Zero Human Errors

Prof. H. YAMASHINA
Kyoto University
Fellow of RSA (the U.K.)
Member of Royal Academy of
Engineering Sciences (Sweden)
 Zero Human Errors
Chapter 1 : Careless mistakes and error proofing
Chapter 2 : Characteristics of human errors in process industry
Chapter 3 : Countermeasures against Human Errors in Process Industry
Chapter 4 : Concept of Fool-Proof / Improvement
Chapter 5 : Achieving zero human errors
Chapter 6 : Typical classification of human errors in process industry
Chapter 7 : Action to be taken to eliminate human errors
Chapter 1: Careless Mistakes and Error Proofing

Preventing careless mistakes by Error-Proofing

The elimination of careless errors is an important topic in every field, not
only in the manufacturing industry but also In offices, sales divisions, and
service organizations.

Human errors take place due

to :
• Mistaken ・ Defectives and
• Misunderstanding Information non-conforming Efficiency
• Misperception decreases
products (quality)
• Misjudgment
• Forgetfulness Man
・ Quality differences The cost
• Absentmindedness Occurrence (quantity) raises
• Inattention of careless
mistakes ・ Missed deadlines
• Carelessness The OEE
Machine (delivery) decreases
• Ambiguity
• Reading wrongly ・ Work holdups
Management
• Writing wrongly Material (efficiency, cost)
power
• Remembering
wrongly ・ Accidents (safety) decreases

etc.

Fig. 1 Occurrence of careless mistakes

Example in some process industry

1. 51.5% of defectives were generated due to human errors.

2. 70.3% of stopped down time was caused by human errors.

3. 31.2% of equipment abnormalities were created by human

errors.

4. The ratio of human errors against total abnormalities was

0.63.

5. Process stop due to a human error 60min/incident

Machine down time due to a human error 15min/incident
Basic error-proofing method
1. Create methods of working that cannot be mistaken no matter who follows
them.
2. Arrange things so that, if an error occurs, either it is immediately noticed or its
effect is nullified.
Implement error-proofing Good products
1. Make things visible (quality)
2. Reduce and eliminate the degree of freedom of choice
Guaranteed
(no room to mischoose a wrong thing)
3. Eliminate interchangeability (limited use, specific use) production volumes
4. Have workers give verbal and hand-signed confirmation (quantity)
5. Implement foot proof concept
6. Install warning lamps and buzzers Just-in-time supply
7. Hide unneeded items, use check lists (delivery)
8. Fit automatic shutdown mechanisms
9. Install mechanisms that prevent machines from working Trouble-free work
if something is wrong (efficiency, cost)
10. Automation (program, sequence)
…fixed, can not be changed by the program and/ or Zero accidents
sequence (safety)
Fig. 2 Implement error proofing

Fool proof: device not to make a mistake

Fail safe: device to prevent the worst thing to happen even if errors take place
Chapter 2: Characteristics of human errors in process industry

Others
Mis-operation
Mistake in timing

Redundant work

Mistake in setting up and

measuring Forget to do what has
to be done (59%)

Mistake in choosing
an object (16%)

Operation is long and intermittent.

Has to do multiple work simultaneously.

Fig. 3 Types of mistakes

 Regular work

Repair

Other irregular work

Changeover (59%)
Irregular work
(94%)

Experiments at the shop (18%)

With local fool proof devices,

overall operations have become more complex.

Fig. 4 Types of operations causing errors

 Repetitive mistakes (6%)

Newly occurred mistakes

(94%)

Although current fool proof devices are effective

more mistakes take place at the irregular operations
which are required only several times per month or year.

Fig. 5 Repetition of errors

Eliminate the sources of mistakes (6%)

Indication (25%)
Not possible to install
fool proof devices (69%)

Already installed
(31%)

It is difficult to install fool-proof devices to less frequent operations.

Fig. 6 Installation of fool-proof devices

Based on the above data, 4 characteristics can be pointed out concerning
the background where human errors take place in process industry.

1. Operations are irregular and discontinuous.

2. In case of two men’s operations, work responsibilities between

the two are not clear.

3. It is not easy to stop operation in case a trouble takes place.

4. There are many similar pieces of equipment Installed which are

difficult to distinguish one from another.
Chapter 3: Countermeasures against Human Errors in Process Industry

Facts ：

• Man cannot stand excessive tension.

• Man gets nervous when a problem takes place.

• Man easily forgets what was informed.

