Transcript Chapter 11

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1.
2.
3.
4.
5.
6.
7.
Check sheets
Pareto Charts
Flow charts
Cause and effect diagram
Histograms
Control Charts
Scatter Diagrams
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Teams should be comprised of key individuals
directly involved with the process being addressed.
Other functional representatives can be brought in
as needed. Each individual brings unique
expertise and perspective to the team and melds
that with the talents of the other team members.
The team process leads to decisions of higher
quality than those arrived at by individuals.
Moreover, members of a team are much more
willing to take ownership in the resultant decisions
and to actively pursue their successful
implementation.
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Launch #1
Using what you are given baseline
the process for shooting the
statapult.
Remember:
Customer desires a rapid-fire,
precise, and accurate launcher that
can launch projectiles over
mountain ranges.
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Objective: To fire the statapult and record the distance in inches for each of the launches.
The measured distance will be from the back base of that launcher to the point
where the ball hits the floor. Use the following grid to record the distances in
the order in which they were obtained (to the nearest inch). This will establish
Launch Number
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Distance (inches)
Rules of Engagement:
(1) Every shot will be launched from a pull back angle of 177 degrees, with the peg
position in the second hole from the top. Each person on the team will perform
an equitable number of launches (or as close thereto as possible). "Launching"
means pulling back and releasing. Record to the nearest half inch.
(2) There will be a time limit of 15 seconds between successive firings. Each group
will be required to police themselves. There will be a penalty associated with late
firings. One practice shot will be allowed.
(3) Plot the distances recorded above as points on the run chart form on the next page.
Connect adjacent points with straight lines, and record the longest distance (Max)
and the shortest distance (Min) and compute the Range = Max - Min.
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1. Clearly state the problem and make sure that all team members
understand it
2. Allow each team member to present his or her ideas
3. Record each suggestion exactly as it was stated. Make no
preliminary judgments on ideas
4. Decide which ideas should be acted upon first, which ones can
wait, and which ones aren't applicable
5. Decide how each idea will be acted upon. Determine who is
responsible and when those actions will be done by.
6. Document all results for use in future meetings, or as evidence
that the problem is fixed.
7. Create a file somewhere in the department to document what
problems have been fixed, and what problems still need to be
worked on
8. If a project is generated from the Brainstorm session, before
leaving the meeting make sure that everyone understands who is
Responsible, who is Accountable, who are the key Contacts, and
whom we should keep Informed throughout the project.
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Objective: Develop a check sheet for what
you think is causing you problems with
accuracy.
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Objective: Develop a Pareto Chart from the data you
recorded on the check sheet.
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100%
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90%
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80%
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70%
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60%
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50%
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40%
10
30%
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20%
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10%
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Objective: Develop a process flow diagram that
explains how to launch a ball.
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Objective: Develop a C&E diagram that explains the
variability of the launching process. Label as
C/N/X.
MANPOWER
METHOD
MACHINE
MEASUREMENT
MOTHER
NATURE
MATERIAL
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Objective: Develop an SOP that accurately
defines each controlled step of the
launching process.
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

Demonstrate the importance of
error proofing
Show error proofing is not difficult
◦ Simplification and standardization is key
◦ Make everyone’s job easier

Encourage you to recognize the
opportunities for error proofing
◦ Operator error rarely acceptable as root
cause
◦ Operator training rarely acceptable as
corrective action
◦ Incorporate into all of your improvement
projects
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Frequency
Human Causes
Machine Causes
Time
The reliability of the parts themselves have
improved dramatically. What has not improved is
the ability of humans to adequately comprehend and
attend to the process of assembling and maintaining
these dramatically more complex machines
Source: FAA Human Factors Guide to Aviation Maintenance
correctly.
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In response to a sharp increase in air traffic
control errors nationwide and the near-collision
of two planes over New York's La Guardia
Airport, the FAA has:
You make the call…
A. Ordered retraining for 10,000 air traffic
controllers.
B. Hired a team of experts to pareto errors, look
for trends, and find the root cause for the errors.
C. Base future salary actions on controller’s
performance.
D. Rewrite the operating procedures placing
messages and warnings in appropriate locations.
