Mistake Proofing and Poka - Yoke

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 Outline
 What is Mistake Proofing?
 Everyday Examples
 Effectiveness & ROI
 Error Proofing and SPC
 Inspection Techniques
 Types of Poka Yokes

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 What is Mistake Proofing?
• The use of process or design features to prevent errors
or their negative impact.
• Also known as Poka yoke, Japanese slang for “avoiding
inadvertent errors” which was formalized by Shigeo
Shingo.

• Inexpensive.
• Very effective.
• Based on simplicity and ingenuity.

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 Principles of Mistake-proofing / Poka-Yoke

1. Elimination (“don’t do it anymore”) is to eliminate the

possibility of error by redesigning the product or process so that the
task or part is no longer necessary.
2. Prevention (“make sure it can never be done wrong”) is to
design and engineer the product or process so that it is impossible to
make a mistake at all.
3. Replacement (“use something better”) is to substitute a more
reliable process to improve consistency.
4. Facilitation (“make tasks easier to perform”) is to employ
techniques and to combine steps to make work easier to perform.

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.
 Principles of Mistake-proofing / Poka-Yoke
5. Detection (“notice what is going wrong and stop it”) is to
identify an error before further processing occurs so that the
user can quickly correct the problem.
6. Mitigation (“don’t let the situation get too bad”) is to seek
to minimize the effects of errors

Elimination, Prevention, Replacement and Facilitation are to

avoid the occurrence of mistakes. Detection and Mitigation are
to minimize the effects of mistakes once they occur.

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 When and How to Use it?

 Processing error: Process operation missed or not performed

per the standard operating procedure.
 Setup error: Using the wrong tooling or setting machine
adjustments incorrectly.
 Missing part: Not all parts are included in the assembly,
welding, or other processes.
 Improper part/item: Wrong part used in the process.
 Operations error: Carrying out an operation incorrectly;
having the incorrect version of the specification.
 Measurement error: Errors in machine adjustment, test
measurement, or dimensions of a part coming in from a supplier.

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 Benefits Of Poka- Yoke
 Assures 1st Piece Quality
 Assures Consistency during Set-Ups
 Prevents Production of Defective Parts
 Makes Quality Problems More Visible
▪ Creates a Safer Work Environment
 EliminatesWaste of Inspection and Repair
 Lowers Cost of Design (DFM) and Cost to Manufacture (Poka-Yoke
Devices)
 Eliminates our dependance on Operators knowledge & vigilance
reduces the chance of defective parts being sent to customer.

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 Everyday Examples
Which dial turns on the burner?

Stove A

Stove B
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 Everyday Examples
How would you operate these doors?

Push or pull? left side or right? How did you know?

A B C

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 Everyday Examples

3.5 inch diskettes cannot be inserted unless diskette

is oriented correctly. This is as far as a disk can be
inserted upside-down. The beveled corner of the
diskette along with the fact that the diskette is not
square, prohibit incorrect orientation.

Fueling area of car has three error-proofing devices:

1. insert keeps leaded-fuel nozzle from being
inserted
2. tether does not allow loss of gas cap
3. gas cap has ratchet to signal proper tightness and
prevent over tightening.
New lawn mowers are required to have a safety bar
on the handle that must be pulled back in order to
start the engine. If you let go
of the safety bar, the mower blade stops in 3
10 seconds or less.
OM
 Everyday Examples

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 Everyday Examples

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 Everyday Examples
Whose signature is required?

Before:

After:

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 Evidence of the Effectiveness

 AT&T Power Systems is first US manufacturer to win the Deming prize.

