mistake proofing - technique

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FICCI CE Mistake proofing Mistake proofing is a scientific technique for improvement of operating systems including materials, machines and methods with an aim of preventing problems due to human error. The term “error” means a sporadic deviation from standard procedures resulting from loss of memory, perception or motion.

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Page 1: Mistake Proofing - Technique

FICCI CE

Mistake proofing

Mistake proofing is a scientific technique for improvement of operating systems including materials, machines and methods with an aim of preventing problems due to human error. The term “error” means a sporadic deviation from standard procedures resulting from loss of memory, perception or motion.

Page 2: Mistake Proofing - Technique

FICCI CE

Examples of mistake proofing

Gas pumps are equipped with hose couplings that break away and quickly shutoff the flow of gasoline.

Page 3: Mistake Proofing - Technique

FICCI CE

Examples of mistake proofing

The bathyscaph is a deep water submarine used to explore the very lowest parts of the ocean.It is electrically powered.Once at the bottom,if the batteries or electrical system fail the best outcome would be for the submarine to return to the surface.The designers made this outcome occur by holding the ballast in place with electromagnets.When power is

lost,the ballast drops off automatically and sub starts it ascent.

Page 4: Mistake Proofing - Technique

FICCI CE

Examples of mistake proofing

File cabinet can pull over if too many drawers are pulled out.

For some file cabinets,opening one drawer locks all the rest ,reducing the chance of the file cabinet tipping.

Page 5: Mistake Proofing - Technique

FICCI CE

Examples of mistake proofing

Fuelling area of the car has three mistake proofing devices :

• Filling pipe insert keeps larger,leaded fuel nozzle from being inserted

• Gas cap tether does not allow the motorist to drive off with out the cap

• Gas cap is fitted with ratchet to signal proper tightness and prevent over tightening.

Page 6: Mistake Proofing - Technique

FICCI CE

Examples of mistake proofing

Automobiles controls have a mistake proofing device to ensure that the key in the on position before allowing the driver to shift out of park.The keys can not be removed until the car is in park.

Page 7: Mistake Proofing - Technique

FICCI CE

Examples of mistake proofing

3.5 inch diskette can not be inserted unless diskette is oriented correctly.This is as far as diskette can be inserted upside-down.

The beveled corner of the diskette pushes a stop in the disk drive out of the way allowing diskette to be inserted.This feature,along with the fact that the diskette is not square,prohibit incorrect orientation.

Page 8: Mistake Proofing - Technique

FICCI CE

Examples of mistake proofing

Electronic car locks can have three mistake proofing devices:

• Ensures that no door is left unlocked.

• Door automatically locks when car exceeds the speed of 18mile an hour.

• Lock won’t operate when door is open and engine is running.

Page 9: Mistake Proofing - Technique

FICCI CE

Examples of mistake proofing

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 mowers blade stops in 3 seconds or less.This is an adaptation of the”dead man switch” from railroad locomotives.

Page 10: Mistake Proofing - Technique

FICCI CE

Examples of mistake proofing

Retail stores use electronic article surveillance to ensure that no one walks away without making payment.

Page 11: Mistake Proofing - Technique

FICCI CE

Examples of mistake proofing

This device continuously monitors the water level. If the level is too low, a valve opens to add water to the pool.

You can see more examples on www.mistakeproofing.com

Page 12: Mistake Proofing - Technique

FICCI CE

Defect Vs errors

It is important to understand that defects and errors are not the same thing. A defect is the result of an error, or an error is the cause of defects as explained below.

Error Defect

Cause Result

Page 13: Mistake Proofing - Technique

FICCI CE

Prevention of defects

Machineor

human errorDetect error

Take corrective

action

zerodefect

Analyze for preventive action

Cause Intermediate result End result

Modify workprocedure to

prevent such errors

WorkProcedure

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FICCI CE

Types of error

• Error in memory of PLAN : Error of forgetting the sequence/ contents operations required or restricted in standard procedures.

• Error in memory of EXECUTION : Errors of forgetting the sequence/contents of operations having been finished.

• Error in PERCEPTION of type : Error of selecting

the wrong object in type or quantity.

