11 - Mistake Proofing

MISTAKE-PROOFING
AND
DEFECT PREVENTION
(POKA-YOKE)
11/02/10 1
Confidential Company Information
Module Objectives
• Understand concept of mistake proofing and its relationship

to defect prevention and product quality.
• Review the tools associated with Mistake-Proofing.
• Discuss opportunities to most effectively utilize these tools.
11/02/10 2
Quality
We are
99%
Good!
Is this good enough?

11/02/10 3
Practical Meaning
99% Good (3 Sigma Process) 99.99966% Good(6 Sigma Process
Postal System
00 Lost Articles Of Mail / Hr 7 Lost Articles / Hr
ne System
Short/Long Landings / Day 1 Short / Long Per 5 Years
ical Profession
000 Wrong Drug Prescriptions / Year 68 Wrong Drug Prescrip
11/02/10 4
What Does 6 Sigma Mean In Your Daily Life ?
PPM
Prescription Writing
IRS - Tax Advice Restaurant Bills

1,000,000 Payroll Processing
100,000
Baggage Handling
10,000
1,000
100
10
Airline
1 Safety Rate
1 2 3 4 5 6 7
Sigma Level
11/02/10 5
Defects and its impact
• Defect free product is a necessity to compete in the

market place. Every Customers has a right to demand
100% good product /service and every provider has an
obligation to provide the same.
• Bad products hurt both reputation and bottom line (Scrap,

rework, warranty….etc.,.)
• Defects have a direct impact on process yield affecting

speed and flow of the product to the customer.
11/02/10 6
Poka-Yoke
• Poka-Yoke in Japanese means mistake proofing. It is the
creation of devices that either makes it impossible to make
mistakes or makes the mistake obvious or detect errors that
have occurred.
• Mistake-Proofing techniques can drive defects out of products

and processes and substantially improve quality and
reliability.
• Any defect or non-conformance to CTQ can be major sources

of customer dissatisfaction and hidden cost for the producer.
• A mistake or an error becomes a defect when it is undetected

or prevented and makes it way to the next operation or to the
customer.
11/02/10 7
Typical Errors
• Processing errors • Wrong parts
• Missing Operation • Damaged materials
• Inappropriate procedures • Tools or equipment

improperly prepared or setup
• Missing parts
• Human Errors
• Missing information
11/02/10 8
Ten Types of Human Error
Forgetfulness:
Sometimes we forget things when we are not concentrating
Example: Air line ticking agent forgets to ask for an ID
2. Errors due to misunderstanding:

Sometimes we make mistakes when we jump to the wrong
conclusion before we’re familiar with the situation.
Example: A person not used to a car with automatic
transmission steps on the brake, thinking it is the clutch.
Errors in identification
Sometimes we incorrectly asses a situation because we vie
it too quickly or are too far away to see it clearly.
Example: A $1 bill is mistaken for a $100 bill.
11/02/10 9
Ten Types of Human Error (Contd.)
4. Errors made by amateurs
Sometimes we make mistakes because of our lack of
experience.
Example: New worker does not know the process or is
just
Willful errors
barely familiar with it.
Sometimes errors occur when we decide that we can ignore
rules under certain circumstances.
Example: Crossing a street against a red light because there are
no cars in sight.
Inadvertent errors
Sometimes we make mistakes inadvertently or without realizing
it.
Example: Someone lost in thought tries to cross the street
without noticing that the light is red.
11/02/10 10
Errors due to slowness
Sometimes we make mistakes because our actions are slo
down by our delays in judgement.
Example: A person learning to drive is slow to step on
the brake.
Errors due to lack of standards
Some errors occur when there are no suitable instructions
work standards.
Example: A measurement may be left to an individual
worker’s discretion.
Surprise errors
Errors sometimes occur when equipment runs differently
than expected.
Example: A machine malfunction without warning.
11/02/10 11
. Intentional errors
Unfortunately, some people make mistakes deliberately,
in an attempt to sabotage or commit a crime. These are lea
common, and should be dealt with as special cases.
istakes happen for many reasons, but almost all can be

revented if we take the time to identify when and why they
appen and then take steps to prevent them by using
istake proofing methods.
11/02/10 12
Inspection
Can we Eliminate defects only by

Inspection?
11/02/10 13
The Inspection Exercise
Count the number of times the 6th letter

of the alphabet appears in the following text:
The necessity of training farm hands for the first

class farms in the fatherly handling of farm live stock
is foremost in the eyes of the farm owners. Since the
forefathers of the farm owners trained the farm hands
for first class farms in the fatherly handling of farm live
stock, the farm owners felt they should carry on with
the family tradition of training farm hands of the first
class farmers in the fatherly handling of farm live stock
because they believe it is the basis of good
fundamental farm management.
11/02/10 14
The necessity of training farm hands for the first

class farms in the fatherly handling of farm live stock
is foremost in the eyes of the farm owners. Since the
forefathers of the farm owners trained the farm hands
for first class farms in the fatherly handling of farm live
stock, the farm owners felt they should carry on with
the family tradition of training farm hands of the first
class farmers in the fatherly handling of farm live stock
because they believe it is the basis of good
fundamental farm management.
11/02/10 15
Theory of Escaping Defects
Escaping Defects
Escaping Defects
Total Defects/Unit
No matter how good your inspection and test processes are, the
more defects you create, the more defects escape to the customer
11/02/10 16
The necessity in training hired hands in the strange

handling of valuable live stock in premier operations is
a priority in the eyes of the operations owners. Since
the ancestors of the owners trained the hired hands in
premier operations in the strange handling of valuable
live stock, the operations owners thought they should
carry on with the happy tradition of training hired
hands in the premier operations in the strange
handling of valuable live stock because they believe it
is the basis of good basic operations management.
11/02/10 17
The necessity in training hired hands in the strange

handling of valuable live stock in premier operations is
a priority in the eyes of the operations owners. Since
the ancestors of the owners trained the hired hands in
premier operations in the strange handling of valuable
live stock, the operations owners thought they should
carry on with the happy tradition of training hired
hands in the premier operations in the strange
handling of valuable live stock because they believe it
is the basis of good basic operations management.
11/02/10 18
Why Is Defect-Free Production So
Important?
• What is the Rolled Throughput Yield if a product is built
at five workstations and each has a yield of Y%?
Workstations
#1 #2 #3 #4 #5
#1 #2 #3 #4
#5
Y = 95% Rolled Throughput Yield = _____%

Y = 99% Rolled Throughput Yield = _____%
A comparatively small improvement in

yield
results in an enormous improvement
in production.
11/02/10 19
Why Is Defect-Free Production So
Important?
• What is the Rolled Throughput Yield if a product

is built at five workstations and each has a yield
of Y%? #1 #2 #3 #4 #5
Workstations
#1 #2 #3 #4 #5
Y = 95% Rolled Throughput Yield = 77.3%

Y = 99% Rolled Throughput Yield = 95 %
A comparatively small improvement in

yield
(from 95 to 99%) results in an
11/02/10
enormous improvement in RTY (From 20
Financial Impact
REJECTION INSPECTION DETECTION PREVENTION

Too Late After the Fact Before It Before it
Before it Ships Escapes Your Happens
Process Step
11/02/10 21
Defect Detection and Prevention
Strategies
Feedback Feedback Feedback

Finished
Inspect
Inspect
Inspect
Finished
Inspect
Inspect
Inspect
Process
Process Process
Process Process
Process Goods/
AA BB BB Goods/
Shipping
Shipping
Successive Checks
• Each process inspects previous process
• Typically, 3 or less critical checks per step
• Effective with small transfer quantities from process to process.
Feedback Feedback Feedback

Finished
Inspect
Inspect
Inspect
Finished
Inspect
Inspect
Inspect
Process
Process Process
Process Process
Process
A
A B
B B
B
Goods/
Goods/ Self-Checks
Shipping
Shipping
• Find defects as they exit process, Immediate feedback & corrective action.
• Stops adding value to defective product.
Prevent the defect from occurring in the first place Poka-Yoke

or to make it immediately evident
11/02/10 22
Some Mistake-Proofing Strategies
• Make it harder to create the error
• Make it possible to reverse the error

• Make it obvious that the error has occurred
• Detect deviations from procedures or fixed values (e.g., Number
of parts)
• Design:
– Design process so it tolerates the error and doesn’t result in a defect

– Design process to decrease complexity
11/02/10 23
Approaches to Mistake Proofing
• Control approach
• Shuts down the process when an error occurs

• High capability of achieving zero defects (ie robust design that can tolerate variation or
eliminates variation or assembly mistakes)
• Warning approach
• Signals the operator to stop the process and correct problem or check for a problem (ie
are parts still ok, is oil level ok)
• Sometimes an automatic shutoff is not an option
• Dials, lights, and sounds to bring attention to the problem
– Automatic email or phone to inform issues
– Safety scorecard that appears when you boot your PC when on the RS network that alerts you to the
plant’s safety metrics.
11/02/10 24
Mistake Proofing Devices
• Types of mistake proofing devices within control or warning

approach can be of:
– Contact type:
• The contact type makes contact with every product or has a physical
shape that inhibits mistakes.
– Example: Fixed diameter hole through which all products must fall and an oversize
product does not fall through and a defect is registered.
– Fixed value type:
• The fixed value method is a design that makes it clear when a part is
missing or not used.
– Example: “Egg tray” used for supply of parts,
– Motion step type:
• The motion step type automatically ensures that the correct number of
steps have been taken.
– Example: An operator is required to step on a foot pedal every assembly cycle, Check
lists, Correct sequence for switches that do not work unless the order is correct.
11/02/10 25
Summary of Mistake Proofing Types
Control Warning
Contact Parking height bars Shop entrance bell
Fixed Value French fry scoop Trays with indentation
Motion Step Foot pedal operated Machine Beepers on ATM
11/02/10 26
Breakout
• Break into Teams

• In 10 minutes, name mistake proofing devices
that exist inside an automobile:
_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
11/02/10 27
Everyday Examples of Mistake
Proofing
• Home
– Automated shut-offs on electric coffee pots
– Child-Proof caps on mediations
– Ground fault circuit breakers for bathrooms or outside electric
circuits
• Office
– Spell check in word processing
– Question prompt “Do you want to delete?” after depressing the
“Delete” button on your computer.
• Factory:
– Dual palm button and light curtains on machines
– Loc-out / Tag-out
• Retail:
– Tamper-Proof packaging
– Bar coding at checkout.
11/02/10 28
Control Approach
Automobile controls have Electronic door locks can have three

a mistake-proofing device mistake-proofing devices:
• Insures that no door is left unlocked.
to insure that the key is in
• Doors automatically lock when the car
the on position before exceeds 18 miles an hour.
allowing the driver to shift • Lock won't operate when door is open and
out of park. The keys the engine is running.
cannot be removed until
the car is in park.
11/02/10 29
Control Approach (Contd.)
Stove burner turns off automatically when pot or pan is

removed.
11/02/10 30
Control Approach (Contd.)
Manhole covers are round because if they were of any other

shape (Ex: Square) it would be possible to accidentally drop
one through the hole while removing it.
11/02/10 31
Warning Approach
Warning lights alert the driver of potential problems.

These devices employ a warning method instead of a
control method.
(Seatbelts, High engine temperature, Low oil pressure)
11/02/10 32
Furnace Blower Door Latch
Will only engage on 1 side.
11/02/10 33
Name Plate
Badge plate holes of

different sizes prevent
assembly of names
plates upside down and
insure plate is level for
appearance CTQ
11/02/10 34
AMP Connectors on IFC Boards
Shape of mating
holes allows for
only one way to
assemble the
connector
11/02/10 35
IFC Board
IFC Board Standoffs that prevent

shorting due to IFC flexing if excessive
force is used to install a harness
connector or wire terminal
11/02/10 36
Silicon Carbide Ignitor Silicon Nitride Ignitor
Wiring Harness for Wiring Harness for

Silicon Carbide Ignitor Silicon Nitride Ignitor
The reversed male and female pins prevent

assembly of Silicon Carbine Ignitor wiring harness
11/02/10 and Silicon Nitride
37 Ignitor and vice versa
Areas Where Mistake Proofing Should be
Considered…..
Where:
 worker attention is needed (manual operations)
 mispositioning is likely.
 adjustment is required.
 SPC is difficult to apply or ineffective.
 training cost and employee turnover are high.
 mixed model production occurs.
 Opportunity for customers to make mistakes
exist.
 field failures are extremely expensive.
11/02/10 38
Examples of Some Useful Mistake-Proofing Devices
• Guide pins, to assure that parts can only be assembled in

the correct way.
• Limit switches, that sense the presence or absence of a part.
• Mistake-proofing jigs, detect defects immediately upstream
of the process ensuring that only the correct part reach the
process.
• Counters, that verify that the correct number of parts or steps
have been taken.
• Checklist, that reminds operators to do certain actions.
• Parts are designed to be robust. (i.e rounded corners to
reduce lacerations. Part standardization to reduce assembly
choices, Parts purchased with gaskets pre-applied so they
can not be omitted due to operator error )
11/02/10 39
Mistake-Proofing
• What are some of the mistake-Proof devices

in your area?
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
11/02/10 40
Levels of Mistake-Proofing
• Level 1 (Best): Process can only be performed correctly. 100%

prevention and make it impossible for errors to occur.
Example:
– Name plate can not be printed or Air handler can not be packed
until the unit has
passed Run Test & Mass Spec.
– Can not “run test” an Air handler unless the blower, Wrapper and
coil bar code matches.
– Inlet and outlet of Driers are of different size preventing assembly
of driers in reverse.
• Level 2 (Better): Detect any mistake as being produced. (Ex: Auto

spell checker in word processor )
• Level 3 (Good): Detect before passing to next operation. (Ex: Mass

spec of coils)
11/02/10 41
Check Assumptions of the Control Plan
Auto Spell check is not foolproof

Human Brain Not Yet Obsolete
I
Eye have a spelling checker,
It came with my PC.
for review
It plainly marks four my revue
I not see
Mistakes eye can knot sea.
through
I’ve runyou’re
this poem threw it
pleased to know
I’m sure your please its
two no.
way
It’s
Its letter perfect in it’s weigh,
told so
My checker tolled me sew.
11/02/10 42
Seven Step Mistake-Proofing Process
Define:
Define:
(1) Identify and describe the defect or potential defect
Measure:
(2) Document defect rates.
Analyze:
Analyze:
(3) Identify:
 Where the defect is made
 Where the defect is discovered
(4) Detail the Sequence of events documented in the standard where the defect is made and determine the deviation from standard.
(5) Determine the root cause of the defect or error condition that is contributing to the defect. (Refer to the observations in step 4 and
Why (5 Whys) the error happens until the root cause is identified). Do not try to develop device yet!!!
Improve and Control:
(6) Identify mistake-proof ideas / devices to prevent the error or defect.
(7) Create a mistake-proof device or implement other mistake-proof solution and try-storm it.
Mistake proof the mistake proof and establish relevant control plan. Ensure that the proposed change is evaluated against
“Process change management” and safety criteria.
11/02/10 43
Mistake-Proofing
• Post-It notes or cards of different colors can be used for

this purpose.
• Example:
– White Post-it can be used to record each element of the operation
where the defect is made in Step 4
– Yellow Post-it to record specific errors, deviation from sequence
or other possible causes of the defect
– Blue Post-it to record ideas for defect prevention that could lead to
mistake-proof devices.
Error and idea writing guidelines
1. Write only one element, cause or idea per note or card

2. Be specific and concrete
3. Use a full sentence – not a phrase or word
4. Write so that other can read
11/02/10 44
Safety, Quality and Productivity
• When arriving at Mistake proofing solution, it

is essential to carefully review impact of the
proposed solution on Safety, Quality and
Productivity (Ex: Process change
management criteria) in addition to ease of
implementation, effectiveness of the device
and cost-benefit impact.
11/02/10 45
Team Work (Proposal 1)
• Each team identify a process from your work area that is producing defects or
has an opportunity for mistake.
• Teams will develop a mistake proof solution based on 7 steps of mistake proofing
(Use the concepts of Poka Yoke strategies, approaches and devices).
• Use the Post-it note method to run the exercise
• Recommend an optimum mistake proofing solution based on effectiveness, cost-

benefit and ease of implementation.
11/02/10 46
Mistake Proofing Example
EXAMPLE OF MISTAKE PROOFING WORK SHEET
Product: Impack Process: Assembly Date:
1. Define and describe the defect : Wrong compressor 2. Measure : (Defect or Incident rate)
Current defect rate at final inspection = 2.5%
3. Location at which Defect is:
Discovered Final Inspection
Produced Station 1
4. Detail the process steps at which defect is made:
Read the compressor model number from the computer screen - Obtain compressor - Assemble on to the base pan - Move unit to next station
5. Analyze : (Investigate and analyze root causes for error)

Factor Cause Factor Cause
Method Not verifying the compressor
6. Improve (Ideas to eliminate or detect early)

Levels of Mistake Proofing: Level 1: 100% Prevention Level 2: Detect as being produced Level 3: Detect before pass to next operation
Cause Mistake Proofing Idea Level Implementation Difficulty Time required Cost
(Easy, Medium, High) (<1 wk, 1-4wk, 4-12 wk, 12-24 wk)
Not verifying the compressor - Auto verify unit model &compressor Level 2 Medium 4-12 weeks $500
- Unit will not be moved to the next
station without postively verifying
compressor.
7. Create Mistake Proof device:

