Post on 14-Apr-2018
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Polaris Veritas, Inc.
Improving Operational Accuracy
A structured systems approach to
Mistake Proofing / ErrorReduction in the Process Industry
Surviving in a world dominated bylow cost Asian manufacturers
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Improving Operational Accuracy Becoming Aware of the nature of Errors
The role of Limbic Responses and how to mitigate the effects How we can change the expectations and behaviors of the operating team
Accountability and Mutual Support Checklists & 2 nd pair of eyes Measure Results
The When, How, Why and Who of Error Proofing Identifying Bear Traps we set for the average operator The Error / Defect pyramids The Potential Error Review Technique and ABC methodology Concentrating on the three weakest areas Poke Yoke, Checklists, 2 nd Pair of Eyes
Conservative Decision Making Management of Change Non Penal Leading Indicators short term reward
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PROGRAM JUSTIFICATION
Currently China and Asia in general havemanufacturing costs of 1/3 1/5 those ofNorth America and Europe
Hoping to survive most internationalmanufacturers have built plants thereusing the latest technology
Making the manufacturers decision tomove operations to China a difficult one
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Typical Reliability ImprovementPrograms Involve
Condition Based Maintenance
Work Planning and Scheduling
Multilevel Root Cause Analysis
Written Management Practices
Operator Asset Care
Reliability Centered Maintenance
Operational Accuracy Improvement - Mistake
Proofing / Error Reduction
Achieving better than < 1:400 errors OperatingAccuracy
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PROGRAM JUSTIFICATIONWorld Class Performance (
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REACTIVE
PROACTIVE
PRECISION
WORLD CLASS
OPERATIONS
Responsive
Work
Planned
Work
Proactive & Disciplined
Routine Problem
Solving
Problem Solving
Focused
Organizational
Learning
NATURE OF BEHAVIOR
OPERATIO
NAL
PERFORMANCE
PLANN
ED
Stable
Sustainable Cultures
TYPICAL ACTIVITIES FOR THE FOUR
STABLE OPERATING STATES
Lead/Com - 0
Planned work 24/yr.
ORIGINAL MAT BYLEDET ENTERPRIZES
Error Rate1: 40
Error Rate 1 : 400 +
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PROGRAM JUSTIFICATION
Operating Accuracy
(Responds poorly to more capital spending
and engineering)
Maintenance materials
Maintenance workmanship
Raw materials Equipment / Process Design
45% +
7%
18%
5%
25%
Published research discuss the five sources of defects :
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AWARENESS Everyone makes mistakes - our object is to
reduce the number and their impact usingteamwork and improved methods
There are no dumb questions
What we think we know but dont is mostdangerous
What is your current operational Error Rate?Probably 1:40 but it could be 1:400
What methods do you use for improving yourown accuracy? Defensive Driving
Improving golf
Having your spouse check what you have written
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AWARENESS In football nobody knowingly drops a pass
In life nobody knowingly makes an error
But there still are many dropped passes and errors
criticism & blame only makes matters worse
Refer to the www. Human Error. com
Professors Panko, Reppening, and Stout
www.serendip.brynmawr.edu
seeing is not believing
http://www.serendip.brynmawr.edu/http://www.serendip.brynmawr.edu/7/29/2019 Case Study for TPM Improving Operational Accuracy
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AWARENESSOur (societies) negative attitude to errors:
The banana skin
Funniest home movies
= Pain, weakness, shame and embarrassment
Cover it up as quickly as possible
Punishment has no place in the error reductionprocess
Preventing small errors from becoming defects
We are not fully responsible for our own actions
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STUDY ACTIVITY ERRORRATE
Baddeley & Longman
[1973]
Entering mail codes. Errors after correction. Per mail code. 0.5%
Chedru & Geschwind[1972]
Grammatical errors per word 1.1%
Dhillon [1986] Reading a gauge incorrectly. Per read. = 1 : 200 0.5%
Dremen and Berry [1995] Percentage error in security analysts' earnings forecasts for reporting earnings.1980 / 1985 / 1990. That is, size of error rather than frequency of error.
