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In this issue we will be discussing another well-known Japanese concept

Poka-Yoke.
Haven't we often blamed ourselves for not averting a disaster? Often! Ironicall! this strikes us onl
after the disaster has plaed havoc" #h does this happen? Is it our inabilit to foresee mistakes and
misread disasters or is it $ust a case of take ever da as it comes? % debatable &uestion! be it the
'hernobl disaster or the recent accidental e(plosion of the 'olumbia space shuttle"
)henomenal failures are a result of sstem variabilit! fault design and non-conformance! eventuall
leading to disasters! involving huge financial and moral setbacks apart from manufacturing*e&uipment
down time"
How can we avoid these problems? +he most effective wa to avoid is to detect and eliminate the root
cause of the problem" )oka-,oke offers an effective wa of achieving this ob$ective"
Happ -eading!!
Poka Yoke: Techniques to Prevent Defects
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Abdel Ahmed PhD
+he .uropean 'entre for +otal /ualit 0anagement
1niversit of 2radford! 3chool of 0anagement
.mm 4ane! 256 7J4! 18
a"m"ahmed9:bradford"ac"uk
)oka ,oke is a &ualit management concept developed b a 0atsushita manufacturing engineer
named 3higeo 3hingo to prevent human errors from occurring in the production line" )oka oke
;pronounced <poh-kah oh-ka<= comes from two Japanese words - <okeru< which means! <to avoid<!
and <poka< which means <inadvertent errors"< +hus! poka oke more or less translates to <avoiding
inadvertent errors<"
3ome people as <fool-proofing< sometimes refer to )oka oke in .nglish" However! this doesn't sound
politicall correct if applied to emploees! so the .nglish e&uivalent used b 3hingo was <error
avoidance"< Other variants like <mistake proofing< or <fail-safe operation< have likewise become
popular"
+he main ob$ective of poke oke is to achieve >ero defects" In fact! it is $ust one of the man
components of 3hingo's ?ero /ualit 'ontrol ;?/'= sstem! the goal of which is to eliminate defective
products"
)oka ,oke is more of a concept than a procedure" +hus! its implementation is governed b what
people think the can do to prevent errors in their workplace! and not b a set of step-b-step
instructions on how the should do their $ob"
)oka oke is implemented b using simple ob$ects like fi(tures! $igs! gadgets! warning devices! paper
sstems! and the like to prevent people from committing mistakes! even if the tr to! +hese ob$ects!
known as poka oke devices! are usuall used to stop the machine and alert the operator if something
is about to go wrong"
%nbod can and should practice poka oke in the workplace" )oke oke does not entail an rocket
science@ sometimes it $ust needs common sense and the appropriate poka oke device" )oka oke
devices should have the following characteristicsA
9" useable b all workers@
B" simple to install@
C" does not re&uire continuous attention from the operator ;ideall! it should work even if the
operator is not aware of it=@
7" low-cost@
D" provides instantaneous feedback! prevention! or correction"
Of course! error proofing can be achieved b e(tensive automation and computeri>ation" However! this
approach is e(pensive and complicated! and ma not be practical for small operations" 2esides! it
defeats the original purpose of poka oke! which is to reduce defects from mistakes through the
simplest and lowest-cost manner possible"
)oka oke is at its best when it prevents mistakes! not when it merel catches them" 3ince human
errors usuall stem from people who get distracted! tired! confused! or demotivated! a good poka oke
solution is one that re&uires no attention from the operator" 3uch a poka oke device will prevent the
occurrence of mistake even if the operator loses focus in what she is doing"
Examples of 'attention-free' Poke Yoke solutions:
9" % $ig that prevents a part from being misoriented during loading
B" Eon-smmetrical screw hole locations that would prevent a plate from being screwed down
incorrectl
C" .lectrical plugs that can onl be inserted into the correct outlets
