mistake proofing techniques
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Lean Six Sigma Operational - Delegate Workbook
SSG06101ENUK - MP/Issue 1.1/ September 2008 1 ©The British Standards Institution 2008
Mistake Proofing Techniques
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SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008
Learning Objectives
At the end of this section delegates will be able to:
• Explain the role of Mistake Proofing within Lean Six Sigma
• Recognise that defects can be eliminated (100% of the time)
• Understand that Mistake Proofing should be focused on process steps that rely on operator vigilance and concentration
• Recognise that simple, low cost devices can be the most effective solutions
• Use a simple process for implementing a Mistake Proofing system
Lean Six Sigma Operational - Delegate Workbook
SSG06101ENUK - MP/Issue 1.1/ September 2008 2 ©The British Standards Institution 2008
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SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008
History of Error Proofing
• Dr Shigeo Shingo attributed with developing the methods
• Originally called Idiot Proofing but recognised that this label
could offend workers so changed to Mistake Proofing (Poka
Yoke in Japanese)
• Literally translated
• Yokeru: to avoid
• Poka: inadvertent errors
• Target of Zero Defects and elimination of QC Inspection
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SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008
Human Error
• Humans make mistakes (errors) because of……
- Forgetfulness - Misunderstanding
- Lack of experience/skills - Lack of concentration
- Laziness - Lack of standards
- Rushing - Taking short cuts
- Malicious intent (deliberate action)
• Errors (can) lead to defects
• Defects are not inevitable and can be eliminated by the use of simple, low cost methods – zero defects
• Mistake Proofing should take over repetitive tasks that depend on vigilance or memory
Lean Six Sigma Operational - Delegate Workbook
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SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008
Types of Error
Four main types of error:
Processing
1. Omitted Processing - Step in process not carried out
Eg form not checked, discount not included, invoice not sent, hole not drilled, part not cleaned
2. Processing Errors - step in process carried out incorrectly
Eg wrong discount included, invoice sent to wrong address, hole drilled in wrong place
Materials
3. Missing materials/information
Eg form not filled out completely, order not complete, screw left out
4. Wrong materials/information
Eg wrong form filled out, wrong information supplied, wrong screw used
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SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008
Shutdown Process
Control Process
Warn Operator
Shutdown Process
Control Flow
Warn Operator
Functions of Poka Yoke
Eliminate
Defects
Predict Defect
(about to occur)
Detect Defect
(occurred)
Lean Six Sigma Operational - Delegate Workbook
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SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008
ABC Fix Explanation Scenario
The Problem:
Automobiles are crossing the
train tracks and getting hit by
a train.
The “ C” Fix:
Place flashing cross signs at
the crossing to alert vehicles.
Dilemma: Vehicles are alerted
of oncoming trains but can still
cross. Problem not solved.
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SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008
ABC Fix Explanation Scenario
The “ B” Fix:
Place cross gates at crossing to further deter crossing of vehicles.
Dilemma: Vehicles are alerted and have limited crossing ability; however does not prevent those who arbitrarily want to cross. Problem deterred but not solved.
The “A” Fix:
Build overpass for vehicles to crosstrain tracks without incident.
Dilemma: None. Problem solved.
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SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008
Blade can stay out without operator touching it
Sharp point
Rounded point
Spring loaded--when operator lets go, the blade goes back in
Guard protecting blade only releases when button is pushed
Extra safety guards make it difficult toaccidentally contact blade
Original Box Cutter
Safety Example
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SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008
Elevators
• Some common safety features are listed below:
� Doors sensors detect if an object/person is blocking
entrance, if so they automatically open
� 2 separate braking systems used. The first is opened by
electrical current, if power is lost the brake closes under
high spring tension. The second is a centrifugal brake
governing the maximum speed
� A host of switches and sensors control the positioning of
the elevator
� Acceleration/deceleration alters with weight in carriage
Lean Six Sigma Operational - Delegate Workbook
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SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008
Medicine (Bottles)
• Up to one in five toddlers can open medicine bottles and chemical containers, even if they have child-resistant tops
• Every year 25,000 under-fives are taken to casualty, suspected of swallowing substances ranging from medicines to household cleaning products
• One in five are admitted to hospital for treatment
• Child-resistant tops are now commonplace on most medicine bottles and household chemicals -but they are child-resistant, not child-proof
Source BBC News
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SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008
Electrical (Household)
• RCD (Residual Current Device)
� Automatically cuts off power supply if a leakage current to ground is detected
• Mains Socket
� Earth pin first to make and last to break contact
� Earth pin has to enter socket to move protective shields from Live and NEUTRAL connections
� Shape prevents incorrect fitment
• 3 Pin Plug
� Only fits one way round
� Ergonomically designed so it is picked up by the case
� Insulation on Live and Neutral to prevent accidental touching of pins
� If wired correctly and plug pulled out by cable, Live first to pull out, Neutral second, Earth last
� Fuse standard for plug no other fuses will fit. Maximum fuse size 13 amp
� If cover is not in place pins push back and cannot enter socket
Lean Six Sigma Operational - Delegate Workbook
