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Printed:
Thursday, October 29, 2015Poka Yoke
The Poka-Yoke System
Is Zero Defects a Reality?
Printed:
Thursday, October 29, 2015Poka Yoke
We have Quality Problems!
In American manufacturing, this statement
leads to an unsatisfactory resolution to the
problem. “We have Quality Problems”
shifts the concerns from the undetermined
true source (operation & process) to an area
where the root cause never occurred
(Quality Control) and the true cause is
addressed and corrected through high cost
inspection methods.
Printed:
Thursday, October 29, 2015Poka Yoke
We Have Quality Problem!
If we review the manufacturing structure
and the functioning elements to which the
product is going to be exposed to, we will
be able to determine possible root causes to
the problems prior to production. This is
known as Quality Planning and if done
properly can eliminate the need for the
Quality Control.
(Man, Material, Machine, Method, or Measurement)
Printed:
Thursday, October 29, 2015Poka Yoke
Section One
Shingo And The
Manufacturing Structure
Printed:
Thursday, October 29, 2015Poka Yoke
Poka Yoke Defined
Shigeo Shingo defines Poka Yoke as:
Poka
– “Inadvertent Mistake That Anyone Can Make”
Yoke
– “To Prevent or Proof”
Printed:
Thursday, October 29, 2015Poka Yoke
Manufacturing is a network of two structures.
Problems Occur When They Disagree!
Process Operation
Printed:
Thursday, October 29, 2015Poka Yoke
Operation & Process
Operation
Some People Know How to Drive a Car! Driving is an Operation.
Process
Some People Know How to Repair a Car! Repairing is a Process.
Printed:
Thursday, October 29, 2015Poka Yoke
Categories of the Process Function
A Process is the flow by which raw materials are
converted into finished goods.
Processes fall into one of the following categories:
Work: assembly, disassembly, alter shape or quality
Inspection: comparison with a standard
Transportation: a change of location
Delay: time during which no work, transportation or
inspection takes place
– Process Delays :Lot does not move until last item finished in
process
– Lot Delays: lot delayed in order to maintain 100, 99, 98 ... 2,1,0
Printed:
Thursday, October 29, 2015Poka Yoke
Categories of the Operation Function
An Operation is the actions performed on
material within the process.
Operations fall into one of the following categories:
Preparation/Adjustments Phase:(setup, tool change, Adjustments)
Principal Operations Phase: Operations repeated in each cycle (Hole
Punch, Drill, Sheer)
– Main Operations (Stamping, Cutting)
– Incidental Operations (movement of press, movement of people)
Marginal Allowances:
– Fatigue
– Hygiene (wash hands, etc.)
– Operations (shut-down to produce rush order, meetings)
– Work place (breaks, cleaning, maintenance)
Printed:
Thursday, October 29, 2015Poka Yoke
5 Elements of Production
Why?
Objects
of
Production
Agents
of
Production
Method
Space Time
What?
Where?
Who?
When?
How?
Printed:
Thursday, October 29, 2015Poka Yoke
Defining The 5 Elements
Objects of Production: Materials: Raw, Finished,
Semifinished, in-process
Agents of Production: People, Machines, Tools, Jigs,
Machine Tools, Incidental Devices, Inspection Equipment,
The Environment, etc.
Methods: Processing System, Load & Capacity Balance,
Processing Conditions
Space: Left to Right, Front to Back, Top to Bottom
Time: Process Time, Production Time, Task Time
Printed:
Thursday, October 29, 2015Poka Yoke
Changes in the Elements
When a change occurs in the
Objects of Production: Methods or the means of
action may change (How)
Space or size and location
may change (Where)
Time (overall start to
finish) or Timing (task
start to finish) may change
(When)
When a change occurs in the
Agents of Production:
When Changes Occur
When Changes Occur, Balance Must be Achieved Again
Printed:
Thursday, October 29, 2015Poka Yoke
4 Process Phenomena's
Process
Operation
Work Inspection Transprotation Storage
Planning, Prepation, &
Adjustment Operations
(setup Operations) J $ É CÌhsbhË`q BËdÌ`whtsv
@`hs
77 ££ ÉÉ 6sbhcdsw`q
7 £ É @`Ìfhs qqt`sbdv
3`whfxd 9 £ É 
5ƒfhdsd
9 £ É 
BËdÌ`whtsv
9 £ É 
PtÌpËq`bd
9 £ É 
Delays
Printed:
Thursday, October 29, 2015Poka Yoke
Shigeo’s Five Questions
A Problem (or Delay) Occurs ask
Why? Describe.