7" Eotches on boards that onl allow correct insertion into edge connectors
D" % flip-tpe cover over a button that will prevent the button from being accidentall pressed
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Three levels of Poka-Yoke:
9" .limination of spills! leaks! losses at the source or prevention of a mistake from being
committed
B" 5etection of a loss or mistake as it occurs! allowing correction before it becomes a problem
C" 5etection of a loss or mistake after it has occurred! $ust in time before it blows up into a ma$or
issue ;least effective=
%lthough man techni&ues have been developed to prevent or control mistakes! most of these
techni&ues are relativel ineffective" .ffective mistake proofing cannot be developed without a sound
understanding of the true characteristics of mistakes" % mistake occurs when a re&uired action is not
performed or is performed incorrectl! a prohibited action is e(ecuted! or information essential for an
action is not available or is misinterpreted"
+here are a number of characteristics associated with poka oke techni&ues that makes it more
effective than other techni&ues" +his includesA
9" 0istake proofing re&uires 9FFG inspection" It is impossible to detect and control rare random
events with sampling inspection" 3ince! 9FFG traditional inspection is too e(pensive and not
9FFG effective in detecting nonconforming product! mistake-proofing methods based on
poka-oke are essential and the onl practical solution"
B" 0istake proofing must be ine(pensive" 2ecause mistakes are rare events and man different
tpes of mistakes must be controlled! companies cannot afford to spend large sums of mone
on each mistake-proofing device"
C" 0an mistake-proofing devices are needed" +oota has an average of 9B mistake-proofing
devices at each workstation"
7" Outcome intervention is best" +he best mistake proofing phsicall prevents errors or detects
when a mistake is about to occur or has occurred" +hus! these techni&ues intervene to block
undesired outcomes rather than controlling casual factors"
D" )revention is better than detection" )reventing mistakes is better than detecting mistakes!
which is better than detecting defects" If a mistake is not detected until a defect is generated!
rework will be re&uired or the hardware must be scrapped" +hus! where possible! it is alwas
better to detect or control the mistake before a defect is generated" 3imilarl! there will be less
wasted effort if mistakes are prevented rather than detected"
H" 'ontrol! 3hutdown! or #arn" 2ecause resources ma be wasted if a process is shutdown! it is
better to control mistakes" If a process is shutdown! however! the problem must be addressed
to proceed" Hence! shutdown provides a more positive control of mistakes than warnings!
which can be ignored"
I" +he 0ost Important /ualit Initiative" Onl mistake-proofing effectivel controls mistakes"
3ignificant &ualit initiatives other than mistake proofing have marginal impact on the
customer perception of &ualit since mistakes are the dominant source of customer problems"
Poka-Yoke: A Misunerstoo !oncept
Poka-Yoke is a Japanese methodology for mistake proofing to avoid non-conformities from entering
into processes. It allows defect detection and elimination at the source. It can also be used as a
continuous improvement tool.
3higeo 3hingo introduced the concept of )oka-,oke in 96H9! when he was an industrial engineer at
+oota 0otor 'orporation" +he initial term was baka-oke! meaning 'fool-proofing'" In 96HC! a worker at
%rakawa 2od 'ompan refused to use baka-oke mechanisms in her work area! because of the
term's dishonourable and offensive connotation" Hence! the term was changed to )oka-,oke! which
means 'mistake-proofing'"
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)oka-,okes are mechanisms used to mistake-proof an entire process" Ideall! )oka-,okes ensure
that proper conditions e(ist before actuall e(ecuting a process step" +hus preventing occurrence of
defects in the first place" #here this is not possible! )oka-,okes perform a detective function!