30%
52%
65%
Edmondson [1996] Errors per medication in hospital, based on data presented in the paper.Per dose. = 1 : 60
1.6%
Grudin [1983] Error rate per keystroke for six expert typists. Told not to correct errors, althoughsome did. Per keystroke.
1%
Hotopf [1980] S sample (speech errors). Per word 0.2%
Hotopf [1980] W sample (written exam). Per word 0.9%
Hotopf [1980] 10 undergraduates write for 30 minutes, grammatical and spelling errors perword
1.6%
Klemmer [1962] Keypunch machine operators, errors per character 0.02% to0.06%
Professor - Raymond Panko - The Human Error Expert
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Klemmer [1962] Bank machine operators, errors per check 0.03%
Kukich [1992] Nonword spelling errors in uses of telecommunication devices for the deaf. 40,000words (strings). Per string.
6%
Mathias, MacKenzie &Buxton [1996]
10 touch typists averaging 58 words per minute. No error correction. In last session. Perkeystroke.
4%
Mattson & Baars [1992] Typing study with secretaries and clerks. Nonsense words. Per nonsense word. 7.4%
Melchers & Harrington[1982]
Students performing calculator tasks and table lookup tasks. Per multipart calculation.Per table lookup. Etc.
1%-2%
Mitton [1987] Study of 170,016 errors in high-school essays, spelling errors. Per word. 2.4%
Potter [1995] Errors in making entries in an aircraft flight management system. Per keystroke. Higherif heavy workload.= 1 : 10
10.0%
Rabbit [1990] Flash one of two letters on display screen. Subject hits one of two keys in response.After correction. Per choice.
0.6%
Schoonard & Boies [1975] Line-oriented text editor. Error rate per word. 3.4% without correction, 0.52% with errorcorrection. an improvement of 500%
3.9%
Shaffer & Hardwick [1968] Residual typing errors per character. Subjects with error rates higher than 2.5% wereexcluded. All qualified touch typists, including excluded. 20 subjects finally used.
0.63%
Swain & Guttman [1983] Interpreting indication on an indicator lamp. Per interpretation. 1 : 1000 0.1%
Swain & Guttman [1983] Error reading an analog meter. Per read. = 1 : 333 0.3%
Swain & Guttman [1983] Choosing an incorrect panel control from a number of similar controls.Per choice.=1 : 333
0.3%
Swain & Guttman [1983] Error reading chart recorder. Per read. = 1 : 166 0.6%
Swain & Guttman [1983] Error reading a graph. Per read. = 1 : 100 1%
Swain & Guttman [1983] Turning control in wrong direction under extreme stress. Per turn. = 1 : 2 50%
Tsao [1990] Nonword spelling errors in uses of TDD (telecommunication devices for the deaf)130,000 strings. Per string.
5%
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MYSTERIES OF THE HUMAN BRAIN
FRONTAL LOBE HIJACKING - some less obvious possible causes of error
YOUThe Responsible
Frontal lobes
NEO MAMMALIANOuter sections
REPTILECore
L
IMBIC
DRIVES
Our 21 st Century brains crave limbicstimulation Action Movies, Thrillers etc
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AWARENESS The brain is essentially unchanged in 35,000 years Left Over'sCanine teeth, Tails, Sympathetic Yawning, Tonsils Limbic
responses Reptilian, Neo Mammalian These responses frequently control your mind - (cerebrum) rather than
you control it Your error prone brain uses complex task sharing and short cuts It cuts & pastes information to speed operation (schema) At any point in time it might have multiple mental processes going on
that you are not aware of We have little personal control of how and why the brain does all of
thisworry / preoccupado Even seeing shouldnt be believing Fatigue & Boredom makes the Limbic Hijacking Process more likely.
Drugs that improve itRitalin ?????
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YOUR LIMBIC RESPONSE WILLDRIVE YOU TO -
Conform to Group Behavior - Group Conformance In a group we assume that someone else will take care of a problem
- Sociproof Dilution of responsibility in the herd - Sociproof Try to achieve the highest possible status - Power Protect possession and Defend team members -Territorialism
(The home team usually wins) Sex drive - ?????