Defective
phenomenon

Personnel factor

Knowledge
Action, Movement
Education, training, OJT

Under continuous stress

In reality nothing can be 100% perfect

Accidents due to carelessness still exist

Physical, environmental factors To prevent

Do not proceed to the next stage In case of error in the In case of abnormal
operational sequence operation the
machine is stopped
An alarm is given in case of abnormal operations
To eliminate
An alarm should be given by warning buzzers As a abnormal
result conditions,
It is necessary to care both warning lamps mechanization and
and buzzers automation can be
If still not perfect used
In an automated
Automatic stop and display are advisable machine, an
abnormal
No other way but normal operation can be made operation stops
the machine
Fig. 7 Personnel factors and physical/environmental factors
Careless mistakes take place by various factors as shown in Fig.8.
Insufficient measurement system
Management Problematic information route
Lack of Information error, Transfer error
Skills Overconfidence
Immaturity Education and Training
Man Bad habits due to past experiences
Attentio Health problems, fatigue, worries
Causes of n Excessive stress
mistakes Loose mind
Carelessness
Absent mindlessness
Error, misunderstanding, misjudgment, misoperation
Poor technique, poor
Method skills
No experiences
Lack of technical review
Insufficient technique
Inappropriate specifications
Machine Poor accuracy, poor functions
Insufficient maintenance
Defective characteristics
Material Defective size
Wrong parts

Fig. 8 Factors influencing mistakes’ occurrence

Prevention of occurrence of overflow

operation

Occurrence Release

(Example) (Example)
Prevention of In case of
Prevent the Prevent the abnormality
mis-insertion occurrence release
Make the machine detection, stop the
in such a way that machine
insertion can be
carried out only in
one direction
Do not depend on personnel.
Try to deal with physical (mechanical)
devices.

Fig. 9 Prevention of occurrence of overflow

Chapter 4: Concept of Fool-Proof / Improvement

1. Fundamental concept of error-proofing

In order not to produce defects, inspection must be made for preventing
recurrence of mistakes. As in shown in Fig 10, inspection can be classified
into two types of inspection. It goes without saying that inspection must be
the first one. Unfortunately, inspection often means the other type of
inspection.

Inspection
Inspectionfor
forDetecting
Detecting
Defects
Defectsfrom
fromGood
GoodOnes
Ones
Inspection
Inspection
Inspection
Inspectionfor
forPreventing
Preventing
Recurrence
Recurrenceof ofMistakes
Mistakes

Fig. 10 Two types of inspection

Defects must be found out immediately right after they have taken
place. For this purpose, 100% inspection must be exercised
theoretically at each process of the line. The problem is how to do
it economically.

(Principle 1)
The mission of inspection is not to select defects from good ones
but eliminate defects.

(Principle 2)
One hundred percent inspection must be exercised in some way
in order not to produce any single defect.
2. Essentials of preventing recurrence of mistakes

The essentials of preventing recurrence of mistakes are:

1. Workers must be installed with the notion that each one

of them is
a quality-control inspector.

2. If they spot a faulty item in the production process, they

should be
encouraged to shut down the whole line to fix it.

3. They tally the defect, analyze it, trace it to the source,

make
corrections, and then keep a record of what happens
afterwards.
(Principle 3)
Each worker must also be a quality-control inspector.

(Principle 4)
If a worker finds out a defect, he himself must stop the line and
inform the person in charge of the trouble. The section which has
produced the defect must take countermeasures immediately.

(Principle 5)
The cause of the defect must be pursued by asking at least five
times WHY it did take place, and the countermeasures must be
taken.
3. Places where inspection should be made
Inspection can be classified into two types of inspection according to the
place where it is done, as is shown in Fig. 11.

Before
Beforethe
theprocess
process Source
Source
Inspection
Inspection
Inspection
Inspection --- Defect Preventive
At
Atand
and/ /or
orafter
afterthe
the
process
processResult
ResultInspection
Inspection
--- Defect Finding
At the process
At the next process
At the inspection on the line
At the final inspection

Fig. 11 Classification of inspection according to the place where it is done

Source inspection means the one which detects the cause of a
mistake in advance before it takes place and prevents it from
happening. For instance, to keep the line going, all the materials
fed to the line must be correct ones. That means, they must be
checked totally before they are put into the line in order to prevent
line stop. This inspection belongs to source inspection.

But in some cases, it is difficult to practice source inspection. Then,

result inspection must be done. This means that inspection is done
after production. So this can be referred to be a defect finding
inspection.
Result inspection can be classified into four types of inspection as
shown in the figure. To find a defect, the earlier, the better
because proper countermeasures can be taken more easily.
Thus, it is vitally important to do inspection within the process right
after operation.

To inspect all the items at the final inspection must be strongly

avoided. Inspectors cannot inspect quality in. The important
matter is that workers must build quality in during their work.
 cost of repair

At the process

At the next process

At the inspection at
the end of the line

In the market

Fig. 12 Cost of repair

4. Means of inspection
There are basically two means for inspection as shown in Fig. 13. Since
human beings are liable to make mistakes, it is always preferable to employ
physical equipment for inspection.
Inspection
Inspectionby
byphysical
physical
equipment
equipment

Inspection
Inspection

Inspection
Inspectionby
byhuman
human
sense
sense

Fig. 13 Classification of inspection means

(Principle 7)
As a means of inspection, some physical equipment must be
employed.
Fig. 14 Classification of Detection Measures (A)
Fig. 14 Classification of Detection Measures (B)
5. Necessity of introducing proof devices

Human beings make mistakes however hard they are trained not
to do so. Instead of setting an acceptable level of mistakes and
sticking to it, as statistical quality control teaches us, we should
develop specialty items - -fool proof devices that can alert an
operator to easily corrected but potentially troublesome defects
without unnecessarily shutting down the line -- and install them
where operators are liable to make mistakes.

