Module 9

• Lean Six Sigma – Control Phase

– SPC and Control charts

– Control Plans
– Visual Management Systems
– Metrics and OEE
– Poke Yoke
– Project Close
Define Measure Analyze Improve Control

Deliverables :
• Documented and implemented monitoring plan, standardized process,
documented procedures, response plan established and deployed,
transfer of ownership (project closure).

2
 Define Measure Analyze Improve Control

Checkpoints for Readiness

Monitoring Plan
• Control plan in place for sustaining improvements (short and long-
term).

Process Standardization
• New process steps, standards, and documentation are ingrained into
normal operations.

Documented Procedures
• Operating procedures are consistent.
• Knowledge gained on process is shared and institutionalized.
3
 Define Measure Analyze Improve Control

Checkpoints for Readiness

Response Plan
• Response plans established, understood, and deployed.

Transfer of Ownership (Project Closure)

• Transfer ownership and knowledge to process owner and process
team tasked with the responsibilities.

4
Statistical Process Control

5
 What is SPC?

• Statistical process control (SPC) is a statistical method to

monitor the performance of a process using control charts in
order to keep the process in statistical control.

• Statistical process control can be used to distinguish between

special cause variation and common cause variation in the
process.

• It presents the voice of the process.

6
 Common Cause Variation

• Common cause variation (also called chance variation) is the

inherent natural variation in any processes.

• It is the random background noise, which cannot be controlled

or eliminated from the process.

• Its presence in the process is expected and acceptable due to

its relatively small influence on the process.

7
 Special Cause Variation

• Special cause variation (also called assignable cause variation) is the

unnatural variation in the process.

• It is the cause of process instability and leads to defects of the products

or services.

• It is the signal of unanticipated change (either positive or negative) in

the process.

• It is possible to eliminate the special cause variation from the process.

8
 Process Stability

• A process is stable when:

– There is not any special cause variation involved in the process

– The process is in statistical control

– The future performance of the process is predictable within certain

limits

– The changes happening in the process are all due to random

inherent variation 9

– There are not any trends, unnatural patterns, and outliers in the
 SPC Benefits

• Statistical process control can be used in different phases of Six

Sigma projects to:

– Understand the stability of a process

– Detect the special cause variation in the process

– Identify the statistical difference between two phases

– Eliminate or apply the unnatural change in the process

10

– Improve the quality and productivity.

 Control Charts

• Control charts are graphical tools to present and analyze the

process performance in statistical process control.

• Control charts are used to detect special cause variation and

determine whether the process is in statistical control (stable).

• Variation solutions:
– Minimize the common cause variation
– Eliminate the special cause variation when it leads to unanticipated
negative changes in the outcome
– Implement the special cause variation when it leads to unanticipated 11

positive changes in the outcome.

 Control Charts Elements

Data Points: individual observations or Upper Line: upper control limit (UCL)
their calculation results
Vertical Axis: Measurement Values

Center Line: the process mean Lower Line: lower control limit (LCL)

Horizontal axis: Time

12
 Control Charts Elements

• Control charts can work for both continuous data and discrete
or count data.

• Control limits are approximately three sigma away from the

process mean.

• A process is in statistical control when all the data points on

the control charts fall within the control limits and have
random patterns only.

• Otherwise, the process is out of control and we need to

investigate the special cause variation in the process. 13
 Possible Errors in SPC

• There are two types of possible errors in interpreting controls

charts.

14
 Possible Errors in SPC

• It is similar to the way of defining the type I and type II errors

in hypothesis testing.

• Control charts can be interpreted as a way of testing the

hypothesis about the process stability.
– Null Hypothesis (H0): The process is stable (i.e., in statistical control).
– Alternative Hypothesis (HA): The process is unstable (i.e., out of
statistical control).

15
 Possible Errors in SPC

• Type I Error
– False positive
– False alarm
– Considering true common cause variation as special cause variation
– Type I errors waste resources spent on investigation.

• Type II Error
– False negative
– Miss
– Considering true special cause variation as common cause variation
– Type II errors neglect the need to investigate critical changes in the process.

16
 Data Collection Considerations

• To collect data for plotting control charts, we need to consider:

– What is the measurement of interest?
– Are the data discrete or continuous?
– How many samples do we need?
– How often do we sample?
– Where do we sample?
– What is the sampling strategy?
– Do we use the raw data collected or transfer them to percentages,
proportions, rates, etc.?

17
 Subgroups and Rational Subgrouping
• When sampling, we randomly select a group of items (i.e., a subgroup) from the
population of interest.

• The subgroup size is the count of samples in a subgroup. It can be constant or variable.

• Depending on the subgroup sizes, we select different control charts accordingly.

• Rational subgrouping is the basic sampling scheme in SPC.

• The goal of rational subgrouping is to maximize the likelihood of detecting special cause
variation. In other words, the control limits should only reflect the variation between
subgroups.

• The number of subgroups, subgroup size, and frequency of sampling have great impact
on the quality of control charts.

18
 Impact of Variation

• The rational subgrouping strategy is designed to minimize the

opportunity of having special cause variation within
subgroups.

• If there is only random variation (background noise) within

subgroups, all the special cause variation would be reflected
between subgroups. It is easier to detect an out-of-control
situation.

• Random variation is inherent and indelible in the process. We

are more interested in identifying and taking actions on special
cause variation. 19
 Frequency of Sampling

• The frequency of sampling in SPC depends on whether we

have sufficient data to signal the changes in a process with
reasonable time and costs.

• The more frequently we sample, the higher costs it may

trigger.

• We need the subject matter experts’ knowledge on the nature

and characteristics of the process to make good decisions on
sampling frequency.
20
21
 Specification Limits & Capable Processes
Specification Limits - often called “voice of the customer” and
used to determine if the product meets a customer
requirement. Usually stated as a LSL and USL but sometimes
you may only have one of these.

A capable process is a stable process that demonstrates the

ability to meet customer requirements. (A purist definition –
The simple fact is that no process is stable forever and ever
and we still need to address the capability of our processes in
the presence of instability)

When we talk capability indices, we're now comparing the

process variation (and sometimes average) to the specification
limits.

Before when we were talking stability, we were comparing the

22process variation to the control limits.
 Control Chart and Control Limits
• The control chart is the
tool used to distinguish
between common and Control Chart
special causes
UCL
• The control limits COMMON
CAUSE
represent the expected CL
variation due to
common cause LCL
24 68 10 1214 16 18 20 22 24 26 28 30 32
Run Order

Control Limits - often called “voice of the process” and used to

identify special causes of variation.
23
 Stable vs Unstable Processes

A stable (or “in control”) process is one in

which the key process responses and
product properties show no signs of special
causes.