Fear and destroy anything different or that which might weaken the tribe- Security
THESE ALL HAVE NEGATIVE EFFECTS IN THE WORKPLACE
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When, How, Why, & What you can doto reduce the number and seriousness
of errors ??? When do the errors occur ?
How do the errors occur ?
Why do the errors occur ?
What is their nature ?
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WHENConditions for increased potential damaging event risk:Low Risk - STABLE OPERATION (95% - 5%)
Extended uneventful vigilance Getting locked into a sub routine (schema) Normal activity
High Risk - TRANSITIONAL OPERATION (5% - 95%) Start-Up and Shut-DownContinuous process plants Upset Operating Condition Emergency Operation Time of day / night High Fatigue
Overtime - extended periods without breaks
Counter progressive shift rotation Not warming up after long break
Unfamiliar Team Make Up Other High Stress
Concentrate improvement effort on transitional situations afteranalyzing error patterns
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WHYTypes of Deviation Errors
INTENTIONAL
OMISSION
COMMISSION
UNINTENTIONAL
DELAY MOVINGTO NEXT STEP
ADDING ALITTLE EXTRA
CATALYST
FAILING TOADD ANY
CATALYST
ADDING THE
WRONG MATERIAL
Sources Analysis of hundreds ofRCAs, CMA,
HOW
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WHEN
EXTREME STRESSAND THREAT
APPROACHINGLOSS OFOPERATING
NORMAL ACTIVITY
LOW STRESS
UNEVENTFUL
OBJECTIVE
< 1: 400WORSENING
PERFORMANCEEFFECTIVENES
S
(errorrate)
TASK LOAD
& FATIQUE
1:2 5 (ORWORSE)
CONTROL
HIGH STRESS
UPSET
CONDITIONSTART UP / SHUTDOWN
ACTUAL
< 1: 250
MODERATESTRESS
EXTENDED
VIGILANCE -
INATTENTIVE
BLINDNESS
THE FREQUENCY OF OPERATING ERROR (THERP)
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WHEN START ++++ HIGH RISK
RELIABILITY / LIFE REDUCING STEPS
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IMPROVING THE SITUATION
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Operating Accuracy - Creating an Error Free
Environment
You need to learn from the mistakes of others, youllnever live long enough to make them all yourself
Maybe it was time that we stopped shouting at thedarkness and started lighting candles?
understanding the other guys problem
Nobody ever gets credit for fixing things which didnthappen!
Organizational Transparency is enough to drive theimprovements we seek?
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FATALITIES
SERIOUS
MINORS &NEAR MISSES
UNSAFEBEHAVIOR
CATASTROPHICFAILURE
MAJOR UNPLANNED
PROCESSINTERUPTION
MINOR DEFECTS
EXTENDED PLANTS/D
SERIOUS PROCESSUPSET
MINOR DEVIATION
POTENTIAL ERRORSUNDETECTED
PRODUCT RECALL
MAJOR ISSUEBEFORE DELIVERY
ISSUE DETECTEDBUT RECOVERABLEIN PART
UNRECOGNIZEDDEFECTS
1
7
3500
35000
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ERROR ANALYSIS - TRIANGLES
In each case, reducing the size of thetriangles base, reduces the frequency ofall the categories of defects
i.e.THE TYPES OF MINOR ISSUES ARE INDICATORS OFLARGER ISSUES
The need to permanently influence /change the behaviors causing the problem
by measuring performance and givingpositive feedback
Non penal
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Who sees ERRORS
VISIBLE
INVISIBLE
8 of 39,000
POTENTIAL ERRORS
THE ERRORS A REGULAROPERATOR SEES
Need Root Cause Analysis$$$$$$$$$$
MINOR ERRORS
SERIOUS
MAJOR
WHAT THE TRAINED
OBSERVER SEES
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SOME TYPICAL OPERATIONAL DEFECTS