(Principle 8)
Even if a certain mistakes rarely takes place, if it is caused by
careless mistakes, it must be eliminated by using fool proof
devices.
6. Worker’s roles and Foremen’s roles
(Principle 9)
If worker produces a defect, he must repair it even if it is a minor
defect. If he causes trouble, he himself must make up for it.

(Principle 10)
If insufficient repair is found out its countermeasures must be taken
immediately.

(Principle 11)
Standard operational procedure must assure 100% quality.
As far as workers strictly follow the standard operational procedure,
defects are not to be produced. Therefore, if defects are found out, it
means that
1. the workers have not followed the standard operation
2. material or parts have not been the right ones
3. machines, equipment, moulds, or jigs must have been broken
down.
Thus, it is possible to simplify the cause for defects.
(Principle 12)
The first thing that the foreman must do is to arrange the line in
such a way that “abnormality can immediately be seen visually”.
The following work quite well to check abnormality.
1. Determination of standard numbers of parts, products, inventory, etc
2. Standardized stores of material or parts
3. Introduction of kanbans
4. Paging mechanism
5. Stop buttons
6. Display panel
7. Classification of the storing place for defects
(Principle 13)
The mission of the foreman is to maintain quality and quantity and
improve the line.
1. He must always pay attention to the line.
2. He must train his workers at his successors.
3. He must see things with a broader view in order to make total
judgment.
4. He must not always stay in the line but it is neither good not to
stay in the line at all.
5. He must always try to make rationalization.
6. He must try to be in contact with workers in such a pleasant way
that they can work willingly.
7. If a trouble takes place, he must be informed and must be able
to eliminate the cause of it.
7. Economy of inspection
In machine processing of drills, reamers, or taps, it is well-known that in inve
rse proportion to the increased number of processed parts, the hole diameter
becomes smaller.
So considering this characteristic that the quality of parts changes as time pa
sses, sampling inspection of the parts in the sequence of their processing can
fulfill the same performance as total inspection.
That is, if the 50th product turns out to be a good one by inspection, then fro
m the 1st to the 49th products are assumed to be all good and if the 100th pro
duct is inspected as good, then from the 51st to the 99th products are taken a
s good. Even when the 100th product is found out to be defective, by checkin
g from the 51st product 100th product, the source of the defect can be found
out.
In usual sampling inspection method, products are picked up at random from
a lot for sampling inspection and based on the statistics of the result, quality c
heck is done.
The number of workpieces between one inspection and another is called quali
ty inspection interval or quality inspection number.
The quality inspection interval must be determined very carefully by tool life.
(Principle 14)
Processed lot in each process can be totally inspected by inspecting
the first workingpiece and the last one.

This rule holds true as long as the standard operational procedure is strictly c
arried out and the processes have been stabilized.

(Principle 15)
Latent defective causes will appear if the number of man-hour is red
uced. It is usually the case that the reduction of man-hour and the im
provement of quality goes together.
8. One-piece flow production

(Principle 16)
One-piece flow production makes it possible to discover defects in
the early stage. Inventory hides all the causes of defects. Especially
at the time of set-up for the new products, one piece flow production
means total inspection of the parts, processes and operations.

1. In the case of one-piece flow production, one defect means 100 %

defective, which also means the requirements of immediate
countermeasures. In the case of lot production, it takes some time
to find defects, which also makes it difficult to find out the causes of
the trouble and to take countermeasures.

2. At the time of launching a new product, it is especially important to

practice one-piece flow production.
9. Product liability
(Principle 17)
All the staff and workers must co-operate to carry out good quality
control and to supply customers with products free from trouble.

10. Right attitude toward zero human errors

The reader may easily notice such immediate ways of thinking as follows:
1. In order to eliminate mistakes, the workers must pay more attention.
2. Since we are too busy, it cannot be helped even if we have mistakes.
3. If defects happen to be produced, they will be rejected at the inspection,
so we do not care very much even if we produce some defects.
4. Since there are too many parts and products, it is natural that we happen
to mix them.
5. It depends on the skill whether the job can be done precisely or not.
Thus, it is natural that the results depend on the individual.
6. Although there is the standard operation procedure, will not follow it, but do
my job in my own way.
7. With such a small change, it is not necessary to inform the foreman of
the change.
8. Although it is rather difficult to do the operation, I am familiar with it, so it
is not necessary to propose a better way.
9. Although there is a quality sample, I do not need to look at it because
I am used to it.
10. Although there are everyday’s checking routines, I do not think I need them
as far as I pay attention to them when necessary.

These ways of thinking must be strongly eliminated for 100% quality control.
They are just hindrance to make improvement.

In conclusion, once the above principles are carried out, eventually defects
can be eliminated.