Why? Describe.
Why? Describe.
Why? Describe.
Why? Response!
Printed:
Thursday, October 29, 2015Poka Yoke
Section Two
Is There a Difference Between An
Error and A Defects?
Printed:
Thursday, October 29, 2015Poka Yoke
Reasons Why We Don’t Need
Poka Yoke
Workers Possess Divine Infallibility
Implementation Costs are High
The World is not a Dynamic
Environment
It is Cheaper to Hirer Sorters
Quality Control  Production
Would Have Nothing To Do
We are All Too Busy
We use SPC for Improvements
Printed:
Thursday, October 29, 2015Poka Yoke
Separating Error From Defect
Humans Make Errors (Cause), Defects Arise
Because Errors Are Made (Effect).
It is Impossible to Eliminate Errors From Tasks
Performed by Humans.
Errors Will Not Turn into Defects if Feedback and
Action Takes Place at The Error Stage.
Changing Occurrences can reduce Reoccurrence
Printed:
Thursday, October 29, 2015Poka Yoke
Causes of Defects
Process Defects
– Process Failure
Operational or Procedure Failures
– Process Error
Incorrect or Imprecise
Product Defects
– Incomplete Product
– Substandard Product
Printed:
Thursday, October 29, 2015Poka Yoke
Levels of Defects
Level 1: Defects Shipped out of Factory (Taylor
Methods)
Level 2: Defects Kept within Factory (Sheward
Methods)
Level 3: Defects Reduced (Juran/Demming Methods)
Level 4: Defects Kept within Production Stage
(Juran/Demming Methods)
Level 5: Defects Not Produced (Shingo Methods)
Printed:
Thursday, October 29, 2015Poka Yoke
Section Three
Inspection
Taylor’s Plan
Shewhart, Demming  Juran’s Plan
Shingo’s Plan
Printed:
Thursday, October 29, 2015Poka Yoke
Inspection Philosophies
Zero Defect
(Source Inspection )
(Poka Yoke Introduced)
Chronic Problem
Solving Methods
(Informative Inspection)
Sporadic Problem
Solving Methods
(Judgment Inspection)
Time
Kaizen
Continuous Improvement
}3 Wise Men
}Shingo }Shewart
}Taylor
Printed:
Thursday, October 29, 2015Poka Yoke
3 Methods of Inspection
Judgment Inspection (Taylor’s)
› Inspection That Discovers Defects
Informative Inspection (Shewhart’s)
› Inspection That Reduces Defects
Source Inspection (Shingo’s)
› Inspection That Eliminates Defects
Printed:
Thursday, October 29, 2015Poka Yoke
Judgment Inspection
Attribute Inspection of
Product Which
Discovers Defects at
the end of the process.
– Rework Costs
– Process Costs of
Nonconformaties
– Scrap Costs
– No Information about
Process
Inspection
Process 1
Process 2
Defects
found at the
end of
Process
Good Bad
Printed:
Thursday, October 29, 2015Poka Yoke
SPC Inspection
Inspection of product Which
Reduces Defects at the end of
process using inner process
checks.
– Inspection Costs
– Delay Costs
– Extra Equipment Costs
+ Scrap Cost Reduced
+ Information (Grading or Variable
Data) Gained about Process
Process 1
Process 2
Inspection
Printed:
Thursday, October 29, 2015Poka Yoke
Source  Sequential Inspection
Inspection Built into the
Operation using Poka Yoke
Devices to Detect Errors
Before They Become
Defects.
+ Pushes Defect Detection Up-front.
Cost Reduced
+ Nonconforming Materials are not
processed.
+ Eliminates need for SPC
– Minimal Cost of Poka Yoke
Devices
+ Reduces Steps in Process
Process 1
Process 2
Poka Inc..Defects
Printed:
Thursday, October 29, 2015Poka Yoke
Section Four
Efficiency  Waste
Printed:
Thursday, October 29, 2015Poka Yoke
Production Efficiency  Waste
Melody
– Flow Production
Rhythm
– Tack Time (Level Production)
Harmony
– Standard Operation Man,
Machine, Material, Method,
Measurement
Any Element Missing or
Incomplete We Have Noise.