1. Missing a step from a procedure 2. Misreading a gage Not sealing (or reporting) process
leakages - blockage 3. Using incorrect tool or apparatus 4. Over / under fills vessel or tank 5. Not receiving or passing on a report
from interfacing shift team 6. Transposing digits in a number series 7. Incorrectly positions valves 8. . Repeatedly resetting an alarm or
other protective devices without action 9. Slow delayed required action 10. Not turning off idle equipment 11. Not making a decision when one
was required 12. Ignoring a process oscillation /
instability 13. Failure to notify others of observed
defects 14. Misunderstanding a request and not
asking the instructor to repeat request Change room shift changeovers
16. Operating equipment withoutunderstanding or authority not havingbeen trained
17. Not leaving something in a securemode
18. Operating something too fast or slow 19. Removing a safety device or
identifying tab 20. Operating equipment known to be
defective without reporting it 21. Improper feed rate or load 22. Adding wrong material to batch 23. Working on equipment while it is
running 24. Not referring to operating procedures
as required 25. Not using (and signing) the correct
checklist where one exists 26. Not preparing equipment / work
permits for repair after written request 27. Not understanding and being afraid
to ask about the chemistry or physicsinvolved
28. Interrupting another person in the
middle of a complex task
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THE IMPROVEMENT PROCESS
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The Process of Mistake Proofing / Error Reduction
Potential Error Review Technique
The program aims to collect Comprehensive Data provided primarily but notexclusively by operators on the potential error forms
The defect data is then analyzed and classified - ten buckets Assign a proven Resource / Technique / Technology to address each
source of the defects Using the ABC - behavioral-based safety principle of implementation
Antecedent BehaviorConsequence..C B A
i.e. Starting with consequence (the screw up) move to the behavior whichpreceded it and finally to the Antecedent .the condition whichfundamentally set it up to happen.
Only dereliction of duty will bring serious sanction sleeping on job, maliceetc. Management must be commitment to a multilevel team based non penalinitiative
The concept of taking increasingly conservative actions as stress increases is
critical
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POTENTIAL ERROR REVIEWTECHNIQUE
Has at its core three questions:
When would a new operator be most likely to make a mistake?
What bear traps have we inadvertently created that the newoperator might step on or fall into?
What errors or potential errors have you recognized in the lastshift cycle?
With that knowledge classify the errors and act to reduce them
with specific narrowly focused techniques
STICKY LABEL
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COLLECTING DATA - ANY OBSERVEDACTUAL SITUATION OR ACTIVITY WITH
POTENTIAL FOR ERROR
WEEK ENDINGSHIFT(Optional)
MAXIMUM OF THREE ASSOCIATED DEVIATIONS
ANALYSIS COLUMN LEAVE BLANK
DESCRIBE SITUATION OR INCIDENT (50 WORDS) DO NOT INCLUDE NAMES
Hey ! This looks like an bear trap to me ?
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THIS IS A BEAR TRAP
WEEKENDING
SHIFT
MAXIMUM OF THREE ASSOCIATED DEVIATIONS
ANALYSIS COLUMN LEAVE BLANK
DESCRIBESITUATION OR INCIDENT (50 WORDS) DO NOT INCLUDENAMES.