We do not need any sophisticated method, but just have to follow strictly the
above principles.
Chapter 5: Achieving zero human errors

1) Toward zero human errors

Growing capable Elimination of near misses

operators who do not
make mistakes Study meetings to eliminate human errors

Fool proof at the time of product changes

Fool proof at the time of changing

Introduction of equipment / doses
fool proof devices
Fool proof devices by proactive approach
to zero human errors

Eliminate unclear standard processes

Establishment of
standards Reconsiderations of standards for zero
human errors

Fig. 15 Toward zero human errors

2) Typical human errors

(1) Misjudge visual information

(ex.)
• Thermometer, pressure gauge.
• Check if the temperature is normal or not by looking at the
• thermometer chart in the control room.
• Check the pressure gauge of the reactor within the range of 1kg/cm2.
(2) Take wrong actions after receiving information

(a) There are time and distance lags.

(ex.) Receive information in the control room. (memorize)

Make a mistake in manipulating valves at the shop. (remind)

(b) Make mistakes in operating the equipment to reach a certain

target and in setting up.

(ex.) Open the valve by looking at the cumulative dose of

the measurement device.

Close the valve at a wrong timing.

(c) Convert the information into values and take actions.

(ex.) Make wrong calculations in determining the oil volume to
add by checking the oil level of the tank.
(3) Forget to do

There are time and distance lags.

Get occupied with other things.

(ex.) Open valves on the 3rd and the 1st floors.

After finishing another job, close the valve on the 1st floor
and forget to close the one on the 3rd floor.

(4) Make mistakes in measurement and / or preparation

(ex. 1) Choose wrong material.

(ex. 2) Choose wrong a measurement device.
(ex. 3) Choose wrong a packing material.
(ex. 4) Make a mistake in reading a scale.
3) Points of countermeasures

1st point: Make "the information" easy to see and read.

(ex. 1) Utilize not only letters but also marks, patterns and colours.

tank
tank

tank

(ex. 2) Clarify the range of normal standard.

Colour the gauge to clarify the

standard or normal value.
2nd point: Call the operator's attention when necessary.

(ex.) A buzzer sounds when the operator forgets to close the valve.
3rd point: Make a device in such a way as to control the action.

(ex.) Prepare a specific scale for each container.

4) Determine the basic conditions, etc.

As a prerequisite of making the “fool-proof device system”, it is

important to determine the “basic conditions of the workshop”.

(1) Stabilize the process operations

Troubles very often cause mis-operations directly, or indirectly.

It is inevitable to stabilize the process operations

・ Determine the basic conditions by inspecting

deteriorations at early stages, detecting small
defectives and carrying out thorough maintenance.

・ Investigate chronic defect.

(2) Secure the environment to be able to carry out accurate operations

Immature skills or irritation of operators may cause mistakes.

It is required to prepare comfortable working environments.

・ Promote 5S activities.

・ Prepare the manuals to cope with troubles.

・ Make every member of the workshop follow the manuals without

fail.
Leaders must take the lead to follow the manuals.

・ By clarifying unclear work assignment or procedures, standardize

operation.

・ Make the work flow clear so that the operation of the next stage
understands easily he has to do.
(3) Prevent mistakes in irregular operations

It is effective to predict or forecast mistakes.

By carrying TBM (Tool Box Meeting) before the operation,

confirm procedures or preparations, check mistakes which took
place in the past and arouse attentions.
 5) Various ideas to prevent human errors
1. Indication
ex.1 Indicate the kind of fluid and ex.2 Indicate the operating times
the direction of flow on pipes on switches

steam water

ex.3 Put labels of "open," "closed" ex.4 Indicate the specific range
on valves on the thermometer

right range

normal open
2. Marking
ex.1 Mark the bolt or nut ex.2 Put color sheet for the right range
at the fastened position on the gauge

ex.3 Mark the timing position of the gear wheels

3. Coloring
ex.1 Put good ones on the blue board ex.2 Distinct the kind of fluid
Put bad ones on the red board by color

good bad
yellow blue

steam water

4. Red tagging

Put a red tag on something to be noticed at a glance

5. Sizing
ex.2 Make internal and external
guides for packing

ex.1 Change mouth diameters

of hoses

NO NO
OK OK
ex.3 Change packing sizes of the
material of the same shape

material A material B

50 pieces 100 pieces

material A material B
6. Numbering

ex.1 Put numbers on the operation points ex.2 Put the same numbers on the
according to the operating procedure fronts of drawer boxes with the
operating procedure ones of the sheets
open ## valve
Form 1

Form 2

Form 3

ex.3 Put sequential numbers according Form 1

to the assembly sequence Form 2

Form 3
7. Sequencing

a method which prohibits the operator from digressing from the

predetermined sequence, thus helps avoid human errors.

ex.
Unless the 1st switch is put on, the 2nd switch cannot put on
(Interlocking system).
8. Putting things in order

ex.1 When all the holes are filled in with parts,

all the necessary parts are there.

ex.2 Draw a line on the spine of the files.

file
file
file
file
file
part storage table
9. Positioning
ex.1 Position the tools by drawing ex.2 Indicate shapes on the floor
shapes on the tool board. for storing materials.

spanner wrench hammer driver

10. Switch cover
ex.1 Put a cover on the switch box ex.2 Insert a cover to prevent the operator
and prevent the operator from from pushing wrong switches.
pushing switches.

on off

cover
cover
 11. Mask card

ex.1 Cover the control panel with a card

with proper openings.
ex.2 Confirm only the opening parts by
putting a mask card on the operation
control panel record.
mask card Operation record

product
name
line operator
mask card
the number
output of defectives

Only three switches can be put on and off.