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SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008
Electrical (General)
• Shapes and colours extensively used to prevent equipment
being incorrectly connected
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SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008
Appliances
• Microwave
� Will not work until the door is shut
• Washing machine
� Will not start until door is closed
� Will not allow door to be opened until cycle is
complete
Lean Six Sigma Operational - Delegate Workbook
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SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008
Low Brake Pad Warning
Indicators• Brake pad wear indicators are fitted to
most modern cars. They are made up of 2 insulated wires which fit in a hole inside the brake pad
• As brake pads wear the insulated cables become exposed and the metal brake disk connects them like a switch
• An electrical signal then lights up a warning lamp on the cars dashboard alerting the driver before the brakes fail
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SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008
Using Shapes and Colours
Lean Six Sigma Operational - Delegate Workbook
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SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008
Software Warnings and
Reminders
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SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008
Using Dialogue Boxes and
Software Checks
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SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008
Using Switches and Automatic
Braking• Safety switches need to be pressed and held before the start
levers will operate.
• Upon release of start lever, brakes automatically come on stopping the cutting blades etc
• Safety interlocks or light beams used to automatically shut down or stop processes
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SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008
Using Checklists
Backup generator functional6
Generator voltage (Min 220v Max 250V)5
Hydraulic pressure (Min 30 bar Max 40
bar)
4
Ailerons functional3
Altimeter calibration (+50 Metres)2
Fuel level (min 1500 Max 2500)1
Pre-flight Checklist
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SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008
Visual Prevention Methods
• Some solutions are better
than others
• Which signs would be the
most successful in
preventing different
nationalities entering the
incorrect toilet?
Ladies Gents
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SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008
Using Lights, Sounds, Signs
and Barriers
Lean Six Sigma Operational - Delegate Workbook
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SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008
Amsterdam Airport: Problem-Airport Cleanliness
Target Practice?!
Error Proofing and FMEA –Complimentary Techniques?
Lean Six Sigma Operational - Delegate Workbook
SSG06101ENUK - MP/Issue 1.1/ September 2008 13 ©The British Standards Institution 2008
SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008
History of FMEA
• First used in the 1960’s in the aerospace industry
during the Apollo missions
• In 1974, the US Navy developed MIL-STD-1629
regarding the use of FMEA
• In the late 1970’s, driven by product liability costs,
FMEA moved into U.S automotive applications
SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008
FMEA Inputs and Outputs
• Inputs
� Process map
� Process history
� Process technical procedures
• Outputs
� List of actions to prevent causes or to detect failure
modes
� History of actions taken
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SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008
FMEA Team
• Team approach is necessary
• Responsible black/green belt leads the team
• Recommended representatives:
� Operators/administrators/supervisors
� Design
� Engineering
� Operations
� Distribution
� Finance
� Information Technology
� Human Resources
SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008
Process
Step/InputPotential Failure Mode Potential Failure Effects
S
E
V
Potential Causes
O
C
C
Current Controls
D
E
T
R
P
N
Actions
Recommended
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
0 0 0 0
What is the input ?
What can go wrong with the
input?
What can be done?
What is the
effect on the
output?
What are the causes?
How bad?
How often?
How well?
(1-10) (1-10) (1-10)
Completing an FMEA
How are
these found or
prevented?
Lean Six Sigma Operational - Delegate Workbook
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SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008
Definition of Terms - Failure Mode
• Definition
� The way a specific process input fails
� Will cause the effect to occur if not corrected or removed
• Examples
� Temperature too high
� Incorrect PO number
� Surface contamination
� Dropped call (customer service)
� Paint too thin
SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008
Definition of Terms - Effect
• Definition
� Impact on customer requirements
� Generally an external customer focus, but can also include downstream processes
• Examples
� Temperature too high: paint cracks
� Incorrect PO number: accounts receivable traceability errors
� Surface contamination: poor adhesion
� Dropped call: customer dissatisfaction
� Paint too thin: poor coverage
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SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008
Definition of Terms - Cause
• Definition
� Sources of process variation that cause the failure mode to occur
� Identification of causes starts with failure modes associated with the highest severity ratings
• Examples
� Temperature too high: thermocouple out of calibration
� Incorrect PO number: typographical error
� Surface contamination: overhead hoist systems
� Dropped call: insufficient number of CS representatives
� Paint too thin: high solvent content
SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008
Definition of Terms - Current
Controls
• Definition
� Systematised methods / devices in place to prevent or detect failure modes or causes (before causing effects)
� Prevention consists of failsafing, automated control and setup verifications
� Controls consist of audits, checklists, inspection, laboratory testing, training, SOP’s, preventive maintenance, etc
• Which is more important to process:
improvement, prevention or detection?