(Waste)
Printed:
Thursday, October 29, 2015Poka Yoke
Types of Waste
Stock Inefficiency
Excess Stock Parts  Materials
Transportation Inefficiencies
Inefficient worker movement
inefficient results from looking for things
Selection inefficient
Defective production
Printed:
Thursday, October 29, 2015Poka Yoke
Cost Contributing to Waste
Materials
Processing
Depreciation
Repairs
Transportation
Recalls
Replacement
Advertising
Printed:
Thursday, October 29, 2015Poka Yoke
Section 5
Shingo’s Method
Printed:
Thursday, October 29, 2015Poka Yoke
Shingo’s Method
A Poka Yoke System uses Poka Yoke
Devices Built into Source or Sequential
Inspection Methods. Properly
Implemented, the System can achieve
Zero Defects
Zero Waste
Zero Delays
Printed:
Thursday, October 29, 2015Poka Yoke
Poka Yoke Devices, Systems  Inspection
Poka Yoke Systems
Control Systems
– Halt the operations, and require feedback and
action before process can resume.
Warning Systems
– Uses signals to warn the operator that the
operations needs feedback and action
(SQC systems have fairly long periods of time between
check stages and feedback execution)
Printed:
Thursday, October 29, 2015Poka Yoke
Poka Yoke Devices, Systems  Inspection
Poka Yoke Devices
Are built within the the process
In General have low cost
Have the capacity for 100% Inspection
(Remember SQC is performed outside the process which
add cost, and allows defects to escape the system)
Printed:
Thursday, October 29, 2015Poka Yoke
Poka Yoke Devices, Systems  Inspection
Inspection with Poka Yoke
Source Inspection (ZQC)
– built into process
– leads to a zero defect Systems
Self Check Informative Inspections (SQC)
– built inside or outside immediate process
– reduces defects to a minimum
Successive Check Informative Inspection (SQC)
– built inside or outside sequential process
– reduces defects to a minimum
Printed:
Thursday, October 29, 2015Poka Yoke
Movie “Poka Yoke”
Printed:
Thursday, October 29, 2015Poka Yoke
Section 6
Tools For Assessment
Printed:
Thursday, October 29, 2015Poka Yoke
Organizing Systems for Zero
Defects
People Materials Methods
Machines Information
+ + +
+
= ?
Printed:
Thursday, October 29, 2015Poka Yoke
Questions to Ask About Present Systems
Can we take current informative inspection systems with
successive checks and improve them to get a system of
informative inspections with self-check methods?
Can we take current informative inspections with self-
check methods and improve them to get source inspection?
Since informative inspections tolerate the occurrence of
defects, can we take these methods and improve them to
get source inspection in which the errors that cause defects
are detected and prevented from turning into defects.
Printed:
Thursday, October 29, 2015Poka Yoke
Greensburg GenCorp Line
Operation 10 Roll Mill
Operation 20 Shuttle
Operation 30 Bracket Weldment
Operation 40 Rivet on Clip
Operation 50 Check  Pack

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Javier Garcia - Verdugo Sanchez - The Poka - Yoke System

  • 1. Printed: Thursday, October 29, 2015Poka Yoke The Poka-Yoke System Is Zero Defects a Reality?
  • 2. Printed: Thursday, October 29, 2015Poka Yoke We have Quality Problems! In American manufacturing, this statement leads to an unsatisfactory resolution to the problem. “We have Quality Problems” shifts the concerns from the undetermined true source (operation & process) to an area where the root cause never occurred (Quality Control) and the true cause is addressed and corrected through high cost inspection methods.
  • 3. Printed: Thursday, October 29, 2015Poka Yoke We Have Quality Problem! If we review the manufacturing structure and the functioning elements to which the product is going to be exposed to, we will be able to determine possible root causes to the problems prior to production. This is known as Quality Planning and if done properly can eliminate the need for the Quality Control. (Man, Material, Machine, Method, or Measurement)
  • 4. Printed: Thursday, October 29, 2015Poka Yoke Section One Shingo And The Manufacturing Structure
  • 5. Printed: Thursday, October 29, 2015Poka Yoke Poka Yoke Defined Shigeo Shingo defines Poka Yoke as: Poka – “Inadvertent Mistake That Anyone Can Make” Yoke – “To Prevent or Proof”
  • 6. Printed: Thursday, October 29, 2015Poka Yoke Manufacturing is a network of two structures. Problems Occur When They Disagree! Process Operation
  • 7. Printed: Thursday, October 29, 2015Poka Yoke Operation & Process Operation Some People Know How to Drive a Car! Driving is an Operation. Process Some People Know How to Repair a Car! Repairing is a Process.