Average outgoing defects reduced by 70%
 A washing machine drain pipe assembly line produced 180,000 units without a
single defect (6 months).
 TRW reduced customer PPM’s from 288 to 2.
 Federal Mogul: 99.6% less customer defects and 60% productivity increase
 DE-STA-CO: reduced omitted parts 800 to 10 ppm with a 15-30%
productivity increase

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 Evidence of the Effectiveness

Cooper Automotive:
 95% less defects than nearest competitor
 75% less injuries
 99.6% less customer defects (13 ppm)
 88% in-plant defect reduction
 70% less warranty cost
 89% scrap reduction (0.7%)
 60% productivity increase

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 Mistake Proofing ROI
 Dana corporation has reported a $500,000 savings resulting from a $6
device
 Ortho-Clinical Diagnostics (Johnson & Johnson) saved $75000
annually by discovering a new use of Post-It® notes
 AT&T Power Systems (Lucent Technologies) reported net saving of
$2545 per device (3300 devices)
 Weber Aircraft reports saving $350,000 during their first year of
implementation of approximately 300 devices.
 GE Aircraft Engines spends a minimum of $500,000 on any in-flight
shut-down (IFSD). Spending $10,000 to stop one IFSD yields 50:1
benefit

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 How to do Error Proofing

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 Tools for Analysis

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 Cost of Poka Yoke Devices

Cost of Poka Yoke Devices

1
0.9
0.8
0.7
Proportion

0.6
Frequency of Occurrence
0.5
0.4 Cumulative Proportion
0.3
0.2
0.1
0
$100 to$250

$250 to $1000
$25 or less

$1000 or more
$25 to $100

Cost
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 Costs of Defects

Does it cost more to make processes better ?

No Making processes better leads to reduced
• Rework
• Scrap
•Warranty costs
• Inspection costs

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 1-10-100 Rule

The 1-10-100 rule states that as a product or service

moves through the production system, the cost of
correcting an error multiplies by 10.

Activity Cost
Order entered correctly $1
Error detected in billing $ 10
Error detected by customer $ 100

Dissatisfied customer shares the experience with others…

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 Mistake proofing Puts
“Knowledge in the World”
In addition to “Knowledge in the Head”

Head: World:
 Provide clues about what
 “Improve” SOPs (increasing to do
complexity?)  Change process design:
 Retrain embed the details in the
process
 Re-certify skills  Frees mind to consider
 Manage & enhance the “big picture”
 Facilitates “knowledge
attentiveness
work”

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 No System of Barriers is Perfect…

Error

Harm

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 No System of Barriers is Perfect…
…But improvements can be made
Error

Error

Harm
Adapted from James Reason’s
Managing the Risk of Organizational Accidents
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 Where does mistake proofing fit?
 Non-Conformances come from many sources
including:
 Variation
 Culture
 Complexity
 Mistakes

Complexity Culture

Each must be managed Mistakes

to improve
quality and reliability.
Variation

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 The difficulties with human error
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

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 Errors are difficult to manage
using statistics.

normal
omitted variation
operation
Probability

Slot width

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 Poka yoke & SPC

X-bar chart p-chart

(measurement data) (attribute data)

Successive- use to sort out special case of np-

checks defects, will not chart,
or improve the process ad hoc design,
Self-checks will also sort out
defects

Source- use as corrective use to eliminate

Inspection action for special specific
causes types of defects

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 Error proofing & SPC
 SPC is good at detecting shifts in the process mean or variance. Changes to the
process must be ongoing to be readily detected.
 Human errors tend to be rare, intermittent events. They are not readily detected
by control charts.
 Use error proofing (not SPC) to reduce defects caused by human error

Motorola got an order of error proofing. magnitude closer to their goal

using a combination of SPC and

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 Individually, mistakes are rare

Task Type Probability

Detection of deviation or inspection 0.07
Alpha input per character 0.008
Numeric input per character 0.003
Assembly per task element 0.00007

As a group they are common

Research study #1 (Harris) >0.80
Research study #2 (Rook) 0.82
Research study #3 (Voegtlen) 0.60
Research study #4 (Headlamps) >0.70
NASA mishaps >0.50
FAA Maintenance problems >0.94

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 Human Error
Have you ever done the following:

 Driven to work and not remembered it?

 Driven from work to home when you meant to stop at a
store?

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 It happens to workers, too

 Workers finish the shift and don’t remember what they have
done.
 After building green widgets all morning, the workers put
green parts on the red widgets in the afternoon.