The temperature gauge on the # 3 hot oil header is obscured bydirty oil on the face and is reading 50 F degrees low THIS IS A BEAR
TRAP REPORT(potential error)
# 8431
# 8431
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ANALYTICAL METHODOLOGY
Having achieved AWARENESS we drive thechange using -
ANTECEDENT Anything which precedes andtriggers the imperfect behavior
BEHAVIOR An observable act which is error prone
CONSEQUENCE Anything which directly followsfrom the Behaviors Creates a potential for error
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THE LINK BETWEEN RCA AND ABC
ABC Root Cause Analysis
(Small Issues) (Big Issues)
ANTECEDENT. LATENTCY
BEHAVIOR HUMAN FACTORS
CONSEQUENCE CAUSE
DEFECT CLASSIFICATION THE TEN BUCKETS
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DEFECT CLASSIFICATION THE TEN BUCKETS
1. Not understanding or participating in structured defect recognition & elimination
2. Lack of clear work instructions Cluttered Presentation Confused Priorities
3. Inadequate person to person & person to group communication
4. Insufficient individual knowledge, accountability & skills training
5. Inadequate tools & equipment
6. Lack of a well defined standard of performance
7. Lack of personal capability / attention / attitude / hurry / overload
8. Lack of understanding of the risk of and management of change
9. Insufficient recognition of appropriate effort *
10. Lack of Tactical Administration, Conservative Decision Making & Leadership (vision) *
* These are linked
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IMPLEMENT PROGRAMS IN COMBINATION1. Structured defect recognition & elimination (Counter Intuitive Aspects)
2. Write clear work instructions Remove cluttered presentation and confused priorities
Look for Poke Yoke opportunities
3. Create written standards for person to person & person to group communication
4. Assign accountability, provide appropriate training and testing
5. Asses the need and provide tools & equipment
6. Write a series of defined operating standards incorporating the 2 nd pair of eyesconcept
7. Minimize periods of / hurry / overload by improved planning and seek ways to showthat changes in individual and group attitude can improve job satisfaction
8. Educate the team in the risks of Management of Change and Conservative DecisionMaking
9. Educate the supervisors and team members how to recognize and reward appropriateeffort *
10. Educate the team so that they can positively influence the Leadership Vision: andday to day - Tactical Administration *
h l d l
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The Role Model Operator Has early recognition of small but abnormal
incongruous conditions
Routinely checks himself and others
Takes appropriate action based on aConservative Decision Making Process
Is comfortable with the consequences of acting
more slowly when fatigued or under stress
Communicates critical information in writing
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A FEW EXAMPLES
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Consequence Operator misses a step in aninfrequently practiced procedure
Behavior He never refers to the out-of-date SOPs and hasno consideration of Self Checks or 2 nd pair of eyes
AntecedentThe SOPs are inaccurate + I know the job.
(Added to much or too little, didnt understand consequence of increased volume)
DEFECT CLASSIFICATION Primary Defect - Lack of available clear work instruction (5)
Secondary Defect - Lack of positive attitude and personalattention (3)
Contributory defect - Insufficient individual knowledge (1)
OLD STYLE OPERATING PROCEDURE
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OLD STYLE OPERATING PROCEDURE
IF THIS WAS A HIGH SCORING DEFECT
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IF THIS WAS A HIGH SCORING DEFECT
Have operators rewrite the operating procedures in TabularSimplified Pictorial format
Simplified using road signs
TabloidT bar Pictorial pictures and diagrams
These would incorporate extensive use of OperatingChecklists during the periods of greatest risk
Write separate sections in procedure documents dedicatedto dealing with Transitional Difficulties and Troubleshooting written by operators for operators
PICTORIAL TABLOID PROCEDURE FORMAT
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PICTORIAL TABLOID PROCEDURE FORMAT
STEPS DETAILS
CONSEQUENCES OF
DEVIATION
IF: An overcharge occursTHEN: temperature control can
be lost
1. Open water charge valve and add100 gallons of water
2. Open acid valve and add 5gallons of 30% acid over 5minutes
3. Charge 80 lbs of catalyst throughman way
4. Start Agitator
The water valve number V-132 , turn onefull turn clockwise to ensure that
it is fully closed after chargingWATER
The acid valve is a quarter turn ballvalve. It must be fully open ( handle isin-line with the pipe)
DO NOT: Delay starting the agitator itmust be started within one minute ofcharging catalystCONSEQUENCE: The vessel outlet willbe plugged and an uncontrolled reactioncould occur
w
CHECKLIST
PLUS DIAGRAMS
B OPERATOR
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STEPS
1. Open water charge valve and add 100gallons of water
2. Open acid valve and add 5 gallonsof 30% acid over 5 minutes
3. Charge 80 lbs of catalyst throughman way
4. Start Agitator
* Step doesnt say start immediately
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A SECOND EXAMPLE OF ERROR CLASSIFICATION
Consequence 2 nd shift double charged catalyst
Behavior Relying on verbal - Casual word of mouth communication
AntecedentHe thought that telling Joe was adequate
(The operator was in a hurry to get home)
DEFECT CLASSIFICATION
Primary defect - Deficient person to person & person to group
communication Secondary - Lack of a Defined Standard of Communication on Shift
Change both verbal and documentary
Contributory - Lack of positive attitude and personal attention
CORRECTIVE ACTION THE TEAM WOULD CREATE A
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CORRECTIVE ACTION - THE TEAM WOULD CREATE ANEW PERFORMANCE STANDARD
Deficient person to person or person to groupcommunication
Remedial action write and implement new standardinvolving the following -
Person to Person Communication Standard
Formal (written) shift change communication Best Practice isadhered to
There are no change room exchanges The relief shift supervisor starts 30 Mins before his crew
Written mandatory electronic shift logs with routine review Individual operators to routinely check each other whileperforming complex tasks
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Periodical Self Audits AgainstWritten Standards
A Performance Standard for Operations
EXAMPLE
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OPERATIONAL ACCURACY PERFORMANCE STANDARD EXAMPLEHow will we know when we are successful?