eliminating defects in the process as earl as possible"
0an consider )oka-,okes as limit switches! optical inspection sstems! guide pins! or automatic
shutoffs that the engineering department should implement" +his is a ver narrow view of )oka-,oke"
+hese mechanisms can be electrical! mechanical! procedural! visual! human! or an other form that
prevents incorrect e(ecution of a process step" )oka-,okes can also be implemented in areas other
than production such as sales! order entr! purchasing! or product development where the cost of
mistakes can be as much as on the shop floor" +he realit is that defect prevention! or defect detection
and removal has widespread applications in most organisations"
+he 'entre for .(cellence in Operations ;'.O= has developed a )oka-,oke framework to help its
clients understand! the various classifications and applications of mistake-proofing mechanisms" Jiven
below is a brief overview of the frameworkA
Prevention-"ase Poka-Yokes:
)revention-based mechanisms sense an abnormalit that is about to happen! and then signal the
occurrence or halt processing! depending on the severit! fre&uenc or downstream conse&uences"
+here are two approaches for prevention-based )oka-,okesA
!ontrol Metho: +his method senses a problem and stops a line or process! so that
corrective action can take place immediatel" +hereb it avoids serial defect generation" %n
e(ample of this is an assembl operation wherein! if one of the components is found to be
missing before the actual assembl step takes place! the process shuts down automaticall"
%nother e(ample is an incomplete sales order! which cannot be released for production until a
true manufacturabilit configuration is defined"
#arnin$ Metho: +his method signals the occurrence of a deviation or trend of deviations
through an escalating series of bu>>ers! lights or other warning devices" However! unlike the
control method! the warning method does not shut down the process on ever occurrence" It
is used when a bandwidth of acceptance e(ists! for a process" %n e(ample could be
pressurising a vessel or a filling operation! in which the results need not be e(actl the same"
%lthough the process continues to run! the )oka-,oke signals the operator to remove a defect
from the line! or make necessar ad$ustments to keep the process under control"
Detection-"ase Poka-Yokes:
In man situations! it is not possible or economicall feasible to prevent defects" +his is particularl so
where the capital cost of the )oka-,oke mechanism! significantl e(ceeds the cost of prevention" In
these situations! defects are detected earl in the process! preventing them from flowing to
downstream processes and multipling the cost of non-conformance" +he three categories of
detection-based )oka-,okes are as followsA
!ontact Metho: +his method detects an deviation in shape! dimensional characteristics or
other specific defects! through mechanisms that are kept in direct contact with the part" %
subset of this categor is the non-contact method! which performs the same function through
devices such as photoelectric cells" %n e(ample of this might include a chute that detects and
removes upside-down or reversed parts! or an in-line gauge that removes dimensional defects
and reroutes them to a defect lockbo("
%ixe &alue Metho: +his method is used in operations! where a set of steps is se&uentiall
performed" +he fi(ed value method
emplos automatic counters or optical devices and controls the number of moves! rate and
length of movement besides other critical operating parameters" In this case! mechanisms are
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usuall built into progressive stamping! welding! 3stems 0anufacturing +echnolog ;30+=!
and automatic insertion e&uipment" 3ometimes this is referred to as odd part out method"
Ki(ed value also includes critical condition detection ;pressure! temperature! current! etc"=
through electronic monitoring devices"
Motion 'tep Metho: +his method ensures that a process or operator does not mistakenl
perform a step that is not part of the normal process" %n e(ample of this is colour coding of
electronic components on drawings and totes to prevent using mi(ed or incorrect parts"
%nother e(ample is a visual to assist customer service representatives! in providing the right
literature sets for various products"
+he best )oka-,oke in the world is a robust design" 0an of the needs for )oka-,okes are attributable
to poor designs and*or unrepeatable processes" +he second-best )oka-,oke in the world is education
and awareness" +he automotive industr is a leader in this area! with the use of its %dvanced )roduct
/ualit )lanning ;%)/)= guidelines and supplier development programmes" 'ompanies such as
0otorola! %llied 3ignal and Jeneral .lectric are also ahead in this area! because the invested in their
3i( 3igma 2lack 2elt programmes! and have taken them upstream into the new product development
process"
"uilin$ a 'tron$ %ounation
+he )oka-,oke philosoph re&uires a strong foundation in +/0 ;+otal /ualit 0anagement=" Kirst!