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 Corrective action
 Recent poll on the Quality newsgroup on the internet: A
majority reported at least 20-30% of corrective actions were
“worker reprimanded and retrained.”
 The admonition to “be more careful” or “pay attention” are
not effective for humans, especially in repetitive
environments.

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 “Be more careful” not effective
 “The old way of dealing with human error was to scold people, retrain
them, and tell them to be more careful … My view is that you can’t do
much to change human nature, and people are going to make mistakes. If
you can’t tolerate them ... you should remove the opportunities for error.”
 “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.”
 “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.”

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 A New Attitude Toward Preventing Errors

“Think of an object’s user as attempting to do a task, getting

there by imperfect approximations. Don’t think of the user
as making errors; think of the actions as approximations of
what is desired.”*

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 A New Attitude Toward Preventing Errors

 Make wrong actions more difficult

 Make it possible to reverse actions —to “undo” them—or make it
harder to do what cannot be reversed.
 Make it easier to discover the errors that occur.
 Make incorrect actions correct.

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 Processes and quality defects

• Almost any business activity can be considered a process.

• Production processes involve the flow of material. Machining,
assembly, and packaging are typical production processes.
• Business processes involve the flow of information. Financial
planning, purchasing & order entry are typical business
processes.
• All processes have the potential for defects. Hence, all
processes offer a opportunity for the elimination of defects and
the resultant quality improvement.

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 What Causes Defects?

1. Poor procedures or standards.

2. Machines.
3. Non-conforming material.
4. Worn tooling.
5. Human Mistakes.

Except for human mistakes these conditions can be

predicted and corrective action can be implemented to
eliminate the cause of defects

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 What Causes Defects?

Human Mistakes

Simple errors- the most common cause of defects-

occur unpredictably.

The defect goal is zero! Make certain

that the required conditions are in
place and controlled to make
acceptable product 100% of the time.

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 Ten Types of Human Mistakes

◼ Forgetfulness

◼ Misunderstanding

◼ Wrong identification

◼ Lack of experience

◼ Willful (ignoring rules or procedure)

◼ Inadvertent or sloppiness

◼ Slowliness

◼ Lack of standardization

◼ Surprise (unexpected machine operation, etc.)

◼ Intentional (sabotage)
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 Achieving Zero Defects

1. Point of Origin Inspection

2. 100 % Audit Checks
3. Immediate Feedback
4. Poka Yoke

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 Judgment Inspection
 Involves sorting the defects out of the acceptable product,
sometimes referred to as “inspecting in quality.”
 The consensus in modern quality control is that “inspecting in
quality” is not an effective quality management approach.
 Judgment inspection does not improve process and should be
used only in the short term.

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 Successive checks & Self-check
(post-production product inspection)

Rework Corrected
or Product
Scrap Attribute
Incorrect Incorrect Setting Rework only
Process Product Function Cue
Parameters Attribute

Search & Correct Correct

Discover Process Product
Causes Parameter Attribute

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 Source Inspection
Incorrect Setting Remedial Correct Correct
Process Function Cue Action Process Product
Source Parameters Parameter Attribute
Inspection

Incorrect Setting Remedial Correct Correct

Process Function Reaction Process Product
Parameters Parameter Attribute
Self-Correcting Process

Redesigned Corrected
Error opportunity elimination Inconsequential Product
(Mistake-Proof Design) Process Attribute
Parameter

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 Inspection

The 3 basic approaches to inspection of processed product are:

Judgement/Standard Inspection
Informative Inspection
Point of Origin Inspection
The first two approaches are widely used and considered
traditional.
Only Point of Origin Inspection actually eliminates
defects.

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 Point of Origin Inspection

Focus on prevention, not detection. May include: Switches that detect miss-fed
parts
One of the 4 basic elements.
Pins that prevent miss-feeding
Differs from Judgement and Informative:
Warning lights
Catches errors
Sound signals
Gives feedback before processing
No risk of making more defective product

Process with Zero Defects

Detect Error
By combining Check and Do, the Doing is
controlled so it cannot be wrong 100% of
the time! Feedback/Corrective Action

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 Check and Do/Point of Origin Inspection

Point of Origin Inspection

• Check for optimum process conditions

before processing is done and errors can be
made.
• Instant feedback.
• Corrections made before defects occur.