An unstable (or “out of control”) process has

both common and special causes present.
24
Selection of Control Chart

25
 Why do we have control charts?
• To determine the average amount
• To determine the spread about the average
• To determine if the process is in control (only
common cause variation)
• To show the result of improvement efforts

26
 Types of Control Chart
• Control charts for variables
• Control Charts for attributes

27
 Control Charts for Variables
• X-bar chart. In this chart the sample means are plotted
in order to control the mean value of a variable (e.g.,
size of piston rings, strength of materials, etc.).
• R chart. In this chart, the sample ranges are plotted in
order to control the variability of a variable.
• S chart. In this chart, the sample standard deviations
are plotted in order to control the variability of a
variable.
• S**2 chart. In this chart, the sample variances are
plotted in order to control the variability of a variable.

28
 Control Charts for Attributes
• C chart. In this chart we plot the number of
defectives (per batch, per day, per machine, per 100
feet of pipe, etc.). This chart assumes that defects of
the quality attribute are rare, and the control limits
in this chart are computed based on the Poisson
distribution (distribution of rare events).

• U chart. In this chart we plot the rate of defectives,

that is, the number of defectives divided by the
number of units inspected (the n; e.g., feet of pipe,
number of batches). Unlike the C chart, this chart
does not require a constant number of units, and it
can be used, for example, when the batches
(samples) are of different sizes.
29
 Control Charts for Attributes
• Np chart. In this chart, we plot the number of defectives (per batch,
per day, per machine) as in the C chart. However, the control limits
in this chart are not based on the distribution of rare events, but
rather on the binomial distribution. Therefore, this chart should be
used if the occurrence of defectives is not rare (e.g., they occur in
more than 5% of the units inspected). For example, we may use this
chart to control the number of units produced with minor flaws.
• P chart. In this chart, we plot the percent of defectives (per batch,
per day, per machine, etc.) as in the U chart. However, the control
limits in this chart are not based on the distribution of rare events
but rather on the binomial distribution (of proportions). Therefore,
this chart is most applicable to situations where the occurrence of
defectives is not rare

30
31
32
 Exercise – Control Chart for Bottle
Filling
• Prepare an X-bar and range chart for the
trialling of a new bottle filling line. The target
fill weight is 50 g
• 5 samples are taken of filled material from the
line each hour for a period of 28 hours
running.
• Determine whether the process is in control

33
Equations for Control Chart
X-bar = Sum of X’s / No. of Subgroups

R-bar = Sum of R’s / No. of Subgroups

X-double bar = Sum of X-bars / No. of Subgroups

For X-bar chart

UCL = X-double bar + (A2* R-bar)

LCL = X-double bar – (A2*R-bar)

For R-chart

UCL = D4*R-bar note for n<7 i.e. Sample size <7, LCL=o
34
Parameters for Creating X-bar Charts

Number of Factor for X- Factor for Factor for Factor to

Observations bar Chart Lower Upper estimate
in Subgroup (A2) control Limit control limit Standard
(n) in R chart in R chart deviation, (d2)
(D3) (D4)
2 1.88 0 3.27 1.128
3 1.02 0 2.57 1.693
4 0.73 0 2.28 2.059
5 0.58 0 2.11 2.326
6 0.48 0 2.00 2.534
7 0.42 0.08 1.92 2.704
8 0.37 0.14 1.86 2.847
9 0.34 0.18 1.82 2.970
10 0.31 0.22 1.78 3.078

35
 Weight Fill Data
4
8
.
48.7 49.2 49.6 49.3 49.2 49.4 50.0 48.9 49.1 48.5 48.9 50.2 49.7 49.4 48.5 49.5 49.3 48.5 47.6 48.9 49.09
X-bar 48.76 48.94 4 2 6 49.5 8 50 6 50.3 8 8 6 8 8 2 49.2 4 2 6 6 6 8 2 5 6 26
4
9
.
X-double 49.2 49.2 49.2 49.2 49.2 49.2 49.2 49.2 49.2 49.2 49.2 49.2 49.2 49.2 49.2 49.2 49.2 49.2 49.2 49.2 49.2 49.2 49.2 49.2 49.22
bar 49.22 49.22 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 22
5
0
.
50.6 50.6 50.6 50.6 50.6 50.6 50.6 50.6 50.6 50.6 50.6 50.6 50.6 50.6 50.6 50.6 50.6 50.6 50.6 50.6 50.6 50.6 50.6 50.6 50.66
UCL 50.62 50.62 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 22
4
7
.
47.8 47.8 47.8 47.8 47.8 47.8 47.8 47.8 47.8 47.8 47.8 47.8 47.8 47.8 47.8 47.8 47.8 47.8 47.8 47.8 47.8 47.8 47.8 47.8 47.88
LCL 47.82 47.82 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 22

1.
R 4 2.9 1.4 2.3 1.7 1.9 3.1 1.9 3.1 1.6 4.2 2.8 2.1 3 2.9 2.9 2.4 2 2 1.5 2.3 2.7 2.2 2.4 5.38 1.5 2.4 2.1

2.
4
R-bar 3 2.43 2.43 2.43 2.43 2.43 2.43 2.43 2.43 2.43 2.43 2.43 2.43 2.43 2.43 2.43 2.43 2.43 2.43 2.43 2.43 2.43 2.43 2.43 2.43 2.43 2.43 2.43

4.
5 36
UCL 4 4.54 4.54 4.54 4.54 4.54 4.54 4.54 4.54 4.54 4.54 4.54 4.54 4.54 4.54 4.54 4.54 4.54 4.54 4.54 4.54 4.54 4.54 4.54 4.54 4.54 4.54 4.54
R 1.4 2.9 1.4 2.3 1.7 1.9 3.1 1.9 3.1 1.6 4.2 2.8 2.1 3 2.9 2.9 2.4 2 2 1.5 2.3 2.7 2.2 2.4 5.38 1.5 2.4 2.1

R-bar 2.43 2.43 2.43 2.43 2.43 2.43 2.43 2.43 2.43 2.43 2.43 2.43 2.43 2.43 2.43 2.43 2.43 2.43 2.43 2.43 2.43 2.43 2.43 2.43 2.43 2.43 2.43 2.43

UCL 4.54 4.54 4.54 4.54 4.54 4.54 4.54 4.54 4.54 4.54 4.54 4.54 4.54 4.54 4.54 4.54 4.54 4.54 4.54 4.54 4.54 4.54 4.54 4.54 4.54 4.54 4.54 4.54

37
 X-bar Chart for Fill Weight Data
51

50.5

50

49.5

49
X-bar

48.5 X-double bar

UCL

48 LCL

47.5

47

46.5

46
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

38
 R-Chart for Fill Weight data
6

R
3 R-bar

UCL

0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
39
 The Four Major Capability /
Performance Indices

• Cp and Cpk address short-term capability

• Pp and Ppk address long-term performance

40
 Process Capability Indices - Cp

-3 +3

LSL USL

Spec Width (door*) USL - LSL

Cp = =
Mfg Capability (car) 6
41
 Process Capability Indices - Cp

LSL USL
USL - LSL
Cp =
6ST

Cp < 1 - not capable

Cp = 1 - marginally capable
Cp > 1 - capable

The average is not part of the formula.

