Pokayoke

 
Overview
We  are  going  to  learn  about  a  powerful  concept  known  as  Pokayoke,  sometimes  
referred  to  as  mistake  or  error  proofing.    Specifically,  you’ll  learn  what  pokayoke  
is  and  why  it’s  so  important  for  any  continuous  improvement  practitioner  to  
understand  and  practice.      

You’ll  also  learn  what  the  different  types  of  pokayoke  devices  are  while  also  
seeing  some  examples  of  different  mistake  proofing  devices  in  action.      

Scenario  
To  get  us  started,  I’d  like  to  present  a  
question.    Do  you  know  why  most  manholes  
are  round?    

To  be  sure,  there  are  many  different  reasons  

and  theories  of  why  manholes  are  round,  but  
one  of  the  most  significant  reasons  is  because  
a  round  cover  can  never  fall  into  the  hole  
whereas  a  square  or  rectangular  manhole  
cover  could  in  fact,  fall  into  the  hole  if  
inserted  the  wrong  way.    

As  it  turns  out,  a  round  manhole  is  an  example  of  what’s  known  as  a  Pokayoke  
device.      

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Defining  Pokayoke  
Formally  defined,  Pokayoke  is  an  error  proofing  technique.  

Poka  means  error  or  mistake  and  yoke  means  to  avoid.    The  true  purpose  of  
pokayoke  is  to  avoid  errors  or  mistakes.    Believe  it  or  not,  we’re  all  surrounded  by  
pokayoke  devices.      

Take  this  bathroom  sink  as  

just  one  example.      

A  potential  mistake  is  that  

someone  may  close  the  
drain  plug,  start  running  
water,  and  walk  away.      

After  a  few  seconds,  water  

could  potentially  spill  out  of  
the  sink  unless,  of  course,  
the  sink  has  a  drain  hole.      

This  drain  hole  is  another  example  of  everyday  pokayoke.  

Pokayoke  is  typically  focused  on  during  the  improve  and  control  phases  of  a  
DMAIC  project.    Like  all  the  tools  we’ve  learned  about  throughout  this  course,  you  
don’t  need  to  be  working  on  a  formal  lean  or  six  sigma  project  to  implement  or  
practice  pokayoke.    

In  fact,  anytime  a  new  product  or  process  is  being  developed,  thinking  of  ways  to  
mistake  proof  the  product  or  process  just  may  be  some  of  the  best  time  spent.    
That’s  an  introduction  to  pokayoke.    

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Why  Pokayoke?  
Now  let’s  turn  our  attention  to  why  
pokayoke  is  such  an  important  part  of  
authentic  continuous  improvement.    To  do  
this,  we  need  to  begin  by  exploring  the  
relationship  between  Errors  and  Defects.      

If  we  think  of  an  iceberg,  the  part  everyone  

sees  is  the  top  which  is  analogous  to  defects.    
As  we  all  know,  the  largest  part  of  an  iceberg  is  totally  out  of  sight  below  the  
water.    This  part  of  the  iceberg  is  analogous  to  errors  or  mistakes.      

Put  another  way,  errors  are  any  deviation  from  the  process  and  defects  are  
produced  when  products  or  processes  deviate  from  the  specifications  or  don’t  
meet  the  expectations  of  our  customer.    In  other  words,  defects  are  created  by  
errors.      

To  be  sure,  not  all  defects  are  created  equal.    To  explain,  let’s  explore  the  five  
levels  of  defects.    First,  the  most  severe  situation  is  when  defects  are  shipped  to  
customers.    The  second  level  is  when  defects  are  found  and  contained  in  house.    

In  many  cases,  this  occurs  during  an  end  of  line  functional  test  or  inspection  
process.    The  third  level  occurs  when  defects  are  being  attacked  and  reduced.    
The  fourth  level  occurs  when  defects  are  found  and  countered  at  the  source  of  
the  problem.      

In  other  words,  once  properly  countered  this  defect  should  never  reoccur  for  the  
same  root  cause.    Lastly,  the  most  favorable  situation  occurs  when  defects  aren’t  
produced  at  all.  By  finding  errors  and  preventing  them  which  is  precisely  what  
pokayoke  is  meant  to  do,  we  can  prevent  defects.      

In  addition  to  preventing  defects,  there  are  other  reasons  pokayoke  is  so  
important.  Well  one  of  these  reasons  is  due  to  something  called  the  autopilot  
effect.      