12. Fail safe

No accident should happen with a fail safe device even human errors
take place.

ex.1 If the cover is taken off, the supply of power

to the machine is stopped.

ex.2 If a person comes into the vicinity of an unsafe area,

the machine will stop automatically.

Note: 1.Confirmation whether the device stands

for the safety side or not must be made.

2.The fail safe device must be checked

periodically whether it functions or not.
 13. Key
ex.1 Lock the door in such away that only ex.2 Lock the value.
the responsible person with the key Only the responsible person with
can get in. the key can change.

ex.3 Unless the key switch is unlocked,

the switch will not be put on.
14. One point manual
ex.1 ・ Operation can be done by referring to the manual.
・ Even a bigger can do easily and master the skill fast.

【 Jigger 】
small
small whisky
large natural water
large

Evian

tasty whisky
natural
【 glass 】 -and-water
water
a big piece of ice
15. Check list

・ Prevent misunderstanding, forgetfulness, misperception and ambiguity

by check list.
・ Abnormal situations can be detected by check list.

ex. 1 1. Standard operation procedure

2. Periodic inspection

3. Multi-items list

4. Multi-points inspection

Note : 1.One checking per one operation.

2. Use the same numbers to operations/machines
with the ones on the check list.
16. Double Check
ex. Confirm the matter with four eyes.
(The effect of confirmation by the same two eyes is limited.)
17. Alarm
ex.1 Abnormality can be detected without watching.
When the liquid level exceed the upper limit, there is an alarm.

abnormal!
the upper limit
of liquid level
warning buzzer

abnormal!

warning lamp
18. Calender
Periodic operations are clearly displayed on the calender,
thus it can be seen when the necessary operation will be carried out,
and missing some operations can be avoided.

ex. 1. Maintenance calender

2. Cleaning calender

3. Project calender

Note: Put it at the place where it can be seen at a glance.

 19. Penalty

An auxiliary method to let the people follow the rule.

It works to let the people remember the rule.

ex ex 2. If you are delayed for more

At a spare parts room than 10 minutes for a
1.
meeting, pay a fine of ￡ 1.
Final confirmation

Have you recorded what you

have taken from the room?

Fine:
￡1
If you forget : Fine of ￡ 10
 20. Automation

Eliminate human intervention to avoid human errors.

ex.1 Operate the pump automatically, ex.2 When bread is baked, the

depending on the liquid level of the tank. toaster will be turned off
automatically.
control
panel
【 Toaster 】

【 liquid level
gauge 】
6) Fool proof devices

1. due to wrong judgment of visual information

2. when action is taken after receiving information

Human errors
take place 3. due to forgetfulness

4. due to wrong measurement and/or preparations

5. due to carelessness and/or rough operation

Fool-proof

Mistakes shall not or do not take place !

Mistakes can be detected ( they become visible) The basis of fool-proof

Mistakes do not flow onto the following process

Alarming
Without paying a great attention,
occurrence of mistakes can be prevented Abnormal situation

Alleviation of attention Alarm the abnormality

Operation can be done easily and safely Alarm by buzzer and lamp

Stop the machine and give

Detection of abnormalities a warning !

Size, shape, weight, pressure and Prediction of

temperature abnormalities, warning

Adjustment/control

Stoppage of the line Mixed method

The line will not start The method which has

unless abnormalities are mixed the above devices
removed

Fig. 16 Concept of fool-proof/ improvement

 Defective
Fool proof Content of countermeasures
Phenomena
Prevention of Similar parts were ・ By standardization, common parts are used
loading wrong loaded ・ By changing shape/ size ( e.g., screw position)
parts of the parts, wrong parts cannot be loaded
Prevention of Parts were loaded ・ By changing the shapes of the parts ( e.g., the
loading parts reversely sizes in the right side and the left side), avoid
reversely loading the parts reversely
Prevention of One process of mac ・ By installing limit switches, change the
forgetting hining was left unope sequence by which the following process does
machining rated not operate unless the limit switch works
operation
Prevention of Sometimes wrong ・ Avoid machining wrong parts by detecting
machining wrong parts have been wrong shape by limit switches
parts machined
Prevention of Short or excessive ・ Cases are used to visually detect shortage or
wrong counting number of parts has excess of wrong parts
of parts taken place
Prevention of Without turning on ・ Make the conveyor system work in such a way
wrong the pressure-resistant unless the resistant-pressure switch is turned
operations switch, was started on, it will not start, or if the resistant-pressure is
not sufficient, the conveyor will stop
Fig. 17 Some examples of fool-proof
Fool proof devices

Even if human errors take place, no loss is generated

a safety device
an alarm
an alerting device
a safety proof device for other set conditions

Human errors

Near misses

Fig. 18 Heinrich’s Law

Error-Proofing System for preventing Mistakes in Number of Backplates Packaged

Before improvement After improvement

Errors in number of plates

packed were completely
eliminated

Graph of number of backplates packaging errors

Fig. 19 Error-Proofing System for Preventing Packaging Errors
Chapter 6: Typical classification of human errors in process industry

How and where do human errors take place?