A measure of potential "best case" process capability if stable and on-target.
Can be misleading if process is unstable or off target.
Must have both a LSL and USL to calculate.
42
 What if Process is Off-Target?

Lower Cust. Tolerance Upper

Spec. Spec.
0.4
Limit Limit
0.3
Cp = 1.33
0.2

Cpk = 1.33 0.1

0.0
-5.33 -4.0 -2.67 -1.33 0 1.33 2.67 4.0 5.33

Lower Upper
Cust. Tolerance
Spec. Spec.
0.4
Limit Limit
0.3

Cp = 1.33 0.2

0.1
Cpk = 0.83
0.0
-5.33 -4.0 -2.67 -1.33 0 1.33 2.67 4.0 5.33
43
 Process Capability Indices - Cpk

LSL USL
Min (USL - avg, avg - LSL)
Cpk =
3ST

Cpk < 1 - not capable

Cpk = 1 - marginally capable
Cpk > 1 - capable avg

Cp = Cpk if process is on target.

Still a measure of potential capability if the process is stable.
Can be used for 1-sided specs. (Cpu, Cpl)
A negative Cpk is possible if the average is outside specifications.
44
 Control Plan
What is it?
An organisational tool to analyse plant performance by key characteristic and
define control actions.

How to create a Control Plan:

1. Select Causal Variable(s). Proven vital few X(s)
2. Define Control Plan
- 5Ws for optimal ranges of X(s)
3. Validate Control Plan
- Observe Y
4. Implement/Document Control Plan
5. Audit Control Plan
6. Monitor Performance Metrics

45
 Control Plans

• The control plans ensure that the changes introduced by a Six Sigma
project are sustained over time.

• Benefits of the Control phase:

• Methodical roll-out of changes including standardization of processes and work
procedures
• Ensure compliance with changes through methods like auditing and corrective
actions
• Transfer solutions and learning across the enterprise
• Plan and communicate standardized work procedures
• Coordinate ongoing team and individual involvement
• Standardize data collection and procedures
• Measure process performance, stability, and capability
• Plan actions that mitigate possible out-of-control conditions
46
• Sustain changes over time.
 What is a Control Plan?

• A control plan is a management planning tool to identify, describe,

and monitor the process performance metrics in order to meet the
customer specifications steadily.

• It proposes the plan of monitoring the stability and capability of

inputs and outputs of critical process steps in the Control phase of a
project.

• It covers the data collection plan of gathering the process

performance measurements.

• Control plans are the most overlooked element of most projects. It is

critical that a good solution be solidified with a great control plan! 47
 Control Plan Elements
• Control Plan
• The clear and concise summary document that details key process steps, CTQs metrics,
measurements, and corrective actions.
• Standard Operating Procedures (SOPs)
• Supporting documentation showing the “who does what, when, and how” in completing the
tasks.
• Communication Plan
• Document outlining messages to be delivered and the target audience.
• Training Plan
• Document outlining the necessary training for employees to successfully perform new
processes and procedures.
• Audit Checklists
• Document that provides auditors with the audit questions they need to ask.
• Corrective Actions
• Activities that need to be conducted when an audit fails.

48
 Control Plan

• The control plan identifies critical process steps that have

significant impact on the products or services and the
appropriate controls mechanisms.

• The control plan includes measurement systems that monitor

and help manage key process step performance.

• Specified limits and targets of the performance metrics are

clearly defined and communicated.

• Sampling plans to collect the measurements are declared:

49

• How many samples are needed?

• How often do we need to sample?
 Control Plan

Key processes and process Critical information regarding key

steps are identified measurements is documented and clarified

50
 Control Plan

Measurements are clearly Other key measurement information is documented: sample

defined with equations size, measurement frequency, people responsible for the
Customer measurement, etc.
specifications
are declared

51
 Control Plan

Where will this measurement or report Control plans identify the mitigating action or
be found? Good control plans provide corrective actions required in the event the
linking information or other report measurement falls out of spec or control.
reference information. Responsible parties are also declared.

52
 Standard Operating Procedures (SOPs)

• Standard Operating Procedures (SOPs) are documents that focus on

process steps, activities, and specific tasks required to complete an
operation.

• SOPs should not be much more than two to four pages.

• SOPs should be written to the user’s level of required detail and

information.
• The level of detail is dependent on the position’s required skills and training

• Good SOPs are auditable, easy to follow, and not difficult to find.
• Auditable characteristics are: observable actions and countable frequencies. Results should be
evident to a third party (compliance to the SOP must be measurable).
53
 SOP Elements

• SOPs are intended to impart high value information in concise

and well-documented manner.
• SOP Title and Version Number:
• Provide a title and unique identification number with version information.
• Date:
• List the original creation date; add all revision dates.
• Purpose:
• State the reason for the SOP and what it intends to accomplish.
• Scope:
• Identify all functions, jobs, positions, and/or processes governed or affected by the SOP.

54
 SOP Elements

• Responsibilities:
– Identify job functions and positions (not people) responsible for carrying out
activities listed in the SOP.
• Materials:
– List all material inputs: parts, files, data, information, instruments, etc.
• Process Map:
– Show high level or level two to three process maps or other graphical
representations of operating steps.
• Process Metrics:
– Declare all process metrics and targets or specifications.
• Procedures:
– List actual steps required to perform the function.
• References:
– List any documents that support the SOP. 55
SOP Template

56
 Communication Plans

• Communication plans are documents that focus on planning and preparing

for the dissemination of information.

• Communication plans organize messages and ensure that the proper

audiences receive the correct message at the right time.

• A good communication plan identifies:

• Audience
• Key points/message
• Medium (how the message is to be delivered)
• Delivery schedule
• Messenger
• Dependencies and escalation points
• Follow-up messages and delivery mediums.

• Communication plans help develop and execute strategies for delivering

changes to an organization. 57
 © Lean Sigma Corporation Lean Six Sigma Training - MTB
58
Communication Plan Template
 Training Plans
• Training plans are used to manage the delivery of training for new processes and
procedures.

• Most GB or BB projects will require changes to processes and/or procedures that must
be executed or followed by various employees.

• Training plans should incorporate all SOPs related to performing new or modified tasks.

• Training plans use and support existing SOPs and do not supersede them.

• Training plans should include logistics:

– One-on-one or classroom
– Instruction time
– Location of training materials
– Master training reference materials
– Instructors and intended audience
– Trainee names.
59
Training Plan Template

60
 Audits

• What is an audit?
– ISO 9000 defines an Audit as “a systematic and independent
examination to determine whether quality activities and related
results comply with planned arrangements and whether these
arrangements are implemented effectively and are suitable to
achieve objectives.”