  • 8. Printed: Thursday, October 29, 2015Poka Yoke Categories of the Process Function A Process is the flow by which raw materials are converted into finished goods. Processes fall into one of the following categories: Work: assembly, disassembly, alter shape or quality Inspection: comparison with a standard Transportation: a change of location Delay: time during which no work, transportation or inspection takes place – Process Delays :Lot does not move until last item finished in process – Lot Delays: lot delayed in order to maintain 100, 99, 98 ... 2,1,0
  • 9. Printed: Thursday, October 29, 2015Poka Yoke Categories of the Operation Function An Operation is the actions performed on material within the process. Operations fall into one of the following categories: Preparation/Adjustments Phase:(setup, tool change, Adjustments) Principal Operations Phase: Operations repeated in each cycle (Hole Punch, Drill, Sheer) – Main Operations (Stamping, Cutting) – Incidental Operations (movement of press, movement of people) Marginal Allowances: – Fatigue – Hygiene (wash hands, etc.) – Operations (shut-down to produce rush order, meetings) – Work place (breaks, cleaning, maintenance)
  • 10. Printed: Thursday, October 29, 2015Poka Yoke 5 Elements of Production Why? Objects of Production Agents of Production Method Space Time What? Where? Who? When? How?
  • 11. Printed: Thursday, October 29, 2015Poka Yoke Defining The 5 Elements Objects of Production: Materials: Raw, Finished, Semifinished, in-process Agents of Production: People, Machines, Tools, Jigs, Machine Tools, Incidental Devices, Inspection Equipment, The Environment, etc. Methods: Processing System, Load & Capacity Balance, Processing Conditions Space: Left to Right, Front to Back, Top to Bottom Time: Process Time, Production Time, Task Time
  • 12. Printed: Thursday, October 29, 2015Poka Yoke Changes in the Elements When a change occurs in the Objects of Production: Methods or the means of action may change (How) Space or size and location may change (Where) Time (overall start to finish) or Timing (task start to finish) may change (When) When a change occurs in the Agents of Production: When Changes Occur When Changes Occur, Balance Must be Achieved Again
  • 13. Printed: Thursday, October 29, 2015Poka Yoke 4 Process Phenomena's Process Operation Work Inspection Transprotation Storage Planning, Prepation, & Adjustment Operations (setup Operations) J $ É CÌhsbhË`q BËdÌ`whtsv @`hs 77 ££ ÉÉ 6sbhcdsw`q 7 £ É @`Ìfhs qqt`sbdv 3`whfxd 9 £ É 5ƒfhdsd 9 £ É BËdÌ`whtsv 9 £ É PtÌpËq`bd 9 £ É Delays
  • 14. Printed: Thursday, October 29, 2015Poka Yoke Shigeo’s Five Questions A Problem (or Delay) Occurs ask Why? Describe. Why? Describe. Why? Describe. Why? Describe. Why? Response!
  • 15. Printed: Thursday, October 29, 2015Poka Yoke Section Two Is There a Difference Between An Error and A Defects?