The biggest percentages of the mistakes which take place at process industry are

(1) in manipulation of valves,

(2) in reporting and confirmation

and

(3) in inputting, setting up and measuring.

It is important to take effective measures

against “mistakes in manipulating valves”.
 Others (8.0)
Preparation (5.7)
Manipulation of valves (29.3)
Sub-assembly / assembly (8.1)

SW manipulation (13.9)
Reporting / confirmation (19.6)

Inputting, setting up
and measuring
(%)
(15.4)

Fig. 20 Clarification of human errors

These mistakes can be classified from the viewpoint of phenomena as follows:

(1) Mistakes caused by not doing what has to be done 48%

(2) Mistakes caused by mis-operation 23%

1) Human errors due to wrong judgment of visual information

Check “Open” or “Closed” of the ball valve at a glance

Improvement method:

By the direction of the cock, operators can see if the ball valve is open or closed.

Before
Directions of the cocks are
not standardized.

Points of improvement

Set the rule for the

directions of cocks
After

Directions of the cocks

follow the rule.
 Prevent mis-operation of stop valves

Improvement method:
Wind the stop valve shaft with colored alminium tapes when it is closed.

Before
Cannot check it the valve is open or closed.

Points of improvement

• Use the colored fluorescent

aluminum tape, which makes
it conspicuous in a dark place.
After
When the valve is open, the shaft with the • The other side of the tape
colored aluminum tape goes up revealing must be glued.
the inside without the colored tape.

When it is
closed.
 Prevent mistakes in choosing the right valve

Improvement method:
Put indications or colors on valves.

Before

The operator chose a wrong valve because there were no

indications on valves and the connected pipes.

To storage tank
After

・ Display the direction on

the head of the handle of
each valve.
・ Change colors according
to the directions.
 Prevent mistakes in judging whether the valve is open or closed

Improvement method:
The operator can judge at a glance whether the valve is open or not.

Before Since it was not easy to judge whether the stop valve is open or not,
the operator tried to open the open valve by excessive power and
broke it.

After

At the level where the valve is

closed,
1) Paint the screw.
2) Put a hose.
 Prevent mistakes in reading the gauge

Improvement method:
Adopt an easier method to read the graduation.

Before The gauge is graduated in 0 – 100%.

The operator makes mistakes in
converting the value into the actual one.

After The unit of graduation has been

changed into the one which can be read
directly without conversion.
 Prevent mis-operation of T type direction valve

Improvement method:
Put labels with different colors and letters on T type direction valve.

Rotate with the shaft.

Match the letters.

Wash
Match the colors.
yellow red red

ma
n uf a
c tu
re
yellow

Letters must be
representing the
name of the
operation.
 Prevent overlooking of the alarm lamp

Improvement method:
Classify the lamps.

Before At the time of changing product types, if several machines must be

stopped simultaneously or the temperatures of machines must be
changed, then alarm lamps switch on at one time, which makes it
difficult to distinguish them from the lamp alarming abnormality.

After For the lamps which are one to alarm specific phenomena,
indicate them by displays.

△temp.
○○STOP abnormal ▲STOP ▽STOP
Shortage
▽mixer ■■device ◆◆equipment OK!
STOP ▲STOP STOP STOP

☆☆tank ●●tank ▲temp.

○○STOP
abnormal temp. abnormal temp. ▲STOP abnormal
 Prevent overlooking of the alarm lamp on the panel of the control room

Improvement method:
Color the alarm lamps according to each system.

In order to start the operation of a machine of a

Before certain system after meeting the temperature
condition, the material supply start switch must be
switched on.
At this stage, the alarm lamp on the instrument panel
must be switched off in order to confirm the
completion of the necessary preparation for start up.
But the operator switched on the start button
overlooking a light being switched on.

After By standardizing the colors of the

alarm lamps following the systems, it t em
dev
ice
p. d
becomes easier to distinguish the rop

lamp being switched on.

 Prevent mistakes in reading the level of the supply tank

Improvement method:
Put a fluorescent float in the tank to ensure easy reading of KCL level.

Before Since it was not easy to check the level of the supply tank (500cc)
of the pH gauge, the person in charge dispatched a wrong
instruction without knowing the tank was empty.

1.0 + 0.3kg/cm3
After Put a fluorescent float in the KCL
supply tank and put graduations on
the outside of the tank.
KCL
Line the control line in red to indicate
the level where KCL must be
supplied. 500cc
2) Human errors when action is taken after receiving information
Prevent mis-operation of valves of branched pipes

Improvement method:
The cock cannot be removed unless the valve is closed.

Cannot be Can be removed

removed when when closed.
it is open.

Points of improvement

The valves without

Further application cocks mean they are
closed.

If there is only one handle,

material is supplied to one
tank only.
 Prevent mis-connection of hoses
Improvement method:
(1) Match with the same color.
(2) Classify the hoses by male and female connectors.
(3) Change sizes.
(4) Change types.

Kinds of improvement

(1) Match the (2) Introduction of

same color. male and
Blue
female
connectors.

Red

Cam-lock type (4) Change types.

(3) Change sizes.

Screwing type
 Prevent mistakes in putting back the taken samples from the process
back to the same group of products

Improvement method:
Each group is colored by a different color.

Before When the samples taken from a process

were put back to the process, they
became mixed with a different group of
products.

left
After Sample containers or check cards sample sample sample resin

are classified by different colors

for each group.
 Prevent mistakes in setting the valves of the measuring equipment

Improvement method:
Indicate the valves to set close to the measuring tool.

Before In case of the changes of production items, the set valves of the measuring
equipment must be changes. The person in charge tried to change the set
valves based on the daily report. But he made a mistakes in setting the valves.
Another operator could not detect the mistake.

After Put all the conditions which are

grade
recorded in the daily report onto
out put
a magnetic sheet and paste it on temp. temp. temp. pressure

the panel close to the

measurement tool.
Based on the sheet, changes in
the set values can be carried
out.

It has become much easier to

check if the set value is correct
or not without consulting the
daily report.
 Prevent mistakes in assembling shifters

Improvement method:
Put a slanted line on the side frame of the shifters.

Before Shifters were assembled in a

wrong sequence.

After Paint a slanted line on the side

frame of the shifters.
 Prevent mistakes in inputting

Improvement method:
Put confirmation items close to the 414141 display.

Before In progressing processes by computer display manipulation, the

necessary confirmation items were neglected.

After Indicate confirmation items for each

process close to the computer
display and input after checking all
the items.
 Prevent mistakes in pushing switches

Improvement method:
Classify the systems by colors.

In stopping one among several systems, the person in charge

Before pushed a wrong button and stopped a different system.

After All the switch boxes are classified

by colors and specific finger wrist
bands are prepared.
 Prevent mistakes in assembling parts

Improvement method:
Decide the storing places of removed parts.

After removing a plug, it was left on

Before the floor for a while. Another
operator could not find it, so he
used a different plug. As a result,
ruined the screw thread.
plug

After Storing cases are installed for

removed plugs and bolts.

bolt ca
se

plug case
 Prevent mistakes in pushing switches
Improvement method:
Install a device in such a way that only the right switches can be switched.

control panel

Before The operator pushed a wrong switch on

the control panel.

display lamp

switch

After Place a transparent acrylic cover on the control panel

control panel and put windows on the

right switches.
In changing the operations, change the
covers as well.
 Prevent mistakes in choosing the kinds of wire net

Improvement method:
Decide the storing place of nets and use kanbans.

Before In case of changing product types, several

shifters are dismantled at one time and wire
nets are changed.
The person in charge chose a wrong type of
wire net and assembled.

After Storing places for each type of wire nets wire net
are determined and indicated by kanbans.
 Prevent mistakes in setting the shifting switch

Improvement method:
Make the graduation of the shifting switch easy to see.

Before In switching the automatic valve in

the workshop by the shifting switch,
place the switch at the wrong
graduation due to difficulty in
reading the graduation.

After Make the indication board bigger and

the switch longer to show the
graduation clearly.
 Prevent mistakes in choosing a switch

Improvement method:
Place covers on the switch which is not in use.

Before When there were 2 different pieces

of material receiving equipments, A
and B, a confusion took place in
choosing the right switch.
stainless
cover

After There is no need of using A and B

at the same time. Therefore a
cover was placed on the switch for
B when A is in use. material
material
 Prevent mistakes in choosing valves

Improvement method:
Make a device in such a way that if a wrong valve is
chosen, the handle will not open.
to A to B to C
tank tank tank
Before Wrong valves were chosen from
the ones of the same shape and
same size.

After Make each spindle and handle of

the valve of different shape so that
only the specific handle can move machine
the valve.
ex

ex
2) Human errors due to forgetfulness
Prevent mis-operation of valves of branched pipes

Improvement method:
By changing two cocks together, they cannot opened simultaneously.
By chaining the valves, only one-side flow is secured.

Valves must be
handled by both
hands.

Don’t make the chain

too long.
 Prevent mistakes due to forgetting to close the valve

Point of attention:
Once one operation is finished, paying attention will move to the next operation.
Man is liable to forget to clear the previous operation.

Before Cleaning with water takes time. Moving to next operation, the
operator forgot to close the valve of cleaning water.

After The operator cannot leave the spot

during cleaning. A spring is installed
to the valve. Once operator’s hand is
off the valve, the valve will be closed.
 Prevent mistakes in operational procedure of handling valves

Improvement method:
Make operational instructions and operate by reading them
sentence by sentence.

Before There exists an operational manual, but it is difficult to read

sentences. The operator does not follow and forget some operation.

process of withdrawal

After Write out the operation procedure

procedures simply on cards. valve open

Take them to the work site valve open

and operate according to valve
them. open
4) Human errors due to wrong measurement and/or preparations
Prevent mis-adjustment of flow adjustment amount at the stop valve

Improvement method:
・ Change round handles of the stop valve into bar handles.
・ Eliminate adjusting by installing stoppers.

