from our weekly newsletter, The Visual Thinker

2016
Posted by & filed under Quality.

Mistake-Proofing Series Part 1 of 8. Read Parts: 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8

Print This Article Print This Article
A Note from Gwendolyn: From 2012-2014, Dr. Martin Hinckley (author of Make No Mistake) and I worked diligently to develop a unique and highly-effective training system for achieving defect-free production: The SMS Method for Perfect Quality, now available online for engineers and operators, and for training trainers. In this issue of The Visual Thinker, we begin a series of eight articles that Martin and I wrote on The SMS Method, under Martin’s signature.

We all make mistakes—things that are not a matter of bad thinking or bad process. Just mistakes. Do these look familiar?

  1. Pushing on a Door Instead of Pulling. Some unlucky bank robbers found a bank door mysteriously locked during business hours. The robbers shot the lock, but the door still wouldn’t open. Fleeing in desperation, they were soon captured. In frustration, the robbers asked what kind of amazing lock the door had that could withstand a bullet attack. The officer explained that the door opens easily if pushed rather than pulled. The bank robbers made a simple mistake.
  2. mistakesDialing the Wrong Phone Number. Have you ever clicked call when you wanted to text? Or selected the wrong person from your contact menu? Another mistake.
  3. Putting on Reading Glasses Instead of Your Regular Glasses? Ever put on your spouse’s glasses? Or put a left-hand contact in your right eye? These are mistakes!
  4. Trying to Put a Sock on the Wrong Foot? I included that as a joke because socks can go on either right or left feet (except for pantyhose). But I bet you sometimes put on socks that don’t match—and not on purpose! My wife makes it easy to get a matching pair by folding matching socks together.

Rare & Random

These are all common errors, hardly worth a mention because the consequences are minimal (except maybe for the bank robber). But conceptually speaking, simple mistakes just like these are the biggest quality problems companies face. The fact is even though mistakes don’t happen all the time, they add up to a lot of problems for everyone. It may not be a big deal if an operator puts an extra screw in a bin of screws—but if a doctor leaves a tool in a patient during surgery, it could be fatal. If a seal is left out of a faucet it may be fairly easy to get a replacement from the local hardware store—but consider the consequences of leaving a ripcord off of a parachute? These are similar mistakes, but some of them have huge consequences.

The good news is: Mistakes are rare. The bad news: They are also random. The combination of these two factors means trouble: It is notoriously hard to control mistakes for the very reason that they are rare—and they are random. We cannot predict them, ever.

One F117 fighter aircraft crashed because 4 out of 5 bolts holding one wing in place were missing! This defect resulted in a crash costing a $100M. Who would ever think that 4 out of 5 bolts could be left out of a wing assembly and the plane could even get off the ground? In the startup of Saturn Motors, a fluid was mislabeled—and so the wrong fluid was put into cars, causing them to fail. But no one could determine which cars had the wrong fluid and which did not. This cost $5B to fix.

Yes, mistakes are rare and random events—but they can cause major problems. Defects! But if we want to deliver outstanding quality, we need a way to detect—or even prevent—every kind of mistake. And that’s what this series (and The SMS Method) is about. It is time to revise our mistaken assumptions (no pun intended)—namely the things that popular practice tell us about both why and how poor quality happens and what to do about it.

The first step in achieving great quality is a clear understanding of the link between mistakes and defects. The second step is to know how to completely eliminate the defects caused by mistakes. When we transform our thinking, we transform ourselves–and fairly fast. Only then can we pursue a highly-effective approach to attaining perfect quality.

Remember: When we control mistakes, we automatically decrease the load, burden, and stress on everyone—and save enormous amounts of money. One such company reports that it completed 25 million operations without a single defect, but not through any form of SPC. They focused instead on the mistake-proofing principles and practices we write about in this series. Wouldn’t you like to learn more about how to achieve this? We dont just believe you can achieve defectfree work, we know you can!