organisations must learn to be customer focused" %s +om )eters once said! <+he customer comes
first! second! third! fourth! fifth! and there ain't no si(th! <
3econd! organisations must promote &ualit ownership at the source! and the need to ensure proper
investment in their people! which enables them to be trul empowered" +hird! a clear distinction has to
be made between good versus bad &ualit"
Kourth! organisations must embrace the )3) philosophA )re-! 3elf-! and )ost-Inspection at the
source" 4ast! )oka-,okes re&uire real-time feedback and corrective action" +hese are the building
blocks of an effective )oka-,oke effort"
0istakes happen in organisations for man reasons! but almost all of them can be prevented! if people
make the effort to identif when problems happen! define root causes! and then take the appropriate
corrective measures" +he ob$ective is to prevent! or at least! detect and weed out defects! as earl as
possible in the process" +he use of simple )oka-,oke mechanisms and other safeguards can help
prevent mistakes from leading to catastrophic events"
!ase 'tu(
A Poka-Yoke !onstruction
Often pro$ects are delaed due to non-conformance and defects" +hese in turn stem from process
variabilit" However! few industries can match the variabilit in construction industries"
Kor instance! a surve conducted in Eorwa in 966L revealed that non conformit! defects! mistakes!
wastage and alterations account for 9FG of the total pro$ect costs! not to mention the time wasted
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during rework and re-construction" +he need to ensure a mistake free*fool proof pro$ect has never
been so forthright" 3o has been the need to incorporate best practices like )oka-,oke"
0ost companies install )oka-,oke devices to detect the root cause of failure" 3uch devices allow
suspension of the process where a defect is detected" 'onse&uentl! necessar corrective measures
can be taken" Eevertheless! $ust installing )oka-,oke devices cannot prevent defects*non-
conformities" It is onl thorough dedication! constant appraisal and learning that an organisation can
improve the responsiveness of the )oka-,oke devices"
The application
In order to devise a streamlined approach to mistake proofing in construction! researchers carried out
si( case studies at construction sites across 2ra>il and .ngland" +he used devices like video
recorders! cameras! work flow charts and approaches such as performance monitoring and interviews
to determine the effects of variabilit at construction sites"
%s the pro$ect progressed! each stage was compared with its ideal and desired results" +his approach
was based on the thought that - <If our ideal and practical progress coincide then the process is
flawless*ideal<" +o ensure that the goal of process improvement was not lost! the ideal result was set
so it could be implemented practicall"
Excerpts from the case
+he results were strikingl similar to what researchers had e(pected" 0assive work in progress was
observed at all construction sites" Kurthermore! improper planning and inefficient utilisation of the
labour force characterised the work" #orkplace sampling indicated dissimilar working trends" +his was
due to lack of a standardised approach" )hotographs taken at the construction site supported these
facts"
The plus points
%s a validation to the researchers assumptions! )oka-,oke devices wherever used improved the
efficienc of the pro$ect and reduced non-conformit! which was a primar concern at few sites"
One such )oka-,oke device prevented the load elevator from moving until the loading doors were
closed" It was often observed that most elevators were under utilised and hence more runs to the
construction sites were re&uired to transport the material than if the elevator was full loaded"
However! with the )oka-,oke device the elevator would move onl if the loading doors were closed
and then the re&uired load*raw material would be transported" +his reduced the pro$ect lead-time"
+his was not the case with all construction sites" 0ost of them did not have even performance
indicators so the process was erratic"
Another Poka-Yoke Device
%part from the elevator )oka-,oke device! another commonl used )oka-,oke device was for mortar
mi(ing" One of the most critical stages of mortar mixing is the stage when water is mi(ed" +his not onl
decides the &ualit of the mortar but also accounts for its strength" In most of the construction sites
studied! workers pour water to prepare mortar manuall"
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-esearchers observed that often-e(cess water was added to the mi( thereb diminishing its &ualit"
.ventuall! the mi( would be thrown awa and a new mi( would be prepared" +his resulted in wastage
of large volumes of raw material ;cement*sand*gravel="
In countries where labour is cheap! construction companies often hire new and ine(perienced
emploees" 5oes ine(perience contribute to raw material wastage? 'hances are fairl high!! Ironicall!