Before Stable flow adjustment was difficult with round handles.

Points of improvement

The handle cannot be

Install a stopper rotated more than once.
After
The valve is stopped at a fixed spot,
which ensures fixed flow adjustment.

Fix the bar

handle firmly.

Change a round handle into a bar handle

 Prevent mis-measurement by messcylinder
Improvement method:
Make each messcylinder for exclusive use.
(1) Mark the gauges and put the item name on.
(2) Color the bottom part of each messcylinder.

Common use Mistakes can take place in the measurement amount or the kinds of items.
errors

Check the amount

by looking at a table.

Specific use
Mark the gauges and
put the item name.

Identify by colors at the bottom of the

messcylinder.
blue
red
Color the bottom part.
 Prevent the measurement mistakes related to platform scales
Improvement method:
・ Make each measuring container for exclusive use.
(1) Indicate the item name and measurement volume on the container.
(2) Indicate the weight of the container on the container.
・ Indicate the total weight (weight of the measuring item + weight of the container)
on the scale.

Before
Measuring volume or item
can be mistaken.

Points of improvement

Specific container for

After specific item.
A 1.5kg
container 0.3kg
The weight of the
container (0.3kg)

Weight of the item

and the measuring
container (1.8kg)
 Prevention of mis-setting of the flow quantity

Object:
Prevent the mis-setting of flow quantity control valve.
Control the flow quantity by putting flow quantity control liners between the valve shaft.

If there are more than one

Liner for 1.8kl/h kind of flow, put different
flow quantity colors on the liners.

flow quantity
control valve
 Prevent mis-measuring of flow quantity by rotor meters

Improvement method:
Paste a sheet of white paper on the others side of the rotor meter and mark
the measuring quantity by writing a line on the gauge.

Before It was not easy to read the gauge without mistakes.

measure 960L/h.

After

Write a line on the gauge to show the measuring quantity.

A sheet of white paper

 Prevent mis-reading the gauge of feeding quantity of the tank

Improvement method:
Put a float in the gauge of the water storage tank.

Put a float in the gauge of the water storage tank.

A colored float
indicates the level
easily.

Water storage tank

The color of the float

must be determined
in such a way that it
can be easily seen.
 Prevent of over-storage of water in the water tank

Improvement method:
Put a water level control leveler in the water tank.

Water level is determined by a leveler A or B.

for higher water level

water level B

water level A

screwed screwed

drainage drainage
5) Human errors due to careless and / or rough operation
Prevent the valves from mis-opening
Improvement method:
・ Set the key to the valve. (ball valve)
・ Fix a nut to the valve. (stop valve)
By opening the valve, a trouble can take place.
Ball valve
Can be opened and closed. Set the key to the valve when it is closed.
trouble

Stop valve
When it is closed, remove the handle and fix a nut in the place.
 Prevent of leakage from tanks or manholes

Improvement method:
Put the matching point on the main body of the tank and the manhole.

Before

If it is not properly placed,

leakage takes place from the
lid packing.

After tank body

Put the matching point on the

tank and the manhole.

matching mark

manhole
 Prevent losses even if an error takes place

Improvement method:
Place a net at the inlet.

Before The operator drops a cup or a container into the tank by

mistake.

After Place a net at the inlet of

the tank.
Chapter 7: Action to be taken to eliminate human errors

Two approaches:

1) Pursing the causes of human errors and taking

countermeasures against them

2) Introduce visual control to avoid human errors everywhere

where there is a risk of creating a human error.
1) Pursing the causes of human errors and taking countermeasures against them

Mistakes must be eliminated

1
discovery of mistakes

4 2
prevention of recurrence pursuit of the cause

3
countermeasure and follow up

Fig. 21 Necessary steps to eliminate mistakes

Step 1

Mistake can be found at various places:

1. mistake to be found at the process

2. mistake to be found at the next process

3. mistake to be found at the inspection

4. mistake to be found at the final inspection

In principle, mistakes must be found out right after

they took place.
Step 2

By asking at least five times WHY , the causes of the

mistakes must be pursed.
The organization for pursuing the cause will be either:

1. by QC circle
2. by special
staff
Step 3

The proper countermeasures must be taken, and the

effects must be carefully followed up.
The following is a list of typical countermeasures:

1. improvement of jigs and tools

2. change of the operational method
3. improvement of everyday control method
4. improvement of the inspection method
5. change of the process
6. improvement of the checking procedure
7. change of the design
8. education of the operator
Step 4

Recurrence of mistakes must be prevented either

1. by mechanization (such as fool proof devices)

(preferable)
or
2. standardization.

And necessary information for preventing recurrence

of mistakes must be fed back.
2) Introduce visual control to avoid human errors everywhere where there is a risk of
creating a human error.

The check list of finding the necessity of introducing fool proof devices
Operation No Not Some Frequent
problem perfect trouble problem
but almost
OK
Choosing the right valve

Judging whether the valve is

open or closed
Reading the gauge

Give priority