Poka Yoke & Mistake Proofing

Lean Manufacturing Series

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Disclaimer and Approved Use
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Contents
1.  Introduction
2.  Background and History
3.  Components and Implementation
4.  Knowledge Check

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Introduction
•  Mistake proofing and poka yoke is the use of process or
design features to prevent errors or their negative
impact.
•  The term Poka yoke is Japanese slang for “avoiding
inadvertent errors” which was formalized by Shigeo
Shingo.
•  Inexpensive.
•  Very effective.
•  Based on simplicity and ingenuity.

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Background and History
•  Poka yoke was developed by Shigeo Shingo in the early
1960’s
•  Shingo was frustrated that statistical methods could
never reduce defect rates to absolute zero

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Background and History
•  While visiting the Yamada Electric plant in 1961, Shingo was
told of a problem that the factory had with one of its
products. Part of the product was a small switch with two
push-buttons supported by two springs. Occasionally, the
worker assembling the switch would forget to insert a spring
under each push-button. Sometimes the error would not be
discovered until the unit reached a customer, and the
factory would have to dispatch an engineer to the customer
site to disassemble the switch, insert the missing spring, and
re-assemble the switch. This problem of the missing spring
was both costly and embarrassing. Management at the
factory would warn the employees to pay more attention to
their work, but despite everyone's best intentions, the
missing spring problem would eventually re-appear.
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 •  Shingo suggested a solution that became the first poka
yoke device:
▫  In the old method, a worker began by taking two springs out of
a large parts box and then assembled a switch.
▫  In the new approach, a small dish is placed in front of the parts
box and the worker's first task is to take two springs out of the
box and place them on the dish. Then the worker assembles the
switch. If any spring remains on the dish, then the worker knows
that he or she has forgotten to insert it.
▫  The new procedure completely eliminated the problem of the
missing springs.

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Components and Implementation
•  Everyday Examples
•  Error Proofing and SPC
•  Inspection Techniques
•  Types of Poka Yokes

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Everyday Examples: Which dial turns on the burner?

Stove A

Stove B

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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 overtightening.
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 seconds or less.

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 Everyday Examples: Whose signature is required?

Before:

After:

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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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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 magnitude closer to their six
sigma goal using a combination of SPC and error
proofing.

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Ineffective Corrective Action
•  Recent poll on a Quality newsgroup on the internet: A
majority reported at least 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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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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What Causes Defects?
1.  Poor procedures or standards.
2.  Machines.
3.  Non-conforming material.
4.  Worn tooling.
5.  Human Mistakes.

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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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Inspection Techniques
•  Judgment
▫  Assess quality of production outputs or sort out defects from
good product.
•  Informative
▫  Assess process by inspecting outputs and using information
gained to control the process (feedback loop)
•  Source
▫  Assess beforehand whether the conditions necessary for high
quality production exist

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Inspection Efficacy

Both Self- Self-Checks Source Inspection

Checks& Source only only
Inspection

1.  Manual operations & 5.  Attribute data 9.  Adjustment & mis-
Works well worker vigilance 6.  External exceed positioning possible
2.  Training cost and internal failure 10.  Blamed for customer
turnover high cost mistakes
3.  SPC ineffective 11. Special causes reoccur  

4.  Very high-speed 7.  X-bar & R

Does not production charts are
work well effective
8.  Destructive
tests

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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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Poka Yoke Results in Quality of Processes
The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then
insert it again.

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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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 Systems
•  Two Poka Yoke System approaches are utilized in
manufacturing which lead to successful zero defect
systems:
▫  Control Approach
–  Shuts down the process when an error occurs.
–  Keeps the “suspect” part in place when an operation is incomplete.
▫  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.
•  Color coding is also an effective non automatic option.

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Common Poka Yoke 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
•  An example of a physical fully extended alarm
contact method is limit sounds
switches that are pressed
when cylinders are driven
into a piston. The switches
are connected to pistons
that hold the part in place. Cannot proceed to
In this example, a cylinder next step.

is missing and the part is

Contact Method using limit
not released to the next switches identifies missing
process. cylinder.

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Physical Contact Devices

Toggle Switches

Limit Switches

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 Energy Contact Devices
Light
•  Photoelectric switches can
be used with objects that
are translucent or
transparent depending
upon the need.
Transmitter Receiver
•  Transmission method: two
units, one to transmit
light, the other to
receive.
Object •  Reflecting method:PE
sensor responds to light
reflected from object to
detect presence.
•  If object breaks the transmission, the machine
is signaled to 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.
•  Another approach is to count the number of parts or
components required to complete an operation in
advance. If operators find parts left over 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 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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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
•  Each category of sensors includes a broad range of
devices that can be used depending on the process.

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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 a defect has occurred.

Pressure transducer

Fiber optic

Vibration
Photoelectric
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Warning Sensors
•  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.

Color Code Lights connected to Micro

switches & timers
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Lights
39
 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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 Knowledge Check

© 2013 Gemba Academy LLC. All rights reserved.

Poka yoke is the use of process or design
features to prevent errors or their negative
impact.
o A) True
o B) False

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What is poka yoke? (Mark all that apply)

1.  Japanese slang

formalized by Shigeo
Shingo.

2.  Inexpensive.

3.  Very effective.

4.  Based on simplicity and

ingenuity.

© 2013 Gemba Academy LLC. All rights reserved. 43

What causes defects? (Mark all that apply)

1.  Poor procedures or

standards.

2.  Machines.

3.  Non-conforming
material.

4.  Worn tooling.

5.  Human Mistakes.

© 2013 Gemba Academy LLC. All rights reserved. 44

What are some types of human mistakes? (Mark all
that apply)

1.  Forgetfulness

2.  Misunderstanding

3.  Lack of experience

4.  Inadvertent or
sloppiness

5.  Intentional (sabotage)

© 2013 Gemba Academy LLC. All rights reserved. 45

Match the assessment technique with its description by
dragging the description to the name of the technique.

Assessment Technique Description

A.  Assess beforehand

□  B
Judgment
whether the conditions
necessary for high quality

□ 
production exist.
C
Informative B.  Assess quality of

□  A
Source
production outputs or sort
out defects from good
product.
C.  Assess process by
inspecting outputs and
using information gained
to control the process
(feedback loop)
© 2013 Gemba Academy LLC. All rights reserved. 46
Match the Poka Yoke System approach with its description by
dragging the description to the name of the approach.

Poka Yoke System Description

□ 
A.  Signals the operator to
B
stop the process and
Control Approach correct the problem.

□  A
Warning Approach
B.  Shuts down the process
when an error occurs.

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What are some common poka yoke devices
currently in use? (Mark all that apply)
1.  Guide Pins

2.  Blinking lights and

alarms

3.  Limit switches

4.  Proximity switches

5.  Counters

6.  Checklists

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How can you implement poka yoke in your organization?

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Congratulations!!!
•  You have completed the course.

•  Visit Superfactory (www.superfactory.com) for more

information on manufacturing excellence.

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