Poka-Yoke and HPI

8/3/2019 Poka-Yoke and HPI

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The Role ofThe Role of PokaPoka--YokeYoke

in Human Performancein Human PerformanceImprovement (HPI)Improvement (HPI)

EFCOG ISMQAWGEFCOG ISMQAWG -- Hot TopicsHot Topics

Presented by:Presented by: JoeJoe LabasLabas, BNL HPI Manager, BNL HPI Manager

March 26, 2008March 26, 2008


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You Dont Know What YouYou Dont Know What You

Dont KnowDont Know

You just flash that thing, itYou just flash that thing, iterases your memory, and youerases your memory, and you

just make up a new one?just make up a new one?


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DefinitionsDefinitions Human PerformanceHuman Performance

INPO: A series of behaviors executed toaccomplish specific results; very simply, humanperformance is behavior and results (HP=B+R)

HPIHPI a disciplined approach to proactively prevent events

triggered by human errorRe + MdRe + Md EE

PokaPoka--yokeyoke JapaneseJapanese manufacturingmanufacturing tooltool (Shingo(Shingo--Toyota)Toyota)

POKAPOKA -- Inadvertent ErrorsInadvertent Errors YOKERUYOKERU -- AvoidAvoid

= Avoid Inadvertent Errors= Avoid Inadvertent Errorsa.k.a.a.k.a. MistakeMistake--ProofingProofing, Error, Error--Proofing,Proofing, FoolFool--proofing (bakaproofing (baka--yoke)yoke)

[reducing error AND managing defenses leads to zero events][reducing error AND managing defenses leads to zero events]


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DefinitionsDefinitions

EventEvent AnAn undesirable changeundesirable change in the statein the stateof structures, systems, or components orof structures, systems, or components orhuman/organizational conditions (health,human/organizational conditions (health,behavior, controls, and so forth)behavior, controls, and so forth) triggeredtriggered

by human errorby human error that exceed establishedthat exceed establishedsignificance criteria.significance criteria.

DefectDefect any deviationany deviation from specifications;from specifications;nonfulfillment of an intended requirement ornonfulfillment of an intended requirement orreasonable expectation for use, includingreasonable expectation for use, includingsafety considerations often due tosafety considerations often due to humanhuman

errorerror..


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Some Guiding PrinciplesSome Guiding PrinciplesHPIHPI

1.1. People arePeople are falliblefallible and even the bestand even the bestmake mistakes.make mistakes.2.2. ErrorError--likely situations are predictable,likely situations are predictable,

manageable, andmanageable, and preventable!preventable!

3.3. Events can beEvents can be avoidedavoided by understandingby understandingthe reasons mistakes occur and applyingthe reasons mistakes occur and applyingthe lessons learned from past events.the lessons learned from past events.

PokaPoka--yokeyoke1.1. Errors areErrors are inevitable!inevitable!2.2. Errors can beErrors can be eliminated!eliminated!3.3. Defects areDefects are preventablepreventable

-- Zero Defects can be achieved!Zero Defects can be achieved!


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SubstitutionSubstitution

Substitute EventSubstitute Event

(or Incident, or(or Incident, or AccidentAccident, or Injury), or Injury)

forfor

DefectDefect

(BTW: Mistakes = Errors)(BTW: Mistakes = Errors)


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Goal of PokaGoal of Poka--YokeYoke

ELIMINATE ERRORS BY:ELIMINATE ERRORS BY:

1.1. designing the errors outdesigning the errors out

(Design Poka(Design Poka--yoke)yoke)

OROR

2.2. controlling the process at the sourcecontrolling the process at the sourceto prevent the errorto prevent the error oror detect thedetect the

error before it becomes a defecterror before it becomes a defect(Process Poka(Process Poka--yoke)yoke)

an accident.an accident.


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Two Types ofTwo Types of ProcessProcess

PokaPoka--Yoke DevicesYoke Devices

Type IType I Eliminate/prevent the error fromEliminate/prevent the error fromoccurring at the source. (Prevent Error)occurring at the source. (Prevent Error)

Type IIType II -- Detect the error (feedback) inDetect the error (feedback) in

thethe processprocess of it occurring, before it resultsof it occurring, before it resultsin a defect. (Prevent Defect)in a defect. (Prevent Defect)an accidentan accident.. Accident)Accident)


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Process PokaProcess Poka--Yoke DevicesYoke Devices

MAKE IT EASY TO DO IT RIGHT!MAKE IT EASY TO DO IT RIGHT!