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 Setting Functions

How are you going to detect an error?

 automatic, not dependent on human attention
 fail in “detect” mode
 simple & low cost if possible

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 Regulatory Function
The real questions you need to ask:

 How are you going to stop the process?

 the worker needs to get the message?
 By audible or visible warning
 By prohibiting further processing

 How are you going to eliminate the possibility of error?

 The Contrapositive of Murphy’s Law
 Simplicity
 Symmetry

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 Put “Knowledge in the World”

Precise outcomes without precise knowledge or action?

provide clues about what to do:

 natural mappings
 affordances
 visibility
 feedback
 constraints

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 Visibility and Feedback
 Visibility means making relevant parts visible, and
effectively displaying system status.
 Feedback means providing an immediate and obvious effect
for each action taken.

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 Mistake Proof or Poka yoke the process!

Not noticing that an error is

made or a machine is not
functioning does not make a
person stupid or foolish.

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 Poka Yoke results in Quality of Processes

Quality the 1st time Cost Leadtime

Transformation = Quality production the 1st time

Inspection….eliminated ???

Transport
Dedicated lines
Storage

Delay/wait One piece flow

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 Quick Feedback

Error correction as soon as possible

Differs from traditional inspection approaches that:
• Correct problems after the process
• Address the problem when errors are already
defects
• In some cases never identify an error has occurred

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 Poka yoke

Mistake proofing systems

Does not rely on operators catching mistakes
Inexpensive Point of Origin inspection
Quick feedback 100% of the time

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 Seven Guidelines to Poka Yoke Attainment

1. Quality Processes - Design “Robust” quality processes to achieve zero defects.

2. Utilize a Team Environment - leverage the teams knowledge,experience to
enhance the improvement efforts.
3. Elimination of Errors - Utilize a robust problem solving methodology to drive defects
towards zero.
4. Eliminate the “Root Cause” of The Errors - Use the 5 Why’s and 2 H’s approach
5. Do It Right The First Time - Utilizing resources to perform functions correctly the
“first” time.
6. Eliminate Non-Value Added Decisions - Don’t make excuses-just do it !
7. Implement an Incremental Continual Improvement Approach-implement
improvement actions immediately and focus on incremental improvements; efforts
do not have to result in a 100% improvement immediately.

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 Poka yoke

Poke-yoke and Point of Origin Inspections( Proactive Approach):

A fully implemented zero defect system requires Poka yoke
usage at or before the inspection points during the process.

Poka yoke will catch the errors

before a defective part is
manufactured 100% of the time.

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 Poka-yoke

Poka yoke and Informative Inspection( Reactive Approach):

•Check occurs immediately after the process.
•Can be an operator check at the process or successive check
at the next process.
•Not 100% effective, will not eliminate all defects.
•Effective in preventing defects from being passed to next
process.

Although not as effective as the

Source inspection approach, this
methodology is more effective than
statistical sampling and does
provide feedback in reducing
defects.
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 Poka yoke Systems Govern the Process

Two Poka Yoke System approaches are utilized in manufacturing

which lead to successful zero defect systems:
1. Control Approach
Shuts down the process when an error
occurs.
Keeps the “suspect” part in place when an operation is
incomplete.
2. Warning Approach
Signals the operator to stop the process and correct the
problem.

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 Control Approach

• Takes human element out of the equation;does

not depend on an operator or assembler.
• Has a high capability of achieving zero defects.
• Machine stops when an irregularity is detected.

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 Warning Approach

• Sometimes an automatic shut off system is not an

option.
• A warning or alarm system can be used to get an
operators attention.
• Below left is an example of an alarm system using
dials, lights and sounds to bring attention to the
problem.
• Color coding is also an effective non automatic
option.

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 Common Mistake proofing Devices
 Guide Pins
 Blinking lights and alarms
 Limit switches
 Proximity switches
 Counters
 Checklists

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 Methods for Using Poka yoke

Poka yoke systems consist of three

primary methods:
1. Contact
2. Counting
3. Motion-Sequence
Each method can be used in a control
system or a warning system.
Each method uses a different process
prevention approach for dealing with
irregularities.

