Archives for category: Mistake Proofing

My family and I love to go fishing. Most of our weekends are spent fishing somewhere as well as our vacations. We normally go for whatever is available in the ocean, lake or river. Sometimes bass, sometimes walleye or trout or blue fish. We do catch and release fishing so others can enjoy the experience as well. I get several people offering me new techniques and lures to catch the big one. I just like fishing but I do try some of the lures. Below is an image of some of the different types lures.

Frogs for lily pads. Crank baits, spinner baits, rooster tails, shad raps which are not pictured below and others that are used in specific conditions. It is amazing how many options there are. And this is just for bass let alone saltwater blue fish or drum or any other species. With these lures comes the technique to use them. Some you just crank them in, some you just float and have them “hop” on the top of the water, some you let them sink and crank a turn and then repeat. Are these techniques and lures statistically significant in catching fish? I don’t know but I am working with others on that question. One thing I do know is that it gets you into the store and gives you options on the water when what you are currently using is not working.

Bass Fishing Lures


Then there is catfish. I am sure there is just as much variation and subtleties to catfish fishing as there is to bass or any other species. What I will say, in my families experience, is that a bass hook, a 1/2 to 1 ounce sinker and a hot dog will bust you some serious hogs!

Hot Dogs

We have caught catfish in several lakes and ponds with this “rig” and have never needed to go back to the bait tackle store for something else. We just go to the local grocery store and buy the doggers. We usually by double so that we can eat some over the fire after the fishing day is done.

I have friends and family that have been fishing for decades longer than I have and have all the experience needed to bring in what ever fish they want to catch. What I find interesting is that when someone gives me the inside scoop on a lure / technique combination and they give me some bright lure with an instruction manual ala Ikea, I feel funny handing over an 8 pack of Ball Park Franks and telling them just drop them on the bottom and relax until they hit. But whether they are impressed or not, it works. That’s what I find sometimes when I am working on a project that I could have some great tools that wows the crowd during a presentation and show them how smart the team is but I would rather just show them how easy it can be to accomplish their goals. Sometimes it takes ANOVA analysis to get to the bottom of an issue. Sometimes it takes going out into the field and watching the process and giving some suggestions or using what the employee feels as pain points to resolve and issue. Just because you have the statistical hammer doesn’t mean everything has to be a complicated nail.





I went to the dentist today. This is the first time in over 6 years. I know, I know. Every 6 months. I felt bad for the dental hygienist but it was a great forrm work out. Anyway, they wanted to do x-rays and they put the film holder in my mouth with a circle on the end. The picture is below. When I asked what it was for they said it helped line up the camera with the film. I thought it was a cool idea. I think it is called a Rinn. It seemed faster than I remember though I wasn’t timing it in the past. I wonder how many images had to be redone because the film didn’t line up with the camera.  I was also wondering how else this concept be used. Could this help with packaging materials that need to be centerlined but the operator can’t see or reach the material due to guarding or confined space issues. What other applications can you think of for a device that lines up a tool you can control and a mating piece that you can’t?


Are there areas where continuous improvement / Lean Six Sigma do not need to be used or shouldn’t be used?

What about a known solution? Is there no risk related to this change? Is everyone aware of the changes? Even if there is a known solution, if it crosses process owners and potential unintended consequences, it is wise to at least review the process, look at an FMEA, Change Management and Control plan.

What about CapEx or buying equipment? Would that need LSS help? Let me ask you, in your experience, how many of these projects have been on-budget, on-time, and SLA’s, service level agreements, are satisfied? I have found that is not the case. Early management, Risk assessment, Widening the options for what to purchase and when are all items that continuous improvement could help with. This doesn’t even include the CapEx process that most companies struggle with.

I started thinking about this idea based on the belief that there are some items and topics that continuous improvement. I now think that there is always a better way and that CI tools can help in any situation. I have had multiple discussions in the companies that I have worked with and almost all of them have had what they perceived as “A players.” They are very capable and smart and know their business but I have rarely seen one of these teams put together a project that produces better results or less unintended consequences than a good process. Great teams have a hard time beating a great process.

I have worked with some companies that start the autonomous maintenance portion of TPM by having the operators make basic or easy adjustments when there is an issue with the equipment. “If this doesn’t work, than call maintenance,” is the mantra.

The issue comes in when the easy or simple item that the operators are supposed to do may not be the best first step. There was a facility that the first step was related to changing a seal that can be replaced without tools. When reviewing the actual MTBF rates of all the different types of repairs, it was found that there were other items that have a higher success rate. The issue with this fix is that tools were required and in some instances LOTO. What do you do with this information?

One, continue to do the same thing – The positive is that the operators are still involved. The downside is that it is not as effective as the best known solution.

B, stop what the operators are doing and go right to the walkie talkie with Maintenance. Potential positive is that there will be less downtime per incident. The downside is that operators become disengaged.

iii, Develop a way to do the repair without tools and safety concerns. This way Maintenance and Operators can work together and make a new process. These are positives but the potential downside is that time will be required, usually in the form of offline discussions and trials, that may take more time both to develop the process. This mean employees are offline working on the process not the product. Sites that are super P&L focused or have a low profit margin product may not be sold on this.

Fourth, the operators, maintenance, and supervision work together and eliminate the downtime all together. Any extra time needed to eliminate the downtime will be paid for by future gains in downtime reduction. This keeps everyone engaged and can be the beginning of a downtime elimination team that will work on downtime elimination instead of Band-Aids.

I was working in a site that wanted and needed a better changeover process on some of their production lines. This site was set up so that there was only 1 maintenance person per line per shift but there was also a 3 hour overlap on some days. We went through the traditional 4 step approach but there was an added complexity to the changeover. The employees who did the changeover were rarely the ones that were there during start-up.

Though the leadership knew this was the right thing to do, it was hard to free up the resources and the time required to do the project effectively. So I came up with a small team, 1 or 2 maintenance techs and 1 operator, to work this process. Also, I did not have any traditional sitdown meetings. We met on the line, during production or changeover and pulled the process together. Even though it was a small group, we were getting a lot accomplished.

Because of this, we developed a feedback loop. We would do the changeover and document the steps, move from internal to external, stream line internal events and the I would come back during production, when the lines was running in steady state, and document the changes, if any, were made. I worked with the operators as well as maintenance staff on the process. Checklists were developed for each type of package. Good stuff.

So we were going into a package change on a Monday to Tuesday and I had sent out the checklists and told the maintenance person to call me when the changeover started so I could document the changes. I also stated in the email that I may not be able to get there due to other commitments but give me a call anyway. I did not receive a call and got up when I normally do. I figured he either got tied up or the changeover was quick and he didn’t need to call. That had happened on occasion.

I get to the site and the first thing I notice is that there is no primary packaging staged for the run. This was around an hour before production so it wasn’t a huge concern but still odd. Then I ran into the maintenance tech.

“Hey, where’s Dave?”, I asked.
“He called off.” he stated

That was not a good sign since he was the one I had been working with and he had the checklists. I reviewed the checklist on the equipment while the maintenance tech worked on another issue. There were packages that had run through the equipment that seemed to be used as “test subjects” to tweak the set-up. Were the settings correct. Nope. In his defence or mine, he had run some product through and it seemed to be working. What did I do? I thought that since this product was slightly different from the one documented, may be it would be okay. Guess what? It wasn’t.

After 2 hours of adjustments and several tongue lashing, we finally got the line running where it should have been. How close was the checklist. Very close but, even at that, there were still some adjustments that we had not captured earlier. This made every one very disappointed in the results for that day.

After discussing the issue with the production manager and site manager, I admitted that it was my fault and that even though the small team had done some great work and that it was still a work in progress, the communication of current state and next steps hurt everyone. What did I do differently?

Made sure the team as well as anyone the team was in contact with related to the project was aware of what was going on and why.

Made sure that there were regular, and timely updates and training where needed. This meant a weekly stand up meeting or posting on the bulletin board of where we were and what’s next.

Didn’t just ask but solicited thoughts on the project and how we could make it better both from stakeholders and those outside the impact zone so that we could incorporate them into the project.

In end, it came out okay and the team was recognized for their good work and the efficiency of the line improved dramatically. The lesson learned – Even if you have a small team working under the radar, you need to broadcast periodically where you are using the radar.

Let me start off by stating I am not a great golfer. Not even a good or passable golfer. I stink. I have gone golfing about 4 times this year and only one long nine golf course. I usually get handed an abacus instead of a scorecard. I score on a par three course what the average golfer does on a traditional 18 hole course. I digress.

I went out a couple of nights ago with my brothers and nephew and after losing 3 balls and breaking every tee I had, my brother gives me the tee in the picture below. Did I mention that it was only the third hole? Anyway, the tee helped.

Golf and Visual Management

The markings gave me the control I needed to hit my tee shot adequately. I am not saying I didn’t make mistakes but I would put the tee lower when I was using an iron or 3 wood. This helped me get the ball in the air without shooting turf further than the ball. I put it on the higher marking when I used a driver. This gave me the ability to not turn the ball into a worm burner. I usually like to use a tee ball tee but that is socially unacceptable where I play golf.

The rest of the course was sloppy at best. It was raining and there was a good bit of lightening. I know, I know, common sense would have gotten off the course. But the tee shots were better than I had done in the past and some of that was related to being able to control the height at which I set up the tee.
Whoever came up with this, I thank you.

I have worked through and trained multiple teams related to group problem solving and one of the items that continues to show up during the training is that now that we have found a root cause, what do you do about it? I have used a process that will hopefully help.

My focus during root cause analysis is skill acquisition not learning so I want a real world example and get into the details instead of a PowerPoint presentation. That being said, once we go down the 5 why road or some other process, inevitably the team gets to the point of now what? Here has been my approach and I am sure there are others so please let me know.

Eliminate – How do we, through the process or through engineering / design can the root cause be eliminated? This can be a page layout in SAP or some other software package, mistake proofing a jig so that the part can only be set up one way, or modifying the equipment so that the issue can’t occur.

Limit – How can I minimize the impact? Once again some of the items above can be used but it also ends up doing some type of preventative maintenance or work instruction to ensure that the impact that the improvements didn’t fix are cleaned up. In the transactional world, this could be a folder that houses all the errors is created and cleaned up on a daily basis. On the manufacturing floor, it could be a box that catches dust and debris and is replaced every shift. For all the hard work the teams I have been associated with, this is where we usually end up.

Troubleshooting and Training – This is perhaps the most difficult of the options because widespread and long standing behaviors will need to be changed. This is the process changing and troubleshooting stage. This usually occurs more on the service and manufacturing arenas but it can also be in the admin / transactional environments. This is where the operator recognizes the error, either through a signal in the process developed in the mistake proofing phase of the team project or a poor quality product. From this the operator goes through a if then checklist to make sure the actions are standardized. Once this set of actions is performed and there is still and issue, maintenance gets involved. This could be IT, Equipment techs or Maintenance Techs on the production or hospital floor. They will go through a similar list of if then checklist until there is resolution.

Once again, I am sure there are other approaches that work as well or better and I would appreciate feedback.
After a couple of real examples are gone through, root cause analysis is a simple skill to acquire, but resolving the issue to satisfaction is where the heavy lifting occurs.