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Autopilot  Effect  
In  his  book,  “The  Design  of  
Everyday  Things”,  Donald  Normal  
states,  “The  human  brain’s  default  
mode  of  operation  is  pattern  
recognition  and  autopilot  
execution.    If  the  pattern  is  
familiar,  a  behavior  that  has  been  
successful  in  the  past  is  
“launched.”  It’s  only  when  
feedback  suggests  that  things  are  not  going  as  planned  that  more  in-­‐depth  
thought  is  called  up.”      

For  example,  have  you  ever  driven  to  or  from  work  and  not  remembered  it?    Have  
you  ever  driven  home  even  though  your  significant  other  specifically  asked  you  to  
stop  at  the  store?    Or  do  your  operators  sometimes  struggle  when  standard  work  
is  updated?      

These  are  just  a  few  examples  of  how  powerful  the  autopilot  effect  can  be  and  
why  if  not  controlled  can  actually  lead  to  problems  including  the  creation  of  
defects.    With  this  said,  since  most  of  us  work  closely  with  other  human  beings,  it  
can  also  be  helpful  to  understand  the  many  different  types  of  errors  we  humans  
unfortunately  make  from  time  to  time.      

Of  course,  just  because  these  errors  are  induced  by  humans  doesn’t  mean  we  
ever  want  to  blame  people.  Instead,  we  must  always  focus  on  how  we  can  
improve  the  process  making  it  difficult,  if  not  impossible,  to  ever  make  another  
mistake  again.      

8  Different  Types  of  Human  Errors  

With  this  said,  here  are  the  eight  different  types  of  human  errors  that  can  lead  to  
defects:  Forgetfulness,  Misunderstanding  Errors,  Detection  Errors,  Errors  made  by  
new  associates,  Willful  errors,  Inadvertent  Errors,  Errors  due  to  slowness,  and  
Errors  due  to  lack  of  standards  and  supervision.      

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In  order  to  combat  these  human  errors,  there  are  different  levels  of  mistake  
proofing  we  can  employ.    First,  level  0  focuses  on  things  such  as  training,  
standardization,  and  things  such  as  control  plans  and  SPC.    With  Level  1  error  
proofing,  we’re  able  to  identify  the  error  with  a  warning  such  as  an  alarm  or  
andon  light.      

With  level  2  error  proofing,  the  error  is  identified  and  the  machine  or  process  
halts  and  waits  for  corrective  action.    With  level  3  error  proofing,  the  error  is  not  
only  identified  but  is  also  corrected  automatically.    Last,  but  certainly  not  least,  
level  4  error  proofing  makes  it  impossible  for  the  error  to  occur.      

Obviously,  our  goal  should  be  to  eventually  get  to  level  4  error  proofing  assuming  
it’s  feasible  and  realistic.    I  mention  feasible  since  the  cost  of  error  proofing  must  
always  be  taken  into  consideration.    To  be  sure,  the  best  error  proof  devices  are  
normally  inexpensive  and  home  grown  in  nature.      

3  Primary  Types  of  Pokayoke  Devices  

With  this  said,  let’s  go  ahead  and  discuss  the  three  primary  types  of  pokayoke  
devices.      

First,  we  have  the  warning  signal  pokayoke.  These  may  be  things  such  as  andon  
lights  as  shown  here  or  even  buzzers  or  other  audible  signals.    The  goal  with  these  
devices  is  simple:  "Don’t  pass  on  bad  quality."      

Second,  we  have  shut  down  pokayoke.    This  may  involve  a  stop  the  line  cord,  or  
some  sort  of  auto  detect  and  stop  device.    Additionally,  things  like  counters  that  
force  the  process  to  stop  are  examples  of  shut  down  error  proof  devices.    The  
primary  function  of  these  devices  is  “Don’t  accept  bad  quality.”      

Lastly,  control  pokayoke  devices  include  things  such  as  locator  pins  making  it  
impossible  to  plug  something  in  wrong,  or  stoppers  on  fixtures,  or  even  indicator  
lights  helping  assemblers  pick  the  correct  part.      

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The  main  goal  here  is  also  simple:  "Don’t  make  bad  quality  parts."    With  this  said,  
no  matter  what  type  of  error  proofing  device  is  used  there  are  many  different  
ways  of  implementing  them.      

Implementing  Error  Proofing  Devices  

First,  manual  devices  are  often  found  to  be  extremely  effective  and  inexpensive.  
In  other  words,  we  may  add  a  locator  pin  to  a  fixture  making  it  easier  to  load  a  
part.      

Second,  automation  can  also  be  leveraged.    For  example,  we  may  use  photo-­‐
electric  sensors  or  other  more  sophisticated  vision  systems  in  order  to  verify  parts  
have  been  properly  produced.      

And  third,  error  proofing  can  be  built  into  the  design  of  the  product  or  service.    
For  example,  the  size  of  a  diesel  fuel  nozzle  is  typically  a  different  size  than  a  
gasoline  nozzle  making  it  difficult  for  someone  to  mistakenly  put  diesel  fuel  into  
their  gasoline  powered  vehicle.      

Implementing  Pokayoke  
So  far  we’ve  learned  what  pokayoke  is,  why  it’s  important,  and  the  different  types  
of  devices  we  can  use.    Let’s  switch  gears  a  bit  and  talk  about  how  to  go  about  
implementing  pokayoke.      

First  once  an  error  is  detected,  we  should  immediately  contain  the  problem  in  
order  to  protect  our  customer.    This  may  require  a  so-­‐called  Band-­‐Aid  solution  
meaning  a  temporary  solution  is  put  into  place.      

Once  the  problem  has  been  contained,  we  should  immediately  enter  into  
problem  solving  mode  in  order  to  identify  countermeasures  that  may  result  in  the  
creation  of  a  pokayoke  device  or  even  multiple  devices.      

And  third,  we  should  continuously  strive  for  zero  defects.    For  example,  perhaps  a  
warning  andon  light  is  installed  to  alert  us  when  a  defect  is  produced  which  helps  
prevent  defects  from  being  passed  on.    

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 Perhaps,  we  can  find  an  even  better  device  that  
makes  it  impossible  to  produce  a  defect.    Here’s  a  
checklist  that  can  be  used  to  ensure  your  
Pokayoke  device  will  be  safe  and  effective.    Does  
it  prevent  the  reoccurrence  of  the  error?    Does  it  
use  wits  over  wallet?      

In  other  words,  the  best  error  proofing  devices  are  usually  inexpensive  and  
creative.    You  don’t  need  to  spend  a  lot  of  money  to  mistake  proof  a  process.    We  
also  want  to  ensure  the  device  is  easy  to  use,  is  safe,  and  is  simple  to  implement.      

Finally,  we  should  be  able  to  easily  maintain  the  device  and  it  should  be  durable.    
With  all  of  this  said,  the  ultimate  test  of  any  Pokayoke  device  is  to  intentionally  try  
to  make  it  fail.    You  see,  human  beings  are  very  ingenious  and  may  eventually  find  
situations  where  the  Pokayoke  will  fail  to  prevent  an  error.      

For  example,  with  a  little  work  even  a  square  peg  can  fit  into  a  round  hole.    See  if  
it’s  possible  to  make  your  pokayoke  device  fail  under  normal,  or  simulated,  
working  conditions.      

Pokayoke  Devices  
Let’s  look  at  a  few  additional  examples  of  
pokayoke  devices.    To  start  with,  we’re  
happy  to  present  Gemba  Academy’s  own  
website!    Our  newest  membership  
software  requires  usernames  to  be  at  
least  six  characters  long.      

If  someone  attempts  to  create  a  

username  less  than  six  characters,  they  
won’t  be  able  to  proceed  as  you  can  see  
here.    In  this  example,  the  assembly  
operation  is  supplied  with  exactly  the  
number  of  parts  needed  to  produce  an  
assembled  unit.      

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At  the  end  of  the  process,  there  should  be  no  parts  left.    If  there  are,  this  tells  us  
that  we’ve  made  an  error.    In  more  advanced  applications,  there  may  be  sensors  
in  the  container  or  beneath  the  parts.    If  the  parts  are  not  removed  from  the  
container,  the  sensor  will  alert  the  assembler  and  stop  the  incomplete  unit  from  
being  passed  downstream.    

Next,  imagine  an  example  where  the  part  is  incorrectly  loaded  on  the  left  and  
correctly  loaded  on  the  right.    Unfortunately  since  this  fixture  only  used  outside  
stops,  it’s  very  easy  to  make  this  mistake.    But  with  the  simple  addition  of  a  pin  
making  it  obvious  when  the  part  isn’t  loaded  correctly,  we’re  able  to  radically  
improve  this  process.      

As  you  can  see,  simple  manually  done  improvements  like  this  can  be  extremely  
advantageous.      

Lastly,  imagine  an  example  of  “Intelligent  automation”  that  detects  errors  using  
sensors  and  stops  the  machine.    In  this  example,  the  machine  will  use  a  sensor  to  
detect  when  a  part  hasn’t  been  properly  machined  once  the  conveyor  belt  
advances  the  part  through  the  sensor.    

Once  the  sensor  sees  the  abnormal  part,  the  machine  will  stop  and  the  Andon  
light  will  turn  from  green  to  red  indicating  a  problem  and  summoning  the  team  
leader  to  address  the  problem  so  it  doesn’t  happen  again.      

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