Presented by John Grout
This webinar is a 60-minute primer into mistake-proofing (a.k.a. poka-yoke). Information about the basics of mistake-proofing, why people make mistakes, and how to start the process of reducing mistakes will be presented in a fast-moving and entertaining format.
Objectives:
Build awareness of mistake-proofing
Introduce a concise presentation format: “pecha kucha," with 20 slides x 0:20 seconds each = 6:40 minutes (we’ll do two of these with discussion in between).
What is mistake-proofing?
Include lots of examples
Why do people err?
How can design eliminate errors?
Next steps in implementation
John Grout is the David C. Garrett Jr. Professor, former dean, and award-winning teacher in the Campbell School of Business at Berry College. Dr. Grout has researched lean supply chain management and mistake-proofing (a.k.a. Poka-Yoke) extensively and published numerous articles on the topic. John was awarded the Shingo Prize for his paper, “The Human Side of Mistake-Proofing” with Douglas Stewart. John has also consulted with a large variety of firms to mistake-proof their processes.
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A Poka-Yoke Primer: Mistake-Proofing and Error Reduction
1. A Poka-Yoke Primer:
Mistake-Proofing
and Error Reduction
Hosted by
Host: Mark Graban
Senior Advisor, KaiNexus
Mark@KaiNexus.com
Presenter: John Grout
Professor, Berry College
jgrout@berry.edu
4. About John Grout, Ph.D.
• Berry College (GA)
• Campbell School of
Business
• Professor, former Dean
• Ph.D. Management Science
• Penn State University
• Shingo Prize, “The Human
Side of Mistake-Proofing”
6. Objectives
• Build awareness of mistake-proofing
• Introduce a concise presentation format: “pecha kucha”
20 x 0:20 = 6:40
• What is mistake-proofing?
– Include lots of examples
• Why do people err?
• How can design eliminate errors?
• Next steps in implementation
7. Agenda
• Introduce Pecha Kucha
• Pecha Kucha 1: Introduce mistake-proofing
• Discuss examples & answer a few questions
• Pecha Kucha 2: Which errors does mistake-proofing work
on and how do I get started?
• Answer more questions about errors and mistake-
proofing
8. Pecha Kucha (ペチャクチャ)
• Pecha Kucha was devised in 2003 by architects Astrid Klein and
Mark Dytham in Tokyo, as a way to attract people to Super
Deluxe, their experimental event space.
• Pecha Kucha is a presentations having 20 slides, each shown for
exactly 20 seconds. The total presentation time was 6:40
seconds, that’s it.
• The format keeps presentations concise, fast-paced and
(hopefully) entertaining.
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34. 2
Intent: Help visitors find their way
Execution: A little confusing
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35. Skill, Rule and Knowledge-based actions
• Skill-based action: action by autopilot.
• Rule-based action: we’ve seen it before and recall a rule
about what action is appropriate.
• Knowledge-based action: Truly novel circumstances
require careful thought and deliberation about what to do.
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43. Root Cause Analysis
• Root Cause: a cause that can be acted upon
such that it meets our goals and objectives and
is within our control
• Look for actions AND conditions
Ignition source
Combustible material
Oxygen
Fire
1. Understand the problem
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44. Effects Caused
by
Causes
1. Injury Fall
2. Fall Wet surface
3. Wet surface Leaky valve
4. Leaky valve Seal failure
5. Seal failure Not maintained
1 2 3 4 5
A continuum of causes
1. Understand the problem
Cause and effect are same thing
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45. Cause and effect are same thing
• Toyota says ask why 5 times
• If it’s a continuum, why not more?
• Keep going until your answer to
why is:
• I don’t know
• I don’t care
Apollo Root Cause Analysis: A New Way of Thinking
by Dean L. Gano
1. Understand the problem
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48. Boeing Moonshine
Shop
• No Money Spent = Creativity at a New
Level
• Scrounge for EVERYTHING!
EVERYWHERE!
• Fast and Inexpensive is the ONLY way to
Try-Storm
• A 50% solution actually implemented, beats
all hell out of a 100% perfect plan, created
by meetings
• Get out of Kansas! To think differently you
have to see and try different things –
LEAVE YOUR WORKSITE! Frequently
3. Learn quickly which ideas are mistakes
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49. 3. Learn quickly which ideas are mistakes
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Day 1: Lots of mock-ups
Day 1.5: discard some ideas
consolidate others
Day 2: proof of concept
Day 2.75: prototype
Day 5: Finished tool
55. Your errors
• What were they?
• Were they skill-, rule-, or knowledge-based?
• Any thoughts about how to prevent them?
– Make the error more obvious
– Create a failure that makes the error more benign
– Help people do things right by putting knowledge in the world
56. A proposal for action: Homework
• Do something meaningful
– Eliminate an error by mistake-proofing
– Create significant cost savings
• Do something you’ll be proud of
• Do something cool
– Brew some moonshine: do something with nothing
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58. Register or get notified of future webinars: www.KaiNexus.com/webinars
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Accelerate Success Now”
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Ed Pound
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Author of Factory Physics for Managers