100%100%100%100%100%100%
80%
100%100%100%100%
90%
90%90%100%80%50%
80%90%60%
1.S O Ps accuracy and claritySOPs are in Simplified /Tabular/ Pictorial format.Multiple checklist are in routine useMarking/Clarity, Accessibility and Orientation of Controls is excellent.Possibility of accidental activation is eliminatedCritical settings are secureEmergency Controls clearly markedAmount of force / effort is appropriate
Bear trap stickers are applied when potential errors are recognizedPoka Yoke techniques are used
2.Personal and group communicationGroup Communication
With the creation of Transparency rather than impose punitive disciplinereviews are made against a Formal Written standard for Groupcommunication -
Daily 24 hour operating reviewProduction/ Maintenance - daily planningMonthly defects checklists are usedMonthly issues are formally ANALYZED and reviewedPlant Managers communication
Person to Person CommunicationFormal (written) shift change communication Best Practice is adhered toThere are no Change room exchangesElectronic shift log analysisThe relief shift supervisor starts 30 Mins before his crew Individual operators routinely check each other while performing complex tasks
Observed
Level of
Success
Target
Level of
Success
Work Process Measure
SUSTAINING THE CHANGE
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SUSTAINING THE CHANGE The Hawthorn Effect
What gets measured, most often, gets improved+ leading indicators
Monthly Data shortest practical period
Requires that feedback be
SOON - CERTAIN - POSITIVE(rather thanlate occasionalnegative)
Peer (trained observer) to Peer immediate
Kaizen Team Based approach Leading Indicators Short term reward - Points
systemgain share..
Periodic Audit
TIMING - WHEN TO ATTEMPT
OPERATIONAL ACCURACY
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Responsive
Work
Planned
Work
Proactive & Disciplined
Routine Problem
Solving
Problem Solving
Focused
Organization
Learning
NATURE OF BEHAVIOR
OPERATIONAL
PERFORM
ANCE
REACTIVE
PLANNED
PROACTIVE
PRECISION
WORLD CLASSOPERATIONS
OPERATIONAL ACCURACY
IMPROVEMENT
OD < 100 points
Lead/Com - 0
Planned work 250 points
Lead/Com 100%Planned work >95%
PdM based >75%
BP/RCA implemented /
shared
>24/yr.
ORIGINAL MAT BY
LEDET ENTERPRIZES
REVIEW
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REVIEW The significance of Improving / Understanding
Operating Accuracy and how it compliments overall
reliability improvement programs Having operators own the improvement process Getting rewarded for driving slower when under stress The underlying conceptsErrors are everywhere
(Panko) Who, when & why the errors are made Collecting details and classifying them by type Narrowly focusing on the most common ten
classes of defect and what we can do to reducethem
The ABC methodology: Antecedent Behavior- -Consequence
The difficulties of Implementation - Trainingoperators as observers
Provide feedback using Leading Indicators
AWARENESS
TECHNIQUE
1
TECHNIQUE2
PROGRAM SUMMARY
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PROGRAM SUMMARY Awareness Problem Prevention Understanding and dealing with your Limbic Responses
Change expectations and behaviors Accountability and Mutual Support Checklists & 2 nd pair of eyes Measure Results
Identifying Bear Traps Analytical technique - The Potential Error Review Technique - ABC Root Cause Analysis After analysis concentrate on the three weakest areas Poke Yoke, Checklists, 2 nd Pair of Eyes Management of Change Conservative Decision Making Non Penal Kaizen - Team based approach Leading Indicators short term reward 2 5 year implementation
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AN E-MAIL SURPRISE
A Recent Message from a Christian Friend
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A Recent Message from a Christian Friend CHRISTIAN WAYS TO REDUCE STRESS
An Angel says, "Never borrow from the future. If you worry about what may happen tomorrow and it doesn't happen, you haveworried in vain. Even if it does happen, you have to worry twice."
