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Chapter 8. Build a Culture That Stops to Fix Problems          193
















        Figure 8-10. Lock and key error-proofing device


                using a quarter-inch steel plate over the front of the QDs that had
                unique slots milled for each separate color (Figure 8-10). Then he
                made a sleeve that was attached to each paint line with a pin config-
                uration that would fit the slot. Just like a lock and key! The prototype
                was installed at one station to test and to verify ease of use. After
                modifications, matching sets were made for each paint station (all
                were identical lock/key configurations).
                Of course, this method is not completely mistake proof. In fact, it’s possi-
                ble to defeat the method for any system that is developed (think about
                computer hackers breaking into “secure” systems). In this case, if the pins
                were broken or removed, the device would be ineffective. To counter
                this possibility the team leader added a check of the pins to the daily
                preshift inspection to verify that everything was in correct working order.

                The cost of this simple solution was about $200 for material and labor,
                and the sleeves only added a few ounces of weight to the operator—
                not a significant ergonomic impact. The device effectively prevented
                the problem with zero recurrences.


            There are some key points that support the effort of mistake proofing. The
        key determinant of your success is your mind-set. Error-proofing techniques
        and tools are simple and easy to apply. The greatest challenge is in discovering
        the root cause and using your imagination to effectively eliminate it.
            There is a hierarchy when it comes to the mistake-proofing effort. The highest
        order is to prevent the occurrence of the error completely. But complete elimina-
        tion is not always feasible or practical. Any system or device that is installed can
        be bypassed if desired. If a prevention device is installed that is problematic or
        cumbersome, people will tend to “work around” it. If you create a cure that is
        worse than the disease, people will sidestep your cure.
            If it’s not possible to completely prevent the error (most of the time), then try
        to detect the error as it occurs. Detection devices or methods are more common
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