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Experts Blame Japanese Incident On Incorrect Equipment
(Matthew L. Wald, New York Times, Oct. 23, 1999). -- CF
After touring the site of last month's nuclear incident in
Japan, three Energy Department experts said the
plant's managers expected workers to follow safety
rules but never explained why the rules were
important.
Frank McCoy, deputy manager of the DOE's Savannah
River Operations Office, said technicians at the
Tokaimura plant were using incorrect equipment to
process nuclear fuel.
McCoy: "Using the system in the right way was
more difficult than anyone would have desired."
The experts said the workers did not understand the
reasons behind rules limiting the size of batches
and containers.
On Sept. 30, plant workers brought too much uranium
together in one spot and created a chain reaction that
lasted for 17 hours.
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Special causes
Hole diameter
Examples:
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1) Misses Hole
2) Worn drill
3) Wrong drill
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• Most of our processes are at a relatively high sigma,
therefore sampling unlikely to catch abnormalities:
sampling aimed at catching process drift not defects
• Want to use error proofing to eliminate the tails of the
 1998, John R. Grout
distribution
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Knowledgebased
( Perform
theory based
analysis)
Skillbased
(routine
actions,
perform on
autopilot)
Task Type
Mean P(d) s level
- Initial problem solving or
0.2
0.85
Troubleshooting
- Detection of deviation or
0.07
1.45
inspection
- Calculation
0.04
1.75
- Dial a 7 Digit phone number
0.021
2.05
- Alpha input per character
0.008
2.40
- Numeric input per character
0.003
2.75
- Control action per demand
0.001
3.10
- Assembly per task element
0.00007 3.80
• Depending on task and environment humans are
typically 2 to 3 sigma
• Errors will occur the trick is preventing them from
becoming defects and escaping to the field
Data from “Human Reliability Data - The State of the Art and the Possibilities”
Jeremy C. Williams, 1989 CEGB
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The concept of poka-yoke has existed for a long time but it was
Japanese manufacturing engineer Shiego Shingo who developed the
idea into a formidable tool for achieving zero defects. Shingo came up
with the term poka-yoke which generally translates as “mistakeproofing” or “fail-safing” – to avoid (yokeru) inadvertent errors (poka).
Generally, any manufacturing or transactional process is
dependant on human intervention, look for ways to either
minimize the intervention (automation, menu choices, mouse
clicks vs. typing), or if human intervention cannot be reduced,
look for ways/methods of….
• Mistake proofing the form/process (provide a template or
overlay)
• Color coding instructions or the form (certain functions
only fill-in a certain color on the form)
• Minimize the writing required (have repetitive or standard
info hard printed onto the form)
• If the form is electronic limiting access, blocking certain
entries, having the computer verify information, or granting
certain permissions may provide some relief.
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Technique
Inadvertent
Willful
Excerpted from:
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Poka-yoke Improving Product Quality by Preventing
Defects
Excerpted from:
Poka-yoke Improving Product Quality by Preventing
Defects
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Demand vigilance
– ask designers and workers to
“be more careful!”
– continue the “blame and train
cycle”
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Eliminate the chance of making the
error
Provide automatic feedback to
sense and fix the error
Make incorrect actions correct
Make wrong actions more difficult
Make it easier to discover the errors
that occur
Make it possible to reverse actions to “undo” them - or make it harder
to do what cannot be reversed
◦ Source inspection
◦ 100% inspection
◦ Immediate feedback and corrective
action.
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Best
Process
Improvement
I. Error Elimination - Prevention - The
opportunity to make the error no
longer exists in the process.
II. Automatic Feedback “Poke-Yoke”
devices - The error is automatically
detected and the process halted
prior to making a defect.
III. Defect Detection and process
adjustment -”Source Inspection”
Defect is discovered at the operation
where generated.
IV. Make it easier to do it right. Colors,
color coding, shapes, symbols,
kitting, checklists, forms,
procedures, process simplification
Subsequent Inspection, Audits,
Perfection Reviews, TPM
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Make it easier to do it right!
Provide clues about what to do
through the use of:
◦ natural mappings
◦ visibility
◦ feedback
Source: The Design of Everyday Things, by D.A.
Norman, 1988, Doubleday
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Which dial turns on the burner?
Stove A
Stove B
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Visibility means making relevant
parts visible(kitting) and
effectively displaying system
status
Feedback means providing an
immediate and obvious effect for
each action taken.