1. Pray
2. Go to bed on time.
3. Get up on time so you can start the day unrushed.
4. Say No to projects that won't fit into your time schedule, or that will compromise your mental health.
5. Delegate tasks to capable others.
6. Simplify and unclutter your life.
7. Less is more. (Although one is often not enough, two are often too many.)
8. Allow extra time to do things and to get to places.
9. Pace yourself. Spread out big changes and difficult projects over time; don't lump the hard things all together.
10. Take one day at a time.
11. Separate worries from concerns. If a situation is a concern, find out what God would have you do and let go of the anxiety. If youcan't do anything about a situation, forget it.
12. Live within your budget; don't use credit cards for ordinary purchases.
13. Have backups; an extra car key in your wallet, an extra house key buried in the garden, extra stamps, etc.
14. K.M.S. (Keep Mouth Shut). This single piece of advice can prevent an enormous amount of trouble.
15. Do something for the Kid in You everyday.
16. Carry a Bible with you to read while waiting in line.
17. Get enough rest.
18. Eat right.
19. Get organized so everything has its place.
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20. Listen to a tape while driving that can help improve your quality of life.
21. Write down thoughts and inspirations.
22. Every day, find time to be alone.
23. Having problems? Talk to God on the spot. Try to nip small problems in the bud. Don't wait until it's time to go to bed to try andpray.
24. Make friends with Godly people.
25. Keep a folder of favorite scriptures on hand.
26. Remember that the shortest bridge between despair and hope is often a good "Thank you Jesus."
27. Laugh.
28. Laugh some more!
29. Take your work seriously, but not yourself at all.
30. Develop a forgiving attitude (most people are doing the best they can).
31. Be kind to unkind people (they probably need it the most.
32. Sit on your ego.
33. Talk less; listen more.
34. Slow down.
35. Remind yourself that you are not the general manager of the universe.
36 . Every night before bed, think of one thing you're grateful for that you've never been grateful for before. GOD HAS A WAY OF
TURNING THINGS AROUND FOR YOU. "If God is for us, who can be against us?" (Romans 8:31)
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Questions ?
For a copy of the updated paper or thePowerPoint presentation please email
me at
polarisver@aol.com
A just discovered conceptA second pair of eyes
POLARIS VERITAS INC
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POLARIS VERITAS, INC.(Stellar North)
Reliability andProcess Safety
Consultants
Houston, Texas, USA
Phone: (01) 281 280 0550Polarisver@aol.com
Driving your Manufacturing
Efficiency to World Class
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BACK UP SLIDES
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SO YOU THINK SEEING IS BELIEVING
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The Hole in the Retina
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Going up or Down ?
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Front or Back
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Curved or Straight Lines ?
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Gray Dots ?
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WHO DO YOU THINK YOU ARE?
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Brain Structure FunctionAssociated Signs and Symptoms
of Damage
YOU
The outermost layer of the cerebralhemisphere which is composed of graymatter. Cortices are asymmetrical. Bothhemispheres are able to analyze sensorydata, perform memory functions, learn newinformation, form thoughts and makedecisions.
Left Hemisphere Sequential Analysis: systematic, logical
interpretation of information. Interpretationand production of symbolic information:language, mathematics, abstraction andreasoning. Memory stored in a languageformat.
Right Hemisphere Holistic Functioning: processing multi-sensory input simultaneