Chapter 1
Chapter 1
INTRODUCTION
Poka-yoke—Mistake proofing
Shigeo Shingo is considered the father of poka-yoke, and is often quoted as saying, "The idea
behind poka-yoke is to respect the intelligence of workers by taking over repetitive tasks or
actions that depend on the vigilance of memory." This process includes adding features to a
design or process to assist the operator in the performance of the task.
Poka-yoke, in any of the various spellings, is another name for error- or mistake-proofing a
design or process. The focus of poka-yoke is to sensitize us about the differences between
prevention and detection and to do something about it. Prevention prevents errors from occurring
or prevents those errors from causing defects. Detection identifies a defect and immediately
initiates a corrective action to prevent multiple defects from leaving the workstation.
Detection devices are used to deal with an error that is difficult to eliminate, or is in the process
of being located. The main idea of a prevention approach is to keep an error from producing
multiple defects. Sometimes the error (or root cause) of the defect is hard to find. In this case, it
is often profitable to create solutions that detect and react to an error or a defect instead of
preventing an error or a defect. Such devices are detection devices.
Using detection devices in error-proofing is different from regular product or process inspection.
Error-proofing initiates a corrective action once an error or defect has been detected. Regular
product or process inspection should not be referred to as error-proofing unless the inspection is
tied to an immediate corrective measure. An example of inspection that is not tied to an
immediate corrective action is SPC (statistical process control) or a continual inspection with a
process controller.
The Poka-Yoke philosophy requires a strong foundation in TQM (Total Quality Management).
First, organisations must learn to be customer focused. As Tom Peters once said, "The customer
comes first, second, third, fourth, fifth, and there ain't no sixth! "
Second, organisations must promote quality ownership at the source, and they need to ensure
proper investment in their people, which enables them to be truly empowered. Third, a clear
distinction has to be made between good versus bad quality.
Fourth, organisations must embrace the PSP philosophy: Pre-, Self-, and Post-Inspection at the
source. Last, Poka-Yokes require real-time feedback and corrective action. These are the
building blocks of an effective Poka-Yoke effort.
Mistakes happen in organisations for many reasons, but almost all of them can be prevented, if
people make the effort to identify when problems happen, define root causes, and then take the
appropriate corrective measures. The objective is to prevent, or at least, detect and weed out
defects, as early as possible in the process. The use of simple Poka-Yoke mechanisms and other
safeguards can help prevent mistakes from leading to catastrophic events.
1.1 HISTORY
The term poka-yoke was applied by Shigeo Shingo in the 1960s to industrial processes designed
to prevent human errors Shingo redesigned a process in which factory workers, while assembling
a small switch, would often forget to insert the required spring under one of the switch buttons.
In the redesigned process, the worker would perform the task in two steps, first preparing the two
required springs and placing them in a placeholder, then inserting the springs from the
placeholder into the switch. When a spring remained in the placeholder, the workers knew that
they had forgotten to insert it and could correct the mistake effortlessly.
Shingo distinguished between the concepts of inevitable human mistakes and defects in the
production. Defects occur when the mistakes are allowed to reach the customer. The aim of
poka-yoke is to design the process so that mistakes can be detected and corrected immediately,
eliminating defects at the source.
1.2 THE NEED FOR POKA-YOKE
History shows that no matter how much we train the operator or document the process, human
error occurs. Poka-yoke is the methodology of reducing or eliminating human error, which
causes defects. The methodology is based on two essential attitudes about human behavior:
mistakes are inevitable, and errors can be eliminated. Based on these attitudes the following
corollary assumptions may be made about work processes and workers:
A poka-yoke methodology alters the work environment with a goal of reducing human errors and
their defects.