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 Contact Method

A contact method functions by detecting whether a sensing

device makes contact with a part or object within the process.

Cylinder present Missing cylinder;piston

fully extended alarm
An example of a physical contact sounds
method is limit switches that are
pressed when cylinders are
driven into a piston. The
switches are connected to
pistons that hold the part in
place. In this example, a
cylinder is missing and the part Cannot proceed
is not released to the next to next step.
process.
Contact Method using limit
switches identifies missing
cylinder.
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 Physical Contact Devices

Toggle Switches

Limit Switches

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 Energy Contact Devices

Photoelectric switches can

Light be used with objects that
are translucent or
transparent depending
upon the need.
Transmission method:
two units, one to
Transmitter Receiver transmit light, the other
to receive.
Reflecting method:PE
sensor responds to light
reflected from object to
Object
detect presence.

If object breaks the transmission, the machine is signaled to shut down.

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 Contact Device

An example of a
contact device
using a limit
switch. In this
case the switch
makes contact
with a metal
barb sensing it’s
presence. If no
contact is made
the process will
shut down.

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 Contact Methods

Do not have to be high tech!

Passive devices are sometimes the best method. These can be as
simple as guide pins or blocks that do not allow parts to be seated
in the wrong position prior to processing

Take advantage of parts designed with an uneven shape!

A work piece with a hole a bump or an uneven end is a perfect
candidate for a passive jig. This method signals to the operator
right away that the part is not in proper position.

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 Counting Method

Used when a fixed number of operations are required within a process,

or when a product has a fixed number of parts that are attached to it.
A sensor counts the number of times a part is used or a process is
completed and releases the part only when the right count is reached.

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 Counting Method

Another approach is to count the number of parts or components

required to complete an operation in advance. If operators find
parts leftover using this method, they will know that something
has been omitted from the process.

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 Motion-Sequence Method

The third poka yoke method uses sensors to determine if a motion or a

step in a process has occurred. If the step has not occurred or has
occurred out of sequence, the the sensor signals a timer or other
device to stop the machine and signal the operator.

This method uses sensors and photo-electric

devices connected to a timer. If movement does
not occur when required, the switch signals to stop
the process or warn the operator.

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 Motion-Sequence Method
In order to help operators select the right parts for the right step in a
process the “sequencing” aspect of the motion-step method is used.
This is especially helpful when using multiple parts that are similar in
size and shape.

In this example, each step of the machine cycle is wired to an indicator

board and a timer. If each cycle of the machine is not performed within
the required “time” and “sequence”, the indicator light for that step will
be turned on and the machine will stop.

Machine Indicator Board

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 Types of Sensing Devices

Sensing devices that are traditionally used in poka yoke

systems can be divided into three categories:
1. Physical contact devices
2. Energy sensing devices

3. Warning Sensors

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 Physical Contact Sensors

These devices work

by physically
touching something.
This can be a
machine part or an
actual piece being
manufactured.
In most cases these
devices send an
electronic signal
when they are
touched.
Depending on the
process, this signal
can shut down the
operation or give an
operator a warning
signal.
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 Touch Switch
Used to physically detect the presence or absence of an object or
item-prevents missing parts.
Used to physically detect the height of a part or dimension.

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 Energy Sensors

These devices work by

using energy to detect
whether or not an
defect has occurred.

Fiber optic

Vibration
Photoelectric

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 Warning Sensors
Color Code
Warning sensors signal the
operator that there is a
problem. These sensors
use colors, alarms, lights to
get the workers attention !

These sensors may be used

in conjunction with a
contact or energy sensor to
get the operators
attention.

Lights connected to
Micro switches &
Lights
timers

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 3 Rules of POKA YOKE
◼ Don’t wait for the perfect POKA YOKE. Do
it now!

◼ If your POKA YOKE idea has better than

50% chance to succeed…Do it!

◼ Do it now….improve later!

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