construction companies persist with such practices" +his is primaril because the do not realise that
the are losing a lot of mone and resources! because it goes unaccounted"
Installing )oka-,oke devices can eliminate such problems" +hese devices prevent e(cess water into
the mortar mi( that might eventuall weaken the structure" +his apart! the save a lot of mone as raw
material wastage is reduced" Kurthermore! the pro$ect lead-time is reduced"
)oka-,oke*mistake proofing does not alwas re&uire devices" 5esign too can help reduce the number
of defects" Kor instance! a window fabricating compan in 2ra>il was getting complaints from its
customers regarding its windows"
Investigation revealed that the sub contractor's compan often forgot to put putt ;% thick! mastic tpe
material! often made from calcium carbonate and a linseed oil! used for setting glass in wood frames
and filling cracks! holes! etc"=" %s a result! the glass pane fell off the wooden frame"
+o avoid this problem the compan decided to attach the window frames with a coating! which was to
be removed to fi( the glass plane" -emoving the coating revealed a laer of putt" +hus! the risk of the
glass pane falling off was reduced"
!onclusion
0anufacturers are now faced with the challenge of a 'cost-and-&ualit' competitive market" +he &ualit
levels that the have to achieve are demanding and re&uire stringent inspection sstems" 'ompanies
now believe that measuring parts on the plant floor improves product &ualit besides minimising
inspection time" Organisations desirous of achieving e(cellent &ualit should aim at eliminating sstem
faults" )oka-,oke is one such fail-safe tool*methodolog that averts mistakes"
)seful links
!oncept an application
*. +ohn ,rout's Poka-Yoke centre )rovides step-b-step reading recommendations to help learn
mistake proofing better" Jlossaries! everda e(amples! a tutorial! and other useful resources are
provided in this document"
http://www.campbell.berry.edu/faculty/jgrout/pokayoke.shtml
-. Poka-Yoke - An explanation
+his )5K document e(plainsA
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+he various causes of defects
.limination of defects
+he applicable tools
+he effectiveness of )oka-,oke
http://www.pepsan.com/Poka-Yoke_tutorial.pdf
.. Poka-Yoke Mistake Proofin$:
)oka-,oke also called 0istake )roofing is a simple method to prevent or at least! detect and weed out
defects! as earl as possible in the process" +his document e(plains the above concept with some real
time e(amples"
http://www.isixsigma.com/library/content/c!"!#a.asp
/. Mistake Proofin$ - #ork instructions
+his document provides step-b-step instructions for mistake proofing an organisation's processes"
http:00111.isixsi$ma.com0li2rar(0content0c3-34-4a.asp
5. Mistake Proofin$: An effective qualit( tool
+his document e(plains
0istake proofing in three simple steps"
3imilarit and difference between K0.% and )oka-,oke"
.(amples of common mistake proofing methods"
http://rac.alionscience.com/pdf/$istakeProofing%PokaYoke&.pdf
6. Poka Yoke for Environmental 7ualit( Mana$ement
+his 5ocument e(plainsA
#hat )oka ,oke is?
)oka ,oke devices and their characteristics
+he three levels of )oka ,oke
#here )oka ,oke works and where it doesn't?
http://www.pojasek-associates.com/'eprints/PokaYoke.doc
8. Error Proofin$ 9Poka Yoke:: !ommon !auses an the steps for appl(in$ it in suppl( chain
+his page e(plains how human errors and e&uipment failures can be minimised through error-proofing
techni&ues to improve suppl chain performance"
http://www.iw(aluechain.com/)olumns/columns.asp*)olumn+d,#-.