Page 15: Mistake Proofing - Technique

FICCI CE

Types of error

• Error in perception of MOVEMENT : Error of misunderstanding/misjudging the shape, position, direction or other characteristics of the objects.

• Error in motion of HOLDING : Error in failing to hold objects.

• Error in motion of CHANGING : Errors of failing to change the shape , position , direction , or other characteristics of object according to the standard.

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FICCI CE

Human error provoking situations

• Complex design• Inadequate written standards• Too many parts• Mix up• Too many steps• Specifications or critical conditions• Too many adjustments• Frequent repetition

Page 17: Mistake Proofing - Technique

FICCI CE

The principles of mistake proofing can be categorized into groups:

A. Prevention of occurrence

B. Minimization of effects

Principles of mistake proofing

Page 18: Mistake Proofing - Technique

FICCI CE

A. Prevention of occurrence

Methods under this principle aim to prevent the occurrence of human errors from all stages of operations and make corrections unnecessary.This can be done through the following 3 methods:-

I. Elimination

II. Replacement

III. Facilitation

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FICCI CE

I. Elimination

Elimination method aims to remove the system properties which generate operations/restrictions susceptible to human errors so as to make them unnecessary. Consider the error of an operator touching a high temperature pipe and getting burnt. One method of preventing this error is to make the pipe safe by covering it with insulating material. This improvement removes the property of the pipe which generates the restriction.

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FICCI CE

Elimination - Example

Alternative design has baffle function stamped into sheet metal cover eliminating troublesome assembly step

Air baffles needed to be attached to cover to direct airflow over hot components. Adhesive could come loose if not properly applied. Baffle also prone to damage during assembly.

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FICCI CE

Replacement

Replacement substitutes a more reliable process to improve consistency.

Examples: use of robotics or automation that prevents a manual assembly error, automatic dispensers or applicators to insure the correct amount of a material such as an adhesive is applied.

Page 22: Mistake Proofing - Technique

FICCI CE

Replacement- Example

Alignment of the adhesive overlay on the faceplate was critical over a series of port holes. If mis-aligned, the overlay would need to be stripped off, the surface cleaned, and a new overlay applied.

The new model replaced this process by eliminating the adhesive overlay and using a more reliable silk screen process.

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FICCI CE

III. Facilitation

The principles of elimination and replacement described above make it unnecessary for operators to perform operations or note restrictions. In contrast to these, the purpose of facilitation is to make such functions as memory, perception and motion required in operations easy for the operators by well designed work stations and thus reduce the occurrence rate of human errors.

Page 24: Mistake Proofing - Technique

FICCI CE

Board orientation on bottom row 180° different from top row. Color coded board insertion screws and panel color-coding facilitate correct board orientation for insertion.

Facilitation - Example

Page 25: Mistake Proofing - Technique

FICCI CE

B. Minimization of effects*

Methods under this principle aim to minimize the effects of human error and focus on processes where the errors develop into serious problems of quality,safety or efficiency. This can be divided into two categories :

I. Detection and

II. Mitigation

*This principle is also known as Stop-in-time.

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FICCI CE

I. Detection

The concept of detection is that even if a human error occurs, the deviations from standard states caused by it can be detected and corrected in the succeeding operation steps. The methods of correcting the detected deviations are classified into two types :

1. Operators are informed or find by themselves the deviations and take necessary corrective action.

2. The deviations are automatically corrected without operators

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FICCI CE

Detection

There are two methods of informing the operator. The first method is to bring errors to the operator’s notice by visual or audible alarms, and the second method is by making the successive operations impossible.

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FICCI CE

A conveyor carries the product under a pivoting flag. A correctly assembled product passes under the flag. An incorrectly assembled product tips the flag, and a sensor detects the flag movement.

Detection - Example

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FICCI CE

The mitigation method aims to make operations redundant or incorporate shock absorbing/protecting materials so as to mitigate the effects of human errors in their development process.

Example : Consider the error of burning out the motor of a production machine by forgetting to switch off the power supply. The mitigation countermeasure is to install a fuse which cuts off the power supply when the temperature reaches certain point.

II. Mitigation