Current conditon:
Operator picks the compressor by reading the model number off the label and places it on the basepan.(The model number is shown by the computer) - Exclusively
human verification
Mistake proof device:

Scanner with system (soft) and conveyor (hard) lock. Operator scans lay-in card and compressor bar code. System does auto-verification validating right compressor
for the unit and accepts only valid compressor bar code. If there is a wrong compressor bar code scanned, the system will not allow operator to initiative lay-in of the
next unit. Further, it will lock the conveyor gate thus not allowing operator to release the unit to the next station.
11/02/10 47
Set a Standard
• Errors are not acceptable
• Use cross-functional teams to design and maintain

processes to be robust
• Make it right the first time
– Good: Design products and processes so that we make it

right the first time
– Best: Design products and processes so we CAN’T make it

wrong any time and get a concurrent productivity
improvement
11/02/10 48
Summary
Why Mistake-Proof?
• Judgment inspection cannot eliminate all defects
• It is natural for humans to make errors
• Errors can be eliminated or stopped from becoming defects by using

mistake proofing concepts and devices.
What are the costs and benefits?
• Devices tend to be inexpensive
• 10:1, 100:1, 1000:1 rates of return cited
11/02/10 49
Team Work (Proposal 2)
• Business, quality or OF leader will propose an area to

apply Mistake proofing.
• Teams will be assigned to the area.
• Teams will go through the methodology and recommend

an optimum solution.
• Winning team is selected. (Ex: Based on effectiveness,

cost-benefit and ease of implementation).
11/02/10 50

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MISTAKE-PROOFING

• Understand concept of mistake proofing and its relationship

• Review the tools associated with Mistake-Proofing.

• Discuss opportunities to most effectively utilize these tools.

Is this good enough?

99% Good (3 Sigma Process) 99.99966% Good(6 Sigma Process

IRS - Tax Advice Restaurant Bills

• Defect free product is a necessity to compete in the

• Bad products hurt both reputation and bottom line (Scrap,

• Defects have a direct impact on process yield affecting

• Mistake-Proofing techniques can drive defects out of products

• Any defect or non-conformance to CTQ can be major sources

• A mistake or an error becomes a defect when it is undetected

• Processing errors • Wrong parts

• Missing Operation • Damaged materials

• Inappropriate procedures • Tools or equipment

2. Errors due to misunderstanding:

istakes happen for many reasons, but almost all can be

Can we Eliminate defects only by

Count the number of times the 6th letter

The necessity of training farm hands for the first

The necessity of training farm hands for the first

The necessity in training hired hands in the strange

The necessity in training hired hands in the strange

Y = 95% Rolled Throughput Yield = _____%

A comparatively small improvement in

• What is the Rolled Throughput Yield if a product

Y = 95% Rolled Throughput Yield = 77.3%

A comparatively small improvement in

REJECTION INSPECTION DETECTION PREVENTION

Feedback Feedback Feedback

Feedback Feedback Feedback

Prevent the defect from occurring in the first place Poka-Yoke

• Make it harder to create the error

• Make it possible to reverse the error

– Design process so it tolerates the error and doesn’t result in a defect

• Shuts down the process when an error occurs

• Types of mistake proofing devices within control or warning

Contact Parking height bars Shop entrance bell

Fixed Value French fry scoop Trays with indentation

Motion Step Foot pedal operated Machine Beepers on ATM

• Break into Teams

Automobile controls have Electronic door locks can have three

Stove burner turns off automatically when pot or pan is

Manhole covers are round because if they were of any other

Warning lights alert the driver of potential problems.

Will only engage on 1 side.

Badge plate holes of

IFC Board Standoffs that prevent

Wiring Harness for Wiring Harness for

The reversed male and female pins prevent

• Guide pins, to assure that parts can only be assembled in

• What are some of the mistake-Proof devices

• Level 1 (Best): Process can only be performed correctly. 100%

• Level 2 (Better): Detect any mistake as being produced. (Ex: Auto

• Level 3 (Good): Detect before passing to next operation. (Ex: Mass

Auto Spell check is not foolproof

• Post-It notes or cards of different colors can be used for

1. Write only one element, cause or idea per note or card

• When arriving at Mistake proofing solution, it