  • 16. Printed: Thursday, October 29, 2015Poka Yoke Reasons Why We Don’t Need Poka Yoke Workers Possess Divine Infallibility Implementation Costs are High The World is not a Dynamic Environment It is Cheaper to Hirer Sorters Quality Control Production Would Have Nothing To Do We are All Too Busy We use SPC for Improvements
  • 17. Printed: Thursday, October 29, 2015Poka Yoke Separating Error From Defect Humans Make Errors (Cause), Defects Arise Because Errors Are Made (Effect). It is Impossible to Eliminate Errors From Tasks Performed by Humans. Errors Will Not Turn into Defects if Feedback and Action Takes Place at The Error Stage. Changing Occurrences can reduce Reoccurrence
  • 18. Printed: Thursday, October 29, 2015Poka Yoke Causes of Defects Process Defects – Process Failure Operational or Procedure Failures – Process Error Incorrect or Imprecise Product Defects – Incomplete Product – Substandard Product
  • 19. Printed: Thursday, October 29, 2015Poka Yoke Levels of Defects Level 1: Defects Shipped out of Factory (Taylor Methods) Level 2: Defects Kept within Factory (Sheward Methods) Level 3: Defects Reduced (Juran/Demming Methods) Level 4: Defects Kept within Production Stage (Juran/Demming Methods) Level 5: Defects Not Produced (Shingo Methods)
  • 20. Printed: Thursday, October 29, 2015Poka Yoke Section Three Inspection Taylor’s Plan Shewhart, Demming Juran’s Plan Shingo’s Plan
  • 21. Printed: Thursday, October 29, 2015Poka Yoke Inspection Philosophies Zero Defect (Source Inspection ) (Poka Yoke Introduced) Chronic Problem Solving Methods (Informative Inspection) Sporadic Problem Solving Methods (Judgment Inspection) Time Kaizen Continuous Improvement }3 Wise Men }Shingo }Shewart }Taylor
  • 22. Printed: Thursday, October 29, 2015Poka Yoke 3 Methods of Inspection Judgment Inspection (Taylor’s) › Inspection That Discovers Defects Informative Inspection (Shewhart’s) › Inspection That Reduces Defects Source Inspection (Shingo’s) › Inspection That Eliminates Defects
  • 23. Printed: Thursday, October 29, 2015Poka Yoke Judgment Inspection Attribute Inspection of Product Which Discovers Defects at the end of the process. – Rework Costs – Process Costs of Nonconformaties – Scrap Costs – No Information about Process Inspection Process 1 Process 2 Defects found at the end of Process Good Bad
  • 24. Printed: Thursday, October 29, 2015Poka Yoke SPC Inspection Inspection of product Which Reduces Defects at the end of process using inner process checks. – Inspection Costs – Delay Costs – Extra Equipment Costs + Scrap Cost Reduced + Information (Grading or Variable Data) Gained about Process Process 1 Process 2 Inspection
  • 25. Printed: Thursday, October 29, 2015Poka Yoke Source Sequential Inspection Inspection Built into the Operation using Poka Yoke Devices to Detect Errors Before They Become Defects. + Pushes Defect Detection Up-front. Cost Reduced + Nonconforming Materials are not processed. + Eliminates need for SPC – Minimal Cost of Poka Yoke Devices + Reduces Steps in Process Process 1 Process 2 Poka Inc..Defects
  • 26. Printed: Thursday, October 29, 2015Poka Yoke Section Four Efficiency Waste
  • 27. Printed: Thursday, October 29, 2015Poka Yoke Production Efficiency Waste Melody – Flow Production Rhythm – Tack Time (Level Production) Harmony – Standard Operation Man, Machine, Material, Method, Measurement Any Element Missing or Incomplete We Have Noise. (Waste)
  • 28. Printed: Thursday, October 29, 2015Poka Yoke Types of Waste Stock Inefficiency Excess Stock Parts Materials Transportation Inefficiencies Inefficient worker movement inefficient results from looking for things Selection inefficient Defective production
  • 29. Printed: Thursday, October 29, 2015Poka Yoke Cost Contributing to Waste Materials Processing Depreciation Repairs Transportation Recalls Replacement Advertising
  • 30. Printed: Thursday, October 29, 2015Poka Yoke Section 5 Shingo’s Method
  • 31. Printed: Thursday, October 29, 2015Poka Yoke Shingo’s Method A Poka Yoke System uses Poka Yoke Devices Built into Source or Sequential Inspection Methods. Properly Implemented, the System can achieve Zero Defects Zero Waste Zero Delays
  • 32. Printed: Thursday, October 29, 2015Poka Yoke Poka Yoke Devices, Systems Inspection Poka Yoke Systems Control Systems – Halt the operations, and require feedback and action before process can resume. Warning Systems – Uses signals to warn the operator that the operations needs feedback and action (SQC systems have fairly long periods of time between check stages and feedback execution)
  • 33. Printed: Thursday, October 29, 2015Poka Yoke Poka Yoke Devices, Systems Inspection Poka Yoke Devices Are built within the the process In General have low cost Have the capacity for 100% Inspection (Remember SQC is performed outside the process which add cost, and allows defects to escape the system)
  • 34. Printed: Thursday, October 29, 2015Poka Yoke Poka Yoke Devices, Systems Inspection Inspection with Poka Yoke Source Inspection (ZQC) – built into process – leads to a zero defect Systems Self Check Informative Inspections (SQC) – built inside or outside immediate process – reduces defects to a minimum Successive Check Informative Inspection (SQC) – built inside or outside sequential process – reduces defects to a minimum
  • 35. Printed: Thursday, October 29, 2015Poka Yoke Movie “Poka Yoke”
  • 36. Printed: Thursday, October 29, 2015Poka Yoke Section 6 Tools For Assessment
  • 37. Printed: Thursday, October 29, 2015Poka Yoke Organizing Systems for Zero Defects People Materials Methods Machines Information + + + + = ?
  • 38. Printed: Thursday, October 29, 2015Poka Yoke Questions to Ask About Present Systems Can we take current informative inspection systems with successive checks and improve them to get a system of informative inspections with self-check methods? Can we take current informative inspections with self- check methods and improve them to get source inspection? Since informative inspections tolerate the occurrence of defects, can we take these methods and improve them to get source inspection in which the errors that cause defects are detected and prevented from turning into defects.
  • 39. Printed: Thursday, October 29, 2015Poka Yoke Greensburg GenCorp Line Operation 10 Roll Mill Operation 20 Shuttle Operation 30 Bracket Weldment Operation 40 Rivet on Clip Operation 50 Check Pack

Editor's Notes

  1. This Course has the following outline: Introduction: Section One “Shingo’s Manufacturing Structure” The main point to consider throughout Section One is to be able to recognize waste, determine where waste occurs. Section Two
  2. It has been my experience that... When difficulties in product arise, Quality Control usually finds it, analyses it, and reports the results to management. This process is fine, it is Quality’s Job to do this. What ends up happening in some situations is Quality ends up owning the Problem. The use of Statistic helps to keep the Problem alive. Although SPC is a good tool for identifying problems it does very little to prevent them from happening. We see week after week of process and product monitoring with small improvements being made but not major jumps. What could be missing. What we see happening is a Fire. Quality Confirms the Fire, monitors its progress and everyone tries to put out the fires. Juran termed this sporadic problem Solving. we use containment practices, but what truly ends up happening, is we all stand around and watches it burn.
  3. This is more in line with what Juran termed Chronic Problem Solving. We need to change the present situation and use a team approach. Quality is not the means to the end, it is simply a point in the process. To find the real problem, we need the Process and Operation Experts, we must look at the whole manufacturing structure and develop a team focus. (this is the APQP class)
  4. Shigeo Shingo, a Japanese Industrial Engineer, contributed many concepts to modern Management and Manufacturing practices. Some of these included the creation of: Zero Quality Control “Shipping No defects” Sequence Inspection “Checking previous work, Prior to starting your task” Source Inspection “Checking ones own work” Poka Yoke “Mistake Proofing” SMED (Single Minute Exchanges of Dies) Although he did not create the concepts of Sequence and Source Inspection, Shingo developed a structure of knowing which to use when.
  5. To obtain the proper base of Shingo’s work, we must adopt the Japanese mind set of manufacturing which differs (Thank GOD) from Frederick W. Taylor. Japanese view manufacturing as a network consisting of two interrelated structures. The Process Structure: the flow by which raw materials are converted into finished goods. Within the process structure, there are four categories to which a process goes through. The Operation Structure: the actions performed on materials. Three categories can be occurring within the operation structure. Preparation and After Preparation adjustments, Principal Operations, Marginal Allowances.
  6. Most People Know How to Drive a Car! Abilities and Tasks differs: Race car driver Truck Driver Sunday Driver Abilities and Task Differ: Designers Repairers Builders
  7. Objects of Production: The Product Materials, Semifinished & Finished Goods Agent of Production: The people in charge of Product, The Machines, Tools, and other equipment assisting them. Man, Machines, Tools, Jigs, Gagging Methods: Means by which actions are performed Work Instructions, Procedures, Manuals Space: Where actions are performed and the locations to and from which objects are transported. Processing system, Balanced Load and Capacity, Processing Condition Time: The timing of work or how long action take. Time and Timing
  8. Humans Make Errors (Cause), Defects Arise Because Errors Are Made (Effect). It is Impossible to Eliminate Defects From Tasks Performed by Humans. Yet Errors Will Not Turn into Defects if Feedback and Action Takes Place at The Error Stage. The Difference Between Occurrence and Reoccurrence The Paint Story “What Did You Learn” The Hammer Story “ Hurts More The Second Time” My Brother & His Stuck Car The Paint Bucket was an Occurrence, I Bring the Paint Can Down with ME. The Hammer is an on going Reoccurrence, I need to Buy an Automatic Nail Gun. My Brother is another story.