has occurred

Why don’t you want to Improve ?

• Stuck in a rut! – (with associated ‘work-arounds’)

• Comfortable with your problems/errors

• Not feeling enough pain to do something different

• Waiting for something to happen

Maybe, you just don’t know what to look for…

Top Causes of Errors

• Processing omissions: leaving out one or more process steps

• Processing errors: process operation not performed according to the standard

• Error in setting up: using wrong tooling or incorrect setting/ adjustment

• Missing parts: not all parts are included in assembly/ process

• Improper part/ item: wrong part installed in assembly

Top Causes of Errors• Processing wrong work piece: wrong part

machined/ processed• Operations errors: incorrect revision or

specification sheet• Errors in equipment, maintenance or

repair: Defects caused by incorrect repairs or component replacement

• Error in preparation of inspection equipment, fixtures or tools: Damaged inspection tooling; poorly designed fixtures or wrong tools; mis-measurement

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Why a “Poka-Yoke” Hierarchy?

So you don’t have to “fix” the problem again!

Full Automation

Awareness

Fail-Proof

Simplification

Training

Behavior typically reverts back

The process is changed to be less dependent upon people

Most Desired

Least Desired

• No Manual Intervention

• Impossible to Fail

• Eliminate Activity

• Certification and Audits

• Notification

38

Why a “Poka-Yoke” Hierarchy?

So you don’t have to “fix” the problem again!

Full Automation

Awareness

Fail-Proof

Simplification

Training

Behavior typically reverts back

The process is changed to be less dependent upon people

Most Desired

Least Desired

• No Manual Intervention

• Impossible to Fail

• Eliminate Activity

• Certification and Audits

• Notification

39

Why a “Poka-Yoke” Hierarchy?

So you don’t have to “fix” the problem again!

Full Automation

Awareness

Fail-Proof

Simplification

Training

Behavior typically reverts back

The process is changed to be less dependent upon people

Most Desired

Least Desired

• No Manual Intervention

• Impossible to Fail

• Eliminate Activity

• Certification and Audits

• Notification

2 states for Poka-Yoke

Occurrence – is the situation as it happens (occurs)

Detection – the situation should alert at the point of mistake [“Shutout” is best]

Occurrence Poka-YokeOccurrence is the situation as it happens (occurs), but … sometimes after the fact also. • An example would be a buzzer or warning light.

– a fire alarm is a type of “Occurrence ” Poka-Yoke.

Occurrence Poka-YokeOccurrence is the situation as it happens (occurs), but … sometimes after the fact also. • An example would be a buzzer or warning light.

– a fire alarm is a type of “Occurrence ” Poka-Yoke.

In general, Occurrence situations that merit ‘Poka-Yoke’ can happen

if there is a chance that:• the required action is not performed• the required action is performed incorrectly• the complexity of process could lead to defects• information required to perform an action is not

understood or easily misinterpreted

Occurrence -example• Computer Start-up Routines

– [password/log-in/pin etc]

• Computer Shut-down Routines• [series of low battery warnings/ actions taken]

Occurrence

For this situation, it’s important to follow these guidelines:

• At assembly, make sure that the wrong parts do not join together (think of Lego pieces that cannot join because they are not from the same Lego set)

• Use of 100% prevention devices such as contoured locators or fitted templates

Occurrence -example

Modern ATM Machines – address this concern: … chance that the complexity of process could lead to defects

Detection Poka-Yoke

In Detection, the situation should alert the operator at the point of mistake

• For example, when one makes a mistake, an effective Poka-Yoke system will alert the operator that a mistake

• was made,

• where it was made,

• and even how the mistake was made

Detection -example

In Detection, these situation should alert the operator at the point of mistake

• Four xample, when one makes a misteak, an effective Poko-Yoke system will alert the operotor that a misteak was made, where it was made, and even how the misteak was made

DetectionHere are some techniques for detection oriented Poka-Yoke:

• Use color coded parts/graphics or images

• Before the fact, or before the defective part proceeds to the next step in the process, a Poka-Yoke system should alert the operator that 100% quality does not exist

• It should be autonomous, or require almost zero intervention, but be an automatic response to a defect; almost reflexive

Detection -example• IS GAS CAP SECURE?– Tighten till you hear the “click”

Detection -example• ARE YOU LOW ON GAS? (but… how low?)

- Detection

Detection -example• LOW ON AIR? (but … which tire?)

- Detection

What are the Conditions? (ripe for poka-yoke)

1. Adjustments

2. Unclear or no instructions

3. Undefined process

4. Many units/mixed units

5. Multiple steps

6. Infrequent production

7. Ineffective or lack of standards

8. Multiple handoffs

9. Hand processing

10.Rapid repetition

11.High volume demand or deadline pressures

12.Environmental conditions

Go Forth

• Identify what your impediments to improvement are and work on those.

• In particular - what are barriers to higher equipment uptime, higher process capability, safer equipment, higher capital and labor productivity without adding cost or more highly trained personnel, and you will be on the right track.

• I call this building better process stability.• Implement One Idea.

Surfin’ for Ideas?

Better Practice Sharing

A Better Practice …

Use CAPS: (Action Verb) then, the event …

In your Outlook Calendar

A Better Practice …

Flow control (3 lanes and 3 cash registers)

A Better Practice …

Label, Label, Label Color code …

A Better Practice …

Which side is gas cap on?…

Points to left side (see arrow)

A Better Practice …

Sign (Warning) Metal tabs (Shut-out)

Which one is the fork?

Visual Management…

A Better Practice …

Countdown to Takeoff –Get on the plane,

people !!

A Better Practice …

Major Airline /Jet way Instruction … bumper within 1”, but not touching

A Better Practice …

A Better Practice …

Green tag for “Carry On” bags that had to be checked.

A Better Practice …

Automatic flush, soap, and water . A locked trash receptacle. Also, a touch-less motion sensor on paper towels…

A Better Practice …

Slotted metal guard (“stand-off”) to prevent accidently stopping luggage conveyor at the airport.

A Better Practice …

A Better Practice …

HEAT INDEX ALERT (signage) for outside operations. Cool down stations / water identified (in blue) …

A Better Practice … P.P.E. REQUIREMENTS to enter into the operation. Steel toe shoes, reflective vest, hard hat, etc.

A Better Practice …

COFFEE/ SINK AREA (signage) for galley operations. Considerate but firm…

A Better Practice …

TIME ALERT (signage) for coffee operations. Denotes how long coffee has been sitting…

A Better Practice …

COFFEE STATION / ORGANIZATION (standard layout) Visual indicator for supplies…

• Retraining people.• Disciplining people who make mistakes.• Work instructions.• Improving the attentiveness of people.• Increased human attention or intervention.

• Poka-Yoke means “mistake proofing”.• Poka-Yoke focuses on preventing and detecting

mistakes before they become errors…• Poka-Yoke is classified as a control method but

can be considered as a solution to a problem as well if it prevents it from occurring.

What Poka-Yoke IS NOT:

What Poka-Yoke IS:

Summary

What Did We Cover Today?In general, ‘Poka-Yoke’ (mistake-proofing) should ultimately be to prevent a foolish action:

Common Guidelines for Poka-yoke (inexpensive, common sense, attack the root cause)

BTW: Don’t do “Fake” Poka-Yoke

Purpose of Poka-yoke (S,C,W)

States – (Occurrence/ Detection)

Operating ‘Conditions’ in which they breed … (multiple handoffs, undefined processes, adjustments, etc)

Better Practice Sharing (they’re out there…)

And, NOW - What is Your Poka-Yoke?

An idea you can put into practice…

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