◦ This is how you can error proof
anything. If you can provide
immediate feedback to the human
operating the process, he/she will
correct the error before a defect is
generated.
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
Customer Satisfaction - Process
variation hurts customers but it
is normally the special causes
which cause them the most pain
◦ Must detect errors and prevent
defects from escaping
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Reduces production disruption
along the supply chain and the
associated cost and liability
Cost reduction - scrap and
rework and fixing downstream
problems are reduced
dramatically
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
Error proofing is of critical
importance internally and at the
customer
◦ Addresses the outliers and affects
what the customers see
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Whenever dealing with processes
look for the red flags and
excessive operator intervention
◦ Process walks are easy to perform
and effective
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You must error proof in the
control phase
Don’t accept operator error as
root cause or operator training as
the only corrective action
To achieve zero defect levels you
must error proof
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Objective: To fire the statapult and record the distance in inches for each of the launches.
The measured distance will be from the back base of that launcher to the point
where the ball hits the floor. Use the following grid to record the distances in
the order in which they were obtained (to the nearest half inch). This will establish
a process baseline.
Launch Number
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
Distance (inches)
Rules of Engagement:
(1) Every shot will be launched from a pull back angle of 177 degrees, with the peg
position in the second hole from the top. Each person on the team will perform
an equitable number of launches (or as close thereto as possible). "Launching"
means pulling back and releasing. Record to the nearest half inch.
(2) There will be a time limit of 15 seconds between successive firings. Each group
will be required to police themselves. There will be a penalty associated with late
firings. Practice shots are not allowed.
(3) Plot the distances recorded above as points on the run chart form on the next page.
Connect adjacent points with straight lines, and record the longest distance (Max)
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Overview
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Why
How
FMEA Types
FMEA Steps
The FMEA Process
Severity Table
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Identifies potential product related
process failure modes.
Assesses the potential customer
effects of the failures.
Identifies the potential
manufacturing or assembly process
causes and identifies process
variables on which to focus controls
for occurrence reduction or
detection of the failure conditions.
Develops a ranked list of potential
failure modes, thus establishing a
priority system for corrective action
considerations.
Documents the results of the
manufacturing or assembly process.
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Failure Mode – The manner in which a part
or process can fail to meet specification. It
is usually associated with a defect or
nonconformance.
Effect – The impact on a customer if a
failure mode is not prevented or corrected.
The customer can be an immediate one or
one downstream.
Cause – A deficiency that results in a
failure mode. Causes are sources of
variability associated with key process
input variables.
A FMEA is best when a team prepares it.
The team should be made up of people
from all areas impacted by the process.The
FMEA is useful in a number of applications:
in determining X’s, helping to define
process improvements and controls, and
others.
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A System FMEA is used to analyze
systems and subsystems in early
concept and design stages. It focuses
on potential failure modes associated
with the functions of a system caused
by design.
A Design FMEA is used to analyze
products before they are release to
production.
A Process FMEA is used to analyze
manufacturing, assembly, and
transactional processes.
A Product FMEA is used to analyze
failure modes that could occur to the
product once it gets into the customers
hands.
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Preparation
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A FMEA begins with a process map. Identify
the process and map its key steps.
List the key process outputs to satisfy customer
requirements.
List the key process inputs for each process
step.
Define a matrix relating product outputs to
process variables .
Rank inputs according to their importance.
The goal in your preparation is to have a
complete understanding of the process you are
analyzing. What are its steps? What are its
inputs and outputs? How do they relate?
**Information for this section taken from: GE Six Sigma Playbook and the AIAG
Reference Manual.**
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Calculate the Risk Priority Number (RPN). This is a
calculation of the relative risk of a particular failure
mode given the ratings assigned for severity,
occurrence, and detection. To calculate, apply the
following equation:
RPN = SEV * OCC * DET
The higher the RPN, the greater the risk for a failure
mode! Careful analysis provides a priority for action.
Improvement
Avoid analysis paralysis. The object of a FMEA is to
initiate action. Select the trouble areas that cause the top
few causes. Determine what action will reduce RPN’s
and establish time frames for their completion. Assign
responsibilities. Once action brings about results,
recalculate RPN’s and put controls into place.
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