Unit: MCMT451A

MISTAKEPROOF A
PRODUCTION PROCESS

™ People with this competency are able to use

mistake-proofing concepts to eliminate the
causes of error and variability from production
processes. They can analyse the process &
develop new methods & train operators in the
new procedures.

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Mistake proofing and
Fail safing
Remember MURPHY’S LAW
“IF SOMETHING CAN GO
WRONG, IT WILL!”

Focus of mistake proofing:

“IF SOMETHING CAN’T GO
WRONG, IT WON’T!”

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Definitions:

Mistake proof:
™ The use of practices and devices that
make it difficult to do a task wrong
and easy to do a task right.
They prompt us to take action
when a problem is about to occur.

Fail safe:
™ A system designed so that if anything goes
wrong, it immediately becomes impossible
for the process to continue.

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 Examples of Mistake proof/
Fail safe Devices

AT HOME
z “dead man bar/switch” in lawnmowers, chainsaw
z “reversal switch” in garage opener
z ground fault circuit interrupter for bathroom or outside pool
AUTO
z seat belts
z air bags
z warning lights
OFFICE
z software dialogue: “are you sure you want to delete?”
SHOP FLOOR
z “dual hand” activation switches
z pre-set torque tools
z pressure release valves
z cargo elevator door has to be closed before elevator moves

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Why Mistake Proofing ?
™ Can’t we just get everyone to concentrate more?
™ Tell them it’s really important!
™ Tell them mistakes are costing us lots of money!
™ What’s wrong with these people?

In general it is safe to say that most errors can

be traced back to some form of human
intervention.

It is also understood that it is natural for

people to FORGET, BECOME BORED, GET
DISTRACTED or in some other way lose
concentration periodically.

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Types of Human Errors

™ I Forgot: Lots to think of or repetitive tasks induce human

forgetfulness
™ I Misunderstood: Lack of training or poorly organised work
instructions lead to errors
™ I Did Not Know: Poor communication system creates situation
where not everyone has the same information
™ I Took A Short Cut: Under pressure we cut corners to achieve
outcomes, we focus on the quantity rather than the quality
™ I Wasn’t Paying Attention: Loss of concentration through
distraction
™ I’m Still Learning: Lack of training structure or skill
assessment can lead to inexperience induced errors

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 Types of Equipment Issues

I Didn’t Know That Was Going To Happen!!!! (Or Did We?)

I Knew It Was Coming!

™ Broken or Worn Tools

™ Dirty Equipment
™ Breakdowns
™ Jammed Cutters
™ Blocked Chutes
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Management by Inspection

F counting:
Count the number of times “F” appears
in the paragraph below:
• count only once (no rework)
• count all Fs (upper and lower case)
• record the total – don’t tell anyone else

No test is perfect; there is always the possibility that the results of the
test will lead you to reject the null hypotheses (H0) when it is actually
true (a type I error) or to fail to reject H0 when it is actually false (a type
II error). It is always possible that your sample mean will be very
different from the population mean. For example, suppose that a certain
normally distributed population has a mean (m) of 10 and a standard
deviation (s) of 2. This means that 95.44% of the values in this
population are between 6 and 14. However, it is always possible that you
could select 10 observations at random and find a sample mean of 4.
From such a sample you would never guess that the true mean of the
population is actually 10!

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Management by Inspection

No test is perfect; there is always the possibility that the results of the
test will lead you to reject the null hypotheses (H0) when it is actually
true (a type I error) or to fail to reject H0 when it is actually false (a type
II error). It is always possible that your sample mean will be very
different from the population mean. For example, suppose that a certain
normally distributed population has a mean (m) of 10 and a standard
deviation (s) of 2. This means that 95.44% of the values in this
population are between 6 and 14. However, it is always possible that you
could select 10 observations at random and find a sample mean of 4.
From such a sample you would never guess that the true mean of the
population is actually 10!

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Mistake Proofing Principles

Keep the whole thing simple, if it becomes too

complicated everyone will lose interest.
™ Get rid of any unnecessary steps or
operation
™ Remove excuses
™ Training and experience
™ Alert Operators
™Work together
™ Use independent action for cross-
checking
™ Use positive communications
™ Prepare for the job ahead of time
™ Integrate operations and inspections
™ Use physical devices
™ Periodic rests
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Assignment:

™ Select an area of your operation known for errors.

Develop and implement a Mistake Proofed system.
Include the following descriptions in your
assignment documentation:
z How you identified and classified sources of
variability/errors in the process
z How you worked with team members and other people
to developed mistake proof methods of performing the
operation
z How you worked with relevant people to plan
implementation of the solution(s)
z How you followed through to ensure implementation
occurred
z How you audited the system to ensure that the change
was sustained

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Mistake Proofing Strategies

™ Zero Defects is the aim. Use systems to

ensure that each product meets required
specifications as it is being processed.
™ No one intentionally creates defective
products, but we can all be distracted by
outside influences that cause us to make
errors unintentionally.
™ Usually customers are the best at detecting
errors. Hence the next production operation
is expert at finding defects.

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 Management by Inspection

What is wrong with inspection?

™ The root cause is not removed.

(It deals only with the symptoms)

™ It assumes that:
z Defects are inevitable
z The more we inspect, the more we can reduce
errors and defects
z Inspection is an effective way to detect all defects

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Implement Mistake Proofing

™ Identify What Errors /Mistakes Are Occurring.

™ Determine the Root Causes.
™ Determine the appropriate form of Mistake Proofing
™ Implement natural feedback within the process.
™ Place your inspection point close to the source.
™ Joint clarification (verify) of information at hand over
™ Keep devices as simple as possible & involve staff in
develop & implementation
™ Start in a pilot area.

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