Presentations
4. Poka Yoke: Presentation:
+his presentation displas and e(plains how mistake proofing can be used towards achieving ?ero
5efect &ualit" 2esides e(plaining the concept it also presents evidences of the effectiveness of
0istake )roofing backing it up with some real time e(amples"
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http://www.campbell.berry.edu/faculty/jgrout/t/e.ppt
;. Presentation - Mistake Proofin$
+his page contains four good presentation covering the topics D3! 4ean*8ai>en! 0istake )roofing! and
/uick 'hangeover" #hile the sample presentations can be freel downloaded the full presentations
will have to be purchased"
http://www.landp.com.au/special/free.php
Trainin$ an consultin$ services
*3. Poka-Yoke - #ork shop
+his page provides information regarding an interactive workshop that focuses on getting people to
recogni>e their critical role in driving down problems and defects in both the internal and e(ternal
customer chains"
http:00111.hi$hperformancesolutions.ca0trainin$<poka(oke.htm
**. P'" !orporation Trainin$ an !onsultin$ 'olutions:
)32 'O-)O-%+IOE is an integrated solution provider assisting organisations accomplish business
e(cellence through people! products and processes" 4ocated in 'hina! Indonesia! 0alasia and
+hailand )32 'orporation provides both training and consulting for various /ualit tools including
)oka ,oke"
http://www.psbcorp.com/consulting/trgsolutions_prosysexcel_costreduct_poka.shtml
*-. Mistake Proofin$: #e2 2ase trainin$
Outbound +rain is the leading Internet distributor of interactive multimedia courseware for
emploee training! specialising in the different courseware that also includes poka oke" Over 9FF
0istake-)roofing e(amples along with traditional Poka Yoke techniques and innovative
application tools and strategies are provided"
http://www.outboundtrain.com/html/reseng/mistakeproof.html
*.. Profit Technolo$ies:
2ased in -iverside! 'alifornia )rofit technologies offers consulting and training for various &ualit
tools and techni&ues that includes )oka ,oke or 0istake proofing"
http://www.profitec.com/training.html
"ooks
*. The "asics of Mistake-Proofin$ b 0ichael -" 2eauregard! -amond J" 0ikulak! -obin ." 0c5ermott
"ook Description
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+he 2asics of 0istake-)roofing will show ou how to identif and use appropriate methods to create
safe products and processes" +his book e(plains each tpe of mistake-proofing simpl and clearl for
all levels of emploees and it is especiall useful for team! work cell! and production emploees" +he
book helps ou to identif which tpe of mistake-proofing to use for a particular application" +he book
also provides
% simple D-step mistake-proofing process"
How to do mistake-proofing based on K0.%s"
.(amples of each tpe of mistake-proofing and when to use
-. =ero 7ualit( !ontrol: 'ource >nspection an the Poka-Yoke '(stem b 3higeo 3hingo! %ndrew )"
5illon ;+ranslator=
"ook Description
5r" 3hingo reveals his uni&ue defect prevention sstem! which combines source inspection and )oka-
,oke ;mistake-proofing= devices that provide instant feedback on errors before the can become
defects" +he resultA 9FF percent inspection that eliminates the need for 3/' and produces defect-free
products" Includes 99B e(amples! most costing under M9FF" +wo-part video program also available@
.. Poka-Yoke: >mprovin$ Prouct 7ualit( b )reventing 5efects b Eikkan 8ogo 3himbun ;.ditor=!
Kactor 0aga>ine ;.ditor=! Eikkan 8ogo 3himbun 4td! Eikkan 8ogo 3himbun! 4td"! Kactor
0aga>ine
"ook Description
If our goal is 9FF percent >ero defects! this book is for ou - a completel illustrated guide to )oka-
,oke ;mistake-proofing= for supervisors and shop-floor workers" 0an )oka-,oke devices come from
line workers and are implemented with the help of engineering staff" +he result is better product &ualit
- and greater participation of workers in improving our processes! products! and our compan as a
whole"
/. Poka-Yoke: Mistake-Proofin$ Moule b Jeoffre 4" 0ika
"ook Description
.liminate all errors and mistakes in the workplace" 2etter than 3i(-3igma! 3imple to learn and
implement it works everwhere! " 3ensei 0ika used this workbook to conduct )oka-,oke events in
over BFF events" Eow ou can have the same workbook!
5. Mistake-Proofin$ for ?perators: The =qc '(stem 9'hopfloor 'eries: b )roductivit )ress
5evelopment +eam ;'reator=! )roductivit 5evelopment +eam ;'reator=! 3hingo
"ook Description
?/' is based on the principle that defects are prevented b controlling the performance of a process
so that it cannot produce defects! even when a machine or a human operator commits a mistake "
Instead of pointing fingers at people! ?/' finds was to keep errors from turning into defects" +his
book introduces front-line workers to the basic methodolog of ?/' in a succinct! eas to read format
that covers all aspects of this important manufacturing improvement strateg"
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