Use Quick and Easy Tools by thinking:Use Quick and Easy Tools by thinking:

CC-- color, colorcolor, color--coding, checklistscoding, checklists

LL location, lockoutlocation, lockoutOO orientation, organizationorientation, organizationPP-- position, placement, physicalposition, placement, physicalSS-- size, shape, sequencing, sensorssize, shape, sequencing, sensors


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PokaPoka--Yoke and Hierarchy of ControlsYoke and Hierarchy of Controls(Controlling the health and safety risks in the workplace)(Controlling the health and safety risks in the workplace)

1.1. Elimination or SubstitutionElimination or Substitution best in design/best in design/

development stagedevelopment stagedesign the hazard or error-potential out of the process; substitutesubstitutesafe materials for hazardous ones, reduce energy; speed, voltage,safe materials for hazardous ones, reduce energy; speed, voltage,sound level, force, change process to eliminate distractions,sound level, force, change process to eliminate distractions,perform task at ground level, automate material handlingperform task at ground level, automate material handling

2.2. Engineering ControlsEngineering Controls remove a hazard or place aremove a hazard or place abarrier betweenbarrier betweenventilation systems, machine guarding, sound enclosures, circuitventilation systems, machine guarding, sound enclosures, circuitbreakers, platforms and guard railings, lift tables, conveyors,breakers, platforms and guard railings, lift tables, conveyors,lockslocks

3.3. Administrative ControlsAdministrative Controls Warnings, Procedures,Warnings, Procedures,

TrainingTraining includes alarms,includes alarms, signs, labelssigns, labels, beepers, computer, beepers, computerwarnings &warnings &training, procedure revisionstraining, procedure revisions, rotation of workers,, rotation of workers,safety equipment inspectionssafety equipment inspections

4.4. Personal Protective EquipmentPersonal Protective Equipment -- safety glasses, ear plugs,safety glasses, ear plugs,face shields, safety harnesses, back beltsface shields, safety harnesses, back belts

Most

Effective

Least

Effective

Design PokaDesign Poka--yokeyoke

Process PokaProcess Poka--yokeyoke


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Alarms and Warnings

Rules (Procedures)

Protective Equipment and Devices

Barriers, Guards and Engineered

Safeguards

Training

DANGER!

INCIDENT

Gaps

The Swiss Cheese Model

Supervisor

DefensesDefenses

(Hierarchy of Controls)(Hierarchy of Controls)

Individual (PPE)

Elimination or Substitution = Design PokaElimination or Substitution = Design Poka--yokeyoke

Engineered Controls =Engineered Controls =

Process PokaProcess Poka--yokesyokes


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PRACTICEPRACTICEBackground:Background:

Work surfaces in a secured lab were foundWork surfaces in a secured lab were foundcontaminated with lead and cadmium andcontaminated with lead and cadmium andneeded to be cleaned.needed to be cleaned.

Industrial Hygiene wanted to keep personnelIndustrial Hygiene wanted to keep personnelout of the lab until the cleanout of the lab until the clean--up wasup wascomplete.complete.

Q: How did they do this?Q: How did they do this?

How would you do this?How would you do this?

(HINT: Use the Hierarchy of Controls with a(HINT: Use the Hierarchy of Controls with aPokaPoka--yoke device)yoke device)


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PRACTICEPRACTICESome Options:Some Options:

1.1. Meet with the scientists and lab techs.Meet with the scientists and lab techs.informing them of the hazard then post ainforming them of the hazard then post asign on the door instructing personnel tosign on the door instructing personnel tostay out of the lab.stay out of the lab. TYPE:TYPE:

2.2. Place Warning tape across the door toPlace Warning tape across the door tolab; in addition to the sign.lab; in addition to the sign. TYPE:TYPE:

3.3. Change the lock on the door and post aChange the lock on the door and post asign instructing personnel who to contact ifsign instructing personnel who to contact ifaccess is required.access is required. TYPE:TYPE:


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HPI and PokaHPI and Poka--yokeyoke

SUMMARYSUMMARY

1.1. Errors (mistakes) are inevitableErrors (mistakes) are inevitable --(people make mistakes)(people make mistakes)

2.2. Errors are Direct Cause of DefectsErrors are Direct Cause of Defects

3.3. Defects are preventableDefects are preventable (i.e. Zero Defects)(i.e. Zero Defects)

Error (Mistake)Error (Mistake) DefectDefect

(Direct Cause)(Direct Cause) (Effect)(Effect)

PREVENT THE ERRORPREVENT THEPREVENT THE ERRORPREVENT THE

ACCIDENTACCIDENT

AccidentsAccidents

AccidentsAccidents AccidentsAccidents


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FINAL THOUGHTSFINAL THOUGHTSPokaPoka--yokes role in HPI:yokes role in HPI:

The approach applies errorThe approach applies error--proofing ideasproofing ideasoriginally developed for safety reasons.originally developed for safety reasons.

-- Shiego Shingo, developer of the Toyota Production systemShiego Shingo, developer of the Toyota Production systemand inventor of the Pokaand inventor of the Poka--yoke device concept!yoke device concept!

performance improvement is not limited tosafety. Organizations that have adopted

human performance improvement (HPI) methods

and practices also report improvedproduct quality, efficiency, and productivity.

- DOEs HP Handbook Nov. 2007


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CONCLUSIONCONCLUSION

The next time you want to beThe next time you want to beSS--AA--FF--EE--R,R, use ause a

Questioning AttitudeQuestioning Attitudetoto

Stop, Think and ActStop, Think and Actby utilizingby utilizingPOKAPOKA--YOKEYOKEthenthen ReviewReviewthe resultsthe results

PokaPoka--YokeYoke The Tool of ChoiceThe Tool of Choice

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Poka-Yoke and HPI

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