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SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008
Definition of Terms - Risk Priority Number (RPN)
• Definition
� The output of an FMEA
� A calculated number based on information you provide, regarding:
• Potential failure modes,
• Effects, and
• Current ability of the process to detect the failures before reaching the
customer
� Calculated as the product of three quantitative ratings, each one
related to the effects, causes, and controls:
RPN = Severity X Occurrence X Detection
EffectsEffects CausesCauses ControlsControls
SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008
Risk Priority Number
• Risk Priority Number is not absolute
• Scaling for severity, occurrence and detection can
be locally developed
• Be aware of customer requirements
• Other categories can be added
� For example, one engineer added an impact score to
the RPN calculation to estimate the overall impact of the
failure mode on the process
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SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008
Definition of Terms
• Severity (of Effect) (1 = Not Severe, 10 = Very Severe)
� Importance of effect on customer requirements
� Could also be concerned with safety and other risks if failure occurs
• Occurrence (of Cause) (1 = Not Likely, 10 = Very Likely)
� Frequency with which a given cause occurs and creates failure mode(s)
� Can sometimes refer to the frequency of a failure mode
• Detection (Capability of Current Controls) (1 = Likely to Detect, 10 = Not Likely at all to Detect)
� Ability of current control scheme to detect or prevent:
• The causes before creating failure mode
• The failure modes before causing effect
SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008
Example Rating Scale
Rating Severity of Effect Likelihood of Occurrence Ability to Detect
10 Hazardous without warningVery high:
Cannot detect
9 Hazardous with warningFailure is almost inevitable
Very remote chance of detection
8 Loss of primary functionHigh:
Remote chance of detection
7Reduced primary function
performance
Repeated failuresVery low chance of detection
6 Loss of secondary functionModerate:
Low chance of detection
5Reduced secondary function
performance
Occasional failuresModerate chance of detection
4Minor defect noticed by most
customers
Moderately high chance of
detection
3Minor defect noticed by some
customers Low:High chance of detection
2Minor defect noticed by
discriminating customers
Relatively few failuresVery high chance of detection
1 No effect Remote: Failure is unlikely Almost certain detection
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SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008
Process
Step
Key Process
Input
Failure Modes - What can go
wrong? Effects Causes
Current
Controls
Pour into
glassBeer volume Overflow
Wasted Beer/
Wet LapDrunk None
Glass too small Visual
Not paying
attentionNone
Too much foam
Bad Taste /
Don't get as
drunk
No tilt Visual
Pouring too highVisual and operator
training
Pouring too fastVisual and operator
training
No Foam
No beer
mustache/ Poor
taste
Flat beer Expiration date
Tilted glass Visual
Slow Pour Operator training
Empty glass No drink Too drunk None
Broken Glass Visual
No Money
Job / Process
Excellence - big
bonus
No Friends Personality
A Well-Loved Process FMEA
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SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008
FMEA Hints
• Keep it simple; not complex (no wall charts)
• Must involve a team, no “lone ranger”
development
• Update it as you move through the roadmap
• Make sure the FMEA is an action tool, not just a
document; use the right half of the tool
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SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008
POKA YOKE Connection to the FMEA
Process
Step/InputPotential Failure Mode Potential Failure Effects
S
E
V
Potential Causes
O
C
C
Current Controls
D
E
T
R
P
N
Actions
Recommended
What is the
process step/
Input under
investigation?
In what ways does the Key
Input go wrong?
What is the impact on the Key
Output Variables (Customer
Requirements) or internal
requirements?
How
Severe
is the
effect to
the
cusotm
er? What causes the Key Input to
go wrong?
How
often d
oes c
ause
or
FM
occur? What are the existing controls and
procedures (inspection and test)
that prevent eith the cause or the
Failure Mode? Should include an
SOP number.
How
well
can y
ou
dete
ct cause o
r F
M? What are the actions
for reducing the
occurrance of the
Cause, or improving
detection? Should
have actions only on
high RPN's or easy
fixes.
0
0
0
Good POKA YOKE devices drive down
occurrence and detection rankings.
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SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008
Poka Yoke Workshop 1Process: Tightening nuts
Problem: Washers left out before tightening
Description of process: Operator adds washer and nut, then tightens using an automatic nut driver.
