I recently had an “oopsie” moment that made me reassess my thoughts on mistake-proofing.
There’s more than one way to fail!
I wanted to score a “quick win” and ran a Pareto Analysis of the top causes of downtime on one of my facility’s processes. The top two areas for concern (the “long poles in the tent” so to speak) were expected. But then I saw something unexpected: The next three lines in the Pareto Chart were closely related in the process. Added together, they were equal to the longest pole! Although technically separate, it didn’t take a huge leap of reasoning to see that those three items were possibly the result of a single cause.
So I jumped into action, and off-to-the-Gemba I went! I closely watched the process steps involved in the area of concern. I spoke to the operators involved in the process. I learned something new about our procedures, and formed a hypothesis on the possible causes.
After more discussion with operators and deeper analysis of historical data, I narrowed my hypothesis down to two likely causes. One potential cause (if it really existed) was difficult to verify and was likely caused by a vendor. The other potential cause was a no-brainer: We had only two possible ways to load raw materials into the process, and there was no Job Aid to visually demonstrate the right way to load materials! Quick win here, a “just do it” solution that costs nothing and fixes everything.
Piece of cake, right? So I dusted off my design skill (not “skills”, but “skill”; I only have one, and am not as skilled as a real designer) and created a handsome poster that showed both the right way (with a big green “check”) and the wrong way (with a big red “x”). I posted it prominently in just the right spot in the process.
Presto! Problem Repeated.
Wait… What???
Less than 60 minutes after posting my fancy new Job Aid, our operator loaded raw materials backwards.
So, how did it happen? The operator was experienced. He knew his job. He’d been working with the company for years and had a stellar reputation.
He was also new to our plant. It was his second day. He’d never used that particular piece of equipment before.
And nobody trained him.
And silly me, I forgot that although Job Aids are great, they can never replace proper training.
Job Aids are not solutions. They are just tools that help along the way. And in my haste to find a quick and easy fix to a problem, I’d forgotten that. And as a result,
Have any embarrassing stories to share? Of course you do! Leave a comment and share your story.