• Audits are used to ensure actions, processes, procedures, and

other tasks are performed as expected.

61
 Audit Guidelines

• Audits should be directed by managers, supervisors, and other accountable positions.

• An audit’s purpose must be well-defined and executed by independent unbiased personnel.

• Auditors must:
– Be qualified to perform their tasks
– Attend and successfully complete an internal auditing training session
– Be able to identify whether or not activities are being followed according to the defined SOP
– Base conclusions on facts and objective evidence
– Use a well documented audit checklist.

• Audits should confirm compliance or declare non-compliance.

62
 Audit Checklists

• Auditors should review the SOPs before preparing checklists or ensure that existing
checklists properly reference SOPs.

• Audit checklists:
– Serve as guides for identifying items to be examined
– Are used in conjunction with understanding of the procedure
– Ensure a well-defined audit scope
– Identify needed facts during audits
– Provide places to record gathered facts.

• Checklists should include:

– A review of training records
– A review of maintenance records
– Questions or observations that focus on expected behaviors
– Questions should be open-ended where possible
63
– Definitive observations yes/no, true/false, present/absent, etc.
Audit Checklist Template

64
5.3.3 Response Plan Elements

65
 What is a Response Plan?

• A response plan should be a component of as many control plan

elements as possible.

• Response plans are a management planning tool to describe

corrective actions necessary in the event of out-of-control
situations.

• There is never any guarantee that processes will always perform as

designed. Therefore, it is wise to prepare for occasions when special
causes are present.

• Response plans help us mitigate risks and, as already mentioned,

should be part of several control plan elements. 66
 Response Plan Elements

• Action triggers
– When do we need to take actions to correct a problem or issue?
• Action recommendation
– What activities are required in order to solve the problem in the process?
The action recommended can be short-term (quick fix) or long-term (true
process improvement).
• Action respondent
– Who is responsible for taking actions?
• Action date
– When did the actions happen?
• Action results
– What actions have been taken?
– When were actions taken?
– What are the outcomes of the actions taken?
67
 Response Plan Elements

Note the response plan element in this control plan template

68
 Response Plan Elements

Note the response plan element in this communication plan template

69
 Response Plan Elements

Note the response

plan element in this
audit checklist

70
 Example of Control Plan Template

CONTROL PLAN Revision Num ber 1.0

Date
Organization:
Location:

Critical to Sig. Significant

Quality Char. Characteristic Chart Chart Chart Measurem ent
Measurem ent Reaction Guage Sam pling Process
Characteristic # Description Type Cham pion Location Method Study Plan Num ber Plan Stability Cp/Cpk

A A-1
A-2

B B-1
B-2
72
73
74
 What is Visual Management?

• Visual Management is a set of techniques for creating a

workplace embracing visual communication and control
throughout the work environment.
• The visual management philosophy is underpinned by the view
that ‘what gets measured & displayed gets done’
• It makes it easy to understand the processes which have been
put into place

75
 Two Tools of Visual Management

Visual Displays Visual Controls

• To make staff aware of • To guide the action of

• related data and • staff members – sign
• information • boards, dos and
• – charts, graphs etc • don’ts signs

76
 Types of Visual Display

• Product and process information

• Area information, boundaries
• Standard work instructions - Standard work charts, etc
• Performance information - tracking against key metrics
• Status of current issues and improvement activities
• Schedules of maintenance, calibration or other support
activities

77
 Types of Visual Controls

• Shadow boards
• Indicators on various items e.g. gauges
• Heijunka boards – showing the status of daily schedules
• Design pull systems (Kanban)

78
Making Metrics Matter

Collecting the right data to solve problems: What makes a metric

valuable?

• Metric data should flow bilaterally between top level and low level
decision-makers

• Metrics should be available in real time and reviewed on a regular

basis

• Metrics must include goals so that abnormalities are visualized at a

glance

• Metrics should have relevance to customer value and should

undergo periodic audits

• Metrics should link to corporate objectives

79
 Some Tips for Visual Management
Make Abnormal Metrics Stand Out
Don’t make your management team search for the data they need. Problem
solving will be more effective if the data is within reach and abnormalities are
easily identifiable.

Color Code
Color can be very powerful to create efficiency when
displaying scoreboard data.

Positioning
Place data at the point of use. If possible, group metrics by
category so that they are easily recognizable in team huddles
and Gemba walks.

Keep up to date:
Don’t lose credibility with your team by displaying obsolete
scoreboard data. If you are not using the data, get rid of the
scoreboard.

80
The A3 Template for Problems and Solutions

Advantage of the A3 Lean template

– Problems within an organization are often addressed superficially.

The deeper, underlying causes of the problem are not always
considered, allowing repetition to lie in wait.

– The same problems will resurface with the result that operational
performance does not improve.

– The A3 Thinking process helps to arrive at a joint and detailed

problem resolution. Underlying causes are thus eliminated.

82
The A3 Template for Problems and Solutions

A3 template is used as a single page report for defining problems and implementing
solutions

Method
1. Identify the problem or need
2. Understand the current situation/state
3. Develop the goal statement – develop the target state
4. Perform root cause analysis
5. Brainstorm/determine countermeasures
6. Create a countermeasures implementation plan
7. Check results – confirm the effect
8. Keep the plan in place

83
84
BACKGROUND TARGET CONDITION/GOAL STATEMENT

Make the business case for selecting What are you trying to achieve and
the problem. Clearly state how the by when. Predict the expected
problem impacts the business. improvement, specifically and
quantitatively.

CURRENT CONDITION/PROBLEM STATEMENT

IMPLEMENTATION PLAN

Indicate the magnitude of the

problem and specific effects on the
business on a qualitative scale, using List actions that will be taken by
graphics if available. whom and by when, in order to
realize the target condition.