Prevent Error/Detect Error
Shutdown/Control/Warn
Before improvement: It is possible
to tighten the nuts even if washers are missing.
After Improvement:
Solution:
(Delete as appropriate)
(Delete as appropriate)
Nut, tightened with no washer
Nut driver
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SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008
Poka Yoke Workshop 2Pprocess: Parts Transport LineProblem: Parts supplied upside down to automatic machinery
Description of Process: A transportation chute feeds parts from a press into the next process. in the next process parts are mounted in the same position as they arrive.
Prevent Error/Detect Error
Shutdown/Control/Warn
Before Improvement: Operators watch
incoming work pieces carefully and remove upside down parts. some are always overlooked.
After Improvement:
Solution:
(Delete as appropriate)
(Delete as appropriate)
Upside DownCorrect Work piece
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SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008
Poka Yoke Workshop 3Process: Inspecting Cassette Tape Decks
Problem: Inspection Tapes out of Sequence
Description of Process: When a cassette deck is inspected, the inspector uses a series of cassettes to check the performance of the unit. It is important that the tests are performed in the correct order and that all tests are done.
Prevent Error/Detect Error
shutdown/control/warn
Before Improvement: A slotted rack was used to store tapes. If a tape was placed on workbench or carried off then inspector could lose track and make errors.
After Improvement:
Solution:
(Delete as appropriate)
(Delete as appropriate)
1 2 3 4 5 67
Storage Rack
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SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008
Poka Yoke Workshop 4
The inspectors found medical notes were confusing – written up with the same “RR”initials for women needing a “routine recall”and those needing a “recall recall”, an urgent reassessment…!!!
44
SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008
Poka Yoke Workshop 5
Lean Six Sigma Operational - Delegate Workbook
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SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008
Poka Yoke Workshop 6
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SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008
Poka Yoke Workshop 7
• City Trader buys $1000000000 worth of shares
instead of $10,000,000.00!
• Accounts pays supplier twice
• Failure to invoice customer for services provided
• Miscalculation in currency exchange
• Your experiences……..?
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SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008
Poka Yoke Summary
• Defects can be eliminated
• Target process steps that are repetitive and rely
on operator vigilance and checking
• Use simple, low cost devices
• Involve the operator in identifying, developing and
implementing devices
• Devices should be challenge tested by
introducing error (defect)
Solutions
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SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008
Poka Yoke Workshop 1Process: Tightening Nuts
Problem: Washers left out before tightening
Description of Process: Operator adds washer and nut, then tightens using an automatic nut driver.
Prevent Error/Detect Error
Shutdown/Control/Warn
Before Improvement: It is possible
to tighten the nuts even if washers are missing.
After Improvement:
Solution:
(Delete as appropriate)
(Delete as appropriate)
Nut, tightened with no washer
Nut driver Nut driverStopper
Washer
thickness
50
SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008
Poka Yoke Workshop 2Process: Parts transport lineProblem: Parts supplied upside down to automatic machinery
Description of Process: A transportation chute feeds parts from a press into the next process. In the next process parts are mounted in the same position as they arrive.
Prevent Error/Detect Error
Shutdown/Control/Warn
Before improvement: Operators watch
incoming work pieces carefully and remove upside down parts. Some are always overlooked.
After Improvement:
Solution:
(Delete as appropriate)
(Delete as appropriate)
Upside downCorrect Work piece
Notch
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SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008
Poka Yoke Workshop 3Process: Inspecting Cassette Tape Decks
Problem: Inspection tapes out of sequence
Description of Process: When a cassette deck is inspected, the inspector uses a series of cassettes to check the performance of the unit. It is important that the tests are performed in the correct order and
that all tests are done.
Prevent Error/Detect Error
Shutdown/Control/Warn
Before Improvement: A slotted rack was used to store tapes. If a tape was placed on workbench or carried off then inspector could lose track and make errors.
After Improvement:
Solution:
(Delete as appropriate)
(Delete as appropriate)
1 2 3 4 5 67
Storage rack
52
SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008
Poka Yoke Workshop 4
The inspectors found medical notes were confusing – written up with the same “RR”initials for women needing a “routine recall”and those needing a “recall recall”, an urgent reassessment…!!!
Lean Six Sigma Operational - Delegate Workbook
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SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008
Poka Yoke Workshop 5
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SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008
Poka Yoke Workshop 6
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SSG06101ENUK – Delegate Slides/Issue 1.1/ September 2008
Poka Yoke Workshop 7
• City Trader buys $1000000000 worth of shares
instead of $10,000,000.00!
• Accounts pays supplier twice
• Failure to invoice customer for services provided
• Miscalculation in currency exchange
• Your experiences……..?
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