ROOT CAUSE ANALYSIS

FOLLOW-UP

Why are we experiencing this

problem. Use a root cause tool like How will the effectiveness of the plan be
fish bone, 5-why's or Pareto. measured, when will it be measured and by
whom. Record results of follow-up.
 <Title> <Name> < date>

BACKGROUND / BUSINESS CASE SOLUTIONS

STAKEHOLDERS
• Customers:
• Team Members:
ACTION ITEMS
CURRENT CONDITION
Action Owner Proposed Actual
Date Date

ANALYSIS/ROOT CAUSES

METRICS/FOLLOW-UP
 Example – Files Mgmt A3

BACKGROUND TARGET CONDITION/GOAL STATEMENT

Electronic files for the Technical Services Bureau are spread over Develop a filing system that contains a comprehensive and
many sub-folders. It is difficult to find information, and it is difficult to logical set of folders and subfolders.
know where to file information Train users and have them committ to using the new
Time is wasted looking for materials. Materials are duplicated in two system.
or more folders, wasting electronic storage space. Develop a file retention policy and stick to it.
Institute a "dead file" system where files removed per the
retention policy are held for a set period, then deleted.
Stick to it!
CURRENT CONDITION/PROBLEM STATEMENT

Air Tech Services capacity 1.85 TB

Air Tech Services current volume 1.32 TB IMPLEMENTATION PLAN

What Who Date Complete

Develop folders and subfolder Team 3/1/2014
criteria and retention policy
Develop criteria for moving Janelle 4/1/2014
files into new system
Review criteria with team Team 4/15/2014
Move folders to new locations Janelle 5/1/2014
Begin new filing system Team 6/1/2014

ROOT CAUSE ANALYSIS

FOLLOW-UP

What Who Date Complete

Review system for excess files Janelle 12/1/2014
Review "dead files" folder Janelle 6/1/2015
and delete
Review annually Janelle no end date

January 24, 2014

 A3

Title: Bahama Bistro Lunch Order Delays Name: Lunch Team Date: June 1st

Background: Proposed Countermeasure(s):

Good service is part of the Bahama Bistro Mission Statement. Countermeasures proposed:
We can't afford dissatisfied customers - we'll lose them. - 5S the Prep Area
- Conduct Cross-Training of all floor staff
- Redesign the order form to make special orders easy to see
Current Conditions: - Institute Standard Work amongst all roles
It takes 28 minutes on average to serve lunch orders. - Switch to a new food vendor
Customers are having trouble fitting this into their lunch hours.
Implementation Plan:
Average Order Lead Time shifted from 28 mins to 15 mins - success!
Target(s)/Goal(s)
The goal is to deliver sandwiches and soups in 16 minutes or
less and entrees in 20 minutes or less by May 10th.

Analysis

Follow Up:
Selected 1 input & 1 process measure as leading indicators for Lunch
Order Lead Time - Researching Transfer opportunities

Some of the root causes:

- Prep area layout causes excess motion & restocking
- There are bottlenecks due to specialization of roles
- Order form not easy for special orders causes rework
- Lots of process variation based on the individual

88
 Problem-Solving Story

January 24, 2014

 OEE
(Overall Equipment Effectiveness)
• What is Overall Equipment Effectiveness?
• OEE (Overall Equipment Effectiveness) is the gold
standard for measuring manufacturing productivity.
Simply put – it identifies the percentage of
manufacturing time that is truly productive.
• An OEE score of 100% means you are manufacturing
only Good Parts, as fast as possible, with no Stop
Time. In the language of OEE that means 100% Quality
(only Good Parts), 100% Performance (as fast as
possible), and 100% Availability (no Stop Time).
• Measuring OEE is a manufacturing best
practice. By measuring OEE and the
underlying losses, you will gain important
insights on how to systematically improve
your manufacturing process. OEE is the single
best metric for identifying losses,
benchmarking progress, and improving the
productivity of manufacturing equipment (i.e.,
eliminating waste).
• Where Do We Start?
• Let’s start at the beginning – with All Time. This is also
called 24/7 time (it includes every minute of every day).
• From All Time, you subtract Schedule Loss, which includes
all time that should be excluded from OEE analysis because
there is no intention of running production during this time
(e.g., plant shutdowns, or periods where there are no
orders). Schedule Loss is part of TEEP (Total Effective
Equipment Performance). It is not part of OEE.
• The remaining time is your Planned Production Time. OEE
begins with Planned Production Time and scrutinizes all
efficiency and productivity losses that occur within that
time, with the goal of reducing or eliminating these losses.
• The three OEE factors, each of which takes
into account a different type of loss.
• They are:
- Availability,
- Performance
- Quality.
• Availability
• Availability takes into account Availability Loss,
which includes any events that stop planned
production for an appreciable length of time
(usually several minutes; long enough for an
operator to log a reason).
• Examples of things that create Availability Loss include
Unplanned Stops (such as equipment failures and
material shortages), and Planned Stops (such as
changeover time). Changeover time is included in OEE
analysis, since it is time that could otherwise be used
for manufacturing. While it may not be possible to
eliminate changeover time, in most cases it can be
significantly reduced. Reducing changeover time is the
goal of SMED (Single-Minute Exchange of Dies).
• The remaining time after Availability Loss is subtracted
is called Run Time.
• Performance
• Performance takes into account Performance
Loss, which accounts for anything that causes the
manufacturing process to run at less than the
maximum possible speed when it is running
(including both Slow Cycles and Small Stops).
• Examples of things that create Performance Loss
include machine wear, substandard materials,
misfeeds, and jams.
• The remaining time after Performance Loss is
subtracted is called Net Run Time.
• Quality
• Quality takes into account Quality Loss, which accounts
for manufactured parts that do not meet quality
standards.
• Examples of things that create Quality Loss include
scrap and parts that need rework
• Rework Parts – Rejected parts that can be reworked
and sold to the customer. Reworked parts do not affect
the OEE calculation as they were not right first time.
OEE does not make a distinction between parts that
can be reworked and parts that are scrapped.
• OEE Quality is similar to First Pass Yield, in that
it defines Good Parts as parts that successfully
pass through the manufacturing process the
first time without needing any rework. The
remaining time after Quality Loss is subtracted
is called Fully Productive Time.
• Our goal is not simply to measure OEE – it is to
maximize Fully Productive Time.
• One of the major goals of OEE programs is to
reduce and/or eliminate what are called the
Six Big Losses – the most common causes of
equipment-based productivity loss in
manufacturing.
• Equipment Failure
• Equipment Failure accounts for any significant
period of time in which equipment is
scheduled for production but is not running
due a failure of some sort.
• A more generalized way to think of equipment
failure is as any unplanned stop or downtime.
Equipment failure is an Availability Loss.
• Examples of common reasons for equipment
failure include tooling failure, breakdowns,
and unplanned maintenance. From the
broader perspective of unplanned stops, other
common reasons include no operators or
materials, being starved by upstream
equipment or being blocked by downstream
equipment.
• There is flexibility on where to set the
threshold between equipment failure (an
Availability Loss) and a minor stop (a
Performance Loss). A good rule of thumb is to
set that threshold based on your policy for
tracking reasons. For example, your policy
might be that any downtime longer than two
minutes should have a reason associated with
it – and thus shall be considered equipment
failure.
• Setup and Adjustments
• Setup and Adjustments accounts for any
significant periods of time in which equipment
is scheduled for production but is not running
due to a changeover or other equipment
adjustment. A more generalized way to think
of Setups & Adjustments is as any planned
stop. Setup and Adjustments is an Availability
Loss.
• Examples of common reasons for Setup and
Adjustments include setup, changeovers, major
adjustments, and tooling adjustments. From the
broader perspective of planned stops, other
common reasons include cleaning, warmup time,
planned maintenance, and quality inspections.
• The largest source of Setup and Adjustment time
is typically changeovers (also referred to as make
ready or setup), which can be addressed through
a SMED (Single-Minute Exchange of Dies)
program.
• Idling and Minor Stops
• Idling and Minor Stops accounts for time
where the equipment stops for a short period
of time (typically a minute or two) with the
stop resolved by the operator. Another name
for Idling and Minor Stops is small stops. Idling
and Minor Stops is a Performance Loss.
• Examples of common reasons for Idling and Minor
Stops include misfeeds, material jams, obstructed
product flow, incorrect settings, misaligned or blocked
sensors, equipment design issues, and periodic quick
cleaning.
• This category usually includes stops that are well under
five minutes and that do not require maintenance
personnel. The underlying problems are often chronic
(same problem/different day), which can make
operators somewhat blind to their impact. Most
companies do not accurately track Idling and Minor
Stops.
• Reduced Speed
• Reduced Speed accounts for time where
equipment runs slower than the Ideal Cycle
Time (the theoretical fastest possible time to
manufacture one part). Another name for
reduced speed is slow cycles. Reduced speed
is a Performance Loss.
• Examples of common reasons for reduced speed
include dirty or worn out equipment, poor
lubrication, substandard materials, poor
environmental conditions, operator inexperience,
startup, and shutdown.
• This category includes anything that keeps the
process from running at its theoretical maximum
speed (a.k.a. Ideal Run Rate or Nameplate
Capacity) when the manufacturing process is
actually running.
• Process Defects
• Process Defects account for defective parts
produced during stable (steady-state) production.
This includes scrapped parts as well as parts that
can be reworked, since OEE measures quality
from a First Pass Yield perspective. Process
defects are a Quality Loss.
• Examples of common reasons for process defects
include incorrect equipment settings, operator or
equipment handling errors, and lot expiration
(e.g., in pharmaceutical plants).
• Reduced Yield
• Reduced Yield accounts for defective parts
produced from startup until stable (steady-state)
production is reached. This includes scrapped
parts as well as parts that can be reworked, since
OEE measures quality from a First Pass Yield
perspective. Reduced Yield can occur after any
equipment startup, however, it is most commonly
tracked after changeovers. Reduced Yield is a
Quality Loss.
• Examples of common reasons for Reduced
Yield include, incorrect settings when a new
part is run, equipment that needs warmup
cycles, or equipment that inherently creates
waste after startup.
• Preferred Calculation
• The preferred OEE calculation is based on the
three OEE Factors: Availability, Performance,
and Quality.
• OEE is calculated by multiplying the three OEE
factors: Availability, Performance, and Quality.
Look at the following OEE data for two
sequential weeks
• OEE is improving. Great job! Or is it? Dig a
little deeper and the picture is less clear.
• Most companies would not want to increase
Availability by 5.0% at the expense of
decreasing Quality by 4.5%.
• Planned Production Time
• As described - the OEE calculation begins with
Planned Production Time. So first, exclude any
Shift Time where there is no intention of
running production (typically Breaks).
• Formula: Shift Length − Breaks
• Example: 480 minutes − 60 minutes = 420
minutes
• Run Time
• The next step is to calculate the amount of time
that production was actually running (was not
stopped). Remember that Stop Time should
include both Unplanned Stops (e.g., Breakdowns)
or Planned Stops (e.g., Changeovers). Both
provide opportunities for improvement.
• Formula: Planned Production Time − Stop Time
• Example: 420 minutes − 47 minutes = 373
minutes
• Good Count
• If you do not directly track Good Count, it also
needs to be calculated.
• Formula: Total Count − Reject Count
• Example: 19,271 widgets − 423 widgets =
18,848 widgets
• Availability
• Availability is the first of the three OEE factors
to be calculated. It accounts for when the
process is not running (both Unplanned Stops
and Planned Stops).
• Formula: Run Time / Planned Production Time
• Example: 373 minutes / 420 minutes = 0.8881
(88.81%)
• Performance
• Performance is the second of the three OEE
factors to be calculated. It accounts for when the
process is running slower than its theoretical top
speed (both Small Stops and Slow Cycles).
• Formula: (Ideal Cycle Time × Total Count) / Run
Time
• Example: (1.0 seconds × 19,271 widgets) / (373
minutes × 60 seconds) = 0.8611 (86.11%)
• Quality
• Quality is the third of the three OEE factors to
be calculated. It accounts for manufactured
parts that do not meet quality standards.
• Formula: Good Count / Total Count
• Example: 18,848 widgets / 19,271 widgets =
0.9780 (97.80%)
• OEE
• Finally, OEE is calculated by multiplying the
three OEE factors.
• Formula: Availability × Performance × Quality
• Example: 0.8881 × 0.8611 × 0.9780 = 0.7479
(74.79%)
The OEE for this shift is 74.79%.
Total Productive Maintenance (TPM)

127
 Introduction to TPM
What is TPM ?
• Total Productive Maintenance (TPM) is
both
–a philosophy to permeate throughout an
operating company touching people of all levels
–a collection of techniques and practices
aimed at maximizing the effectiveness (best possible
return) of business facilities and processes

128
129
It is a Japanese approach for
• Creating company culture for maximum efficiency
• Striving to prevent losses with minimum cost
– Zero breakdowns and failures, Zero accident, and
Zero defects etc
• The essence of team work (small group activity)
focused on condition and performance of facilities to
achieve zero loss for improvement
• Involvement of all people from top management to
operator

130
 History/Origin

• TPM first introduced in Japan 20 years ago and

rigorously been applied in past 10 years
• TPM planning & implementation in Japanese factories
supported by JIPM (Japan Institute of Plant
Maintenance)
• Awarded yearly prizes to various industries:
✓ Automotive
✓ Metals
✓ Chemicals
✓ Rubber
✓ Food
✓ Glass etc.

131
• Initially implemented in
high-to-medium volume production areas

• Later successfully applied in:

✓ Low-volume production
✓ High-to-low volume assembly
✓ Development areas
✓ Warehouse
✓ Whole range of industry

132
 Role of TPM
Answers of the following questions are able to tell
what role TPM can play within a company:

➢ Does TPM replace traditional maintenance

techniques ?
➢ Why is it so popular and important ?
➢ What are its policies and objectives ?
➢ How does it fit in with TQM ?
➢ What are its steps, activities and components?
➢ What are its benefits and results ?

133
 TPM and Traditional Maintenance
➢ Reactive maintenance inherently wasteful and
ineffective with following disadvantages:

• No warning of failure
• Possible safety risk
• Unscheduled downtime of machinery
• Production loss or delay
• Possible secondary damage

134
Need for:
• Stand-by machinery
• A stand-by maintenance team
• A stock of spare parts

Costs include:
• Post production
• Disrupted schedule
• Repair cost
• Stand-by machinery
• Spare parts
135
➢ Real cost of reactive maintenance is more
than the cost of maintenance resources and
spare parts

➢ Pro-active maintenance (planned, preventive

and predictive) more desirable than reactive
maintenance

136
➢ TPM enables or provides:

• The traditional maintenance practices to

change from reactive to pro-active
• A number of mechanisms whereby
✓ Breakdowns are analyzed
✓ Causes investigated
✓ Actions taken to prevent further
breakdowns
• Preventive maintenance schedule to be
made more meaningful

137
• To ‘free up’ maintenance professionals to:
✓ Carry out scheduled and preventive
maintenance
✓ Gather relevant information as important
input to the maintenance system
✓ Keep the system up to date
✓ To review cost effectiveness
• To develop and operate a very effective
maintenance system an integral part of
manufacturing

138
 Why is TPM so popular and important ?
Three main reasons:

1. It guarantees dramatic results (Significant

tangible results)
• Reduce equipment breakdowns
• Minimize idle time and minor stops
• Less quality defects and claims
• Increase productivity
• Reduce manpower and cost
• Lower inventory
• Reduce accidents

139
2. Visibly transform the workplace
(plant environment)

• Through TPM, a filthy, rusty plant covered in oil

and grease, leaking fluids and spilt powders can
be reborn as a pleasant and safe working
environment
• Customers and other visitors are impressed by
the change
• Confidence on plant’s product increases

140
3. Raises the level of workers knowledge and
skills

As TPM activities begin to yield above concrete

results, it helps:
• The workers to become motivated
• Involvement increases
• Improvement suggestions proliferate
• People begin to think of TPM as part of the job

141
 TPM Policy and Objectives
Policy and objectives:
• To maximize overall equipment
effectiveness (Zero breakdowns and failures,
Zero accident, and Zero defects etc) through total
employee involvement

• To improve equipment reliability and

maintainability as contributors to quality and to
raise productivity

142
 TPM Basic policy and objectives
(Contd.)
• To aim for maximum economy in equipment
for its entire life

• To cultivate equipment-related expertise and

skills among operators

• To create a vigorous and enthusiastic work

environment

143
TPM Corporate policy for the following purposes:

• To aim for world-class maintenance,

manufacturing performance and quality

• To plan for corporate growth through business

leadership

144
TPM Corporate policy (Contd.):

• To promote greater efficiency through greater

flexibility

• Revitalize the workshop and make the most of

employee talents

145
Production dept.TPM to Companywide
TPM

146
 12 TPM Development Program
Steps
Preparation

1. Formally announce the decision to introduce TPM

2. Conduct TPM introductory education and publicity

campaign

3. Create TPM promotion organization

147
Preparation (Contd.)
4. Establish basic TPM policy and goals

5. Draft a master plan for implementing TPM

Introduction
6. Kick off TPM initiatives
(to cultivate the atmosphere to raise morale,
inspiration and dedication)

148
Implementation
7. Build a corporate constitution designed to
maximize the effectiveness of facilities
i. Conduct focused improvement activities
ii. Establish and deploy autonomous maintenance
program
iii. Implement planned maintenance program
iv. Conduct operation and maintenance skills
training

8. Build an early management system for new

products and equipment

149
Implementation (Contd.)
9. Build a quality maintenance system

10. Build an effective administration and support

system
11. Develop a system for managing health, safety,
and the environment

Consolidation
12. Sustain a full TPM implementation and raise
levels (Prize)

150
 Five fundamental TPM activities

1. Autonomous maintenance
2. Equipment improvement
3. Quality maintenance
4. MP(Maintenance Prevention) system-
building
5. Education and training

151
152
153
 TPM and Total Quality
➢ TPM is an essential component of TQM

➢ TPM resembles TQM in following aspects:

• Total commitment to the program by upper level
management
• Employee empowered to initiate corrective actions
• Changes in employee mind-set towards their job
responsibilities

154
Components of TPM

155
 Practical Components of TPM
To be achieved through TPM team:
➢Restore, maintain and continuously improve
the existing facilities

Role of maintenance Role of operation

personnel personnel
o Carry out major o Maintain ‘basic’
repairs machinery condition to
prevent deterioration

156
Role of maintenance Role of operation
personnel (contd.) personnel (contd.)
o Improve weak points and o Monitor machinery
eliminate deterioration effectiveness
o Plan and carry out o Regularly inspect to
preventive maintenance detect problems
o Analyze breakdowns and o Carry out simple
performance, and carry out improvements / repairs
predictive maintenance

157
➢Detect and eliminate faults and problems

Faults that: Problems that:

o Cause breakdowns o slow down the

and/or stoppages operator and make
life difficult
o Slow the process
down o Make
changeovers difficult
o Cause breakdowns
and/or stoppages o Slow down the
operator and make
life difficult

158
Faults and Problems

159
 ➢Detect and eliminate faults and problems

Faults that: Problems that:

o Slow the process o Make changeovers

down difficult

o Cause o Make workplace dirty,

inconsistency oily and smelly

o Cause rejects o Make the machinery

dangerous to operate
o Provide safety and setup => lead to
hazards injury

160
➢ Establish, monitor and improve
process effectiveness

Following six big losses to recognize, measure

and reduce:

1. Breakdown losses due to failures and repairs

2. Setup and adjustment losses

1and 2 = availability loss

161
 Six big losses (Contd.):

3. Idling and minor stoppage losses

4. Speed losses
5. Scrap and rework losses
6. Start-up losses

3 and 4 = performance loss

5 and 6 = quality loss

162
➢ Establish and maintain a clean, neat
and tidy workplace
(This TPM component describes good house keeping)

Translation of 5 Japanese S’s

1. Seiso => Shine / Cleanliness
(Thoroughly clean the workplace)

Advantages:
– Pleasant and safer workplace and improved morale
– No wear, corrosion and failure of machinery due to
dirt and debris

163
Seiso Advantages (contd.):
– Easy detection of oil leakage and spilage
– Psychological effects for improved reactions and
performances
– Reduced hazards and more visible warning signs

2. Seiri => Sort / Arrangement

(Eliminate unnecessary items)
Better arrangement for ease of access and use of:
– Facilities, tools, fixtures and materials etc.
which brings substantial benefits

164
3. Seiton => Set In Order / Neatness
Efficient and effective storage method
– Defined location for storage of every facility
required for production process
– Encourage people to return the facility after use

4. Shitsuke => Sustain / Discipline

(Sustain new status quo ‘everything in its place’)
Required to ensured that facilities are:
– Returned in proper location after use
– Kept clean and tidy
– Repaired / replaced if damaged

165
5. Seiketsu => Standardize / Order

Order and control to be established for:

– The above procedures and mechanisms
– Introduction of CAN DO activities at early stage
– Part of the company culture

166
➢ Identify and eliminate inherent
faults:

– Discover inherent faults either in design

and manufacturing of machinery or in
methods of operation

– Try to reduce their effect wherever

possible

167
Identify and eliminate inherent faults
(contd.):

– Propose a project with a specially skilled

small team to focus on inherent faults to
improve overall effectiveness which
includes:

✓ Availability improvement through

➢ Changeover and setup reduction
➢ Reliability improvement
➢ Maintainability improvement

168
✓ Performance improvement through
• Chronic (big) loss analysis and improvement
• Process improvement
• Operational improvement

✓ Quality improvement through

• Process capability study and improvement
• Poka yoka (mistake proofing) design
• Operational stability re-design

169
➢ Provide maintenance systems to
support facilities
– Introduce more professional tools and techniques
(autonomous maintenance) to establish and
restore machinery condition

– Maintenance systems and resources are to be

designed, implemented and continuously
improved

– Specialist skills to provide for breakdowns,

servicing and improvement of complex controls
and mechanisms

170
➢ Purchase and install facilities that
provide best return

The selection and purchase of new

machinery must be approached:

– In a professional and structured way

– As an integral part of the overall manufacturing

system

171
The selection and purchase of new
machinery must be approached (Contd.):

– To conform the TPM philosophy of the

company

– To meet the present and future need of the

business

– To achieve world-class competitive

performance in manufacturing

172
Measuring Effectiveness of Facilities
The effectiveness of facilities
– is its best possible return generated
– is calculated as percentage of each group of 6 big
losses (discussed earlier)

Overall facilities effectiveness (OEE) =

%Availability x %Performance x %Quality
• Breakdown losses • Idling and minor • Scrap and
stoppage losses rework losses
• Set-up and
adjustment losses • Speed losses • Start-up losses

173
 Tangible and Intangible Benefits of TPM
➢ Tangible benefits:
o Productivity up due to
✓ Sudden breakdowns down
✓ Overall facilities effectiveness up

o Process defect rate down

o Customer compliant/claims down
o Products and work-in-process down
o Shutdown accidents down
o Pollution incidents down
o Improvement suggestions up

174
Tangible benefits (contd.):

o Financial losses drop due to reduction in breakdowns

o Repair costs drop
o Maintenance labour-hours reduce
o Energy costs reduce
o Company’s manufacturing profit ratio up

175
➢ Intangible benefits:
o Achieving full-self management
✓ Operators have ownership of their equipments
✓ They look after it by themselves without direction

o Eliminating breakdowns and defects

o Growing confidence and ‘can-do’ attitude
o Making previously dirty and oily workplaces to a
unrecognizably clean, bright and lively
o Giving better image to the visitors and thereby getting
more orders

176
177
Summarized Results of TPM

178
179
180
181
 POKA-YOKE
to avoid (yokeru) inadvertent errors (poka)
182
 What is Poke-yoke?
A method that uses sensor or other devices for catching errors that
may pass by operators or assemblers.

1. Control Approach
- Shuts down the process when an error
occurs.
- Keeps the “suspect” part in place when
an operation is incomplete.
2. Warning Approach
- Signals the operator to stop the
process and correct the problem.

183
 Types of Human Error
• Careless errors (inattention, forgetfulness)
• Errors due to misunderstanding
• Identification errors ( failure to notice problems)
• Errors caused by amateurs
• Compulsive errors (refusal to obey rules)
• Inadvertent errors (fatigue, distraction)
• Errors due to slowness (delay in judgement)
• Errors due to lack of standards ( written and visual)
• Surprise errors ( process not capable, malfunctions)
• Intentional errors ( sabotage)
• Speed related errors ( impatience)
• Random human error ( variation in people)

184
 Red Flag Conditions
(potential for human error)
• Workers having to make adjustments to part or process
step
• Tooling and Tooling changes (perishable, changes between
runs)
• Dimensions, specifications, critical conditions
• Many/ mixed parts
• Multiple steps in process
• Infrequent production
• Lack of an effective standard
• Symmetry / assymetry
• Rapid repetition
• High volume of activity
• Environmental conditions
185
 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.

186
187
 Common Mistake-proofing Devices

• Guide Pins
• Blinking lights and alarms
• Limit switches
• Proximity switches
• Counters
• Checklists

188
Types of Sensing Devices
1. Physical contact devices
2. Energy sensing devices
3. Warning Sensors

189
 Warning Sensors
Color Code
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.

Lights connected
Lights to Micro switches
& timers
190
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.
191
 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 fully

extended alarm sounds

An example of a physical contact

method is limit switches that are
pressed when cylinders are driven into
a piston. The switches are connected
to pistons that hold the part in place.
In this example, a cylinder is missing
and the part is not released to the next Cannot proceed
to next step.
process.
Contact Method using limit
switches identifies missing
cylinder.
192
 Contact Device

An example of a
contact device using a
limit switch. In this
case the switch makes
contact with a metal
barb sensing it’s
presence. If no
contact is made the
process will shut
down.

193
 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.

194
 Energy Contact Devices
Photoelectric switches can
Light
be used with objects that
are translucent or
transparent depending upon
the need.
Transmission method: two units,
Transmitter Receiver one to transmit light, the other
to receive.
Reflecting method:PE sensor
responds to light reflected from
object to detect presence.
Object

If object breaks the transmission, the machine is signaled to shut down.

195
 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.

In the example to the right a limit switch is

used to detect and count when the required
amount of holes are drilled. The buzzer
sounds alerting the operator that the
appropriate amount of steps have been taken
in the process.

196
 Counting Method

Another approach is to count the number of parts or components required

to complete an operation in advance. If operators finds parts leftover using
this method, they will know that something has been omitted from the
process.

“I have an extra
part. I must have
omitted a step!”

197
 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 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.

198
 Motion-Sequence Method
In order to help operators select the right parts for the right step in a process
the “sequencing” aspect of the motion-step method is used. This is especially
helpful when using multiple parts that are similar in size and shape.
In this example, each step of the machine cycle is wired to an indicator board
and a timer. If each cycle of the machine is not performed within the required
“time” and “sequence”, the indicator light for that step will be turned on and
the machine will stop.

Machine Indicator Board

199
 Exercise – Mistake Proofing
• Identify 4 levels of mistake proofing to
prevent accident at a railway crossing.

200
201
 Project Closure
• Communication of Results
• Closure Checklist
• Project Report
• Recognition of team performance

202
 Project Review Checksheet
• Have goals been met?
• What are project learnings?
• Have learnings been communicated?
• Have new SOPs been put in place?
• Time frame achieved?
• Project Budget met?
• Audit plan in place?
• Is project closed or handed over?
• Future potential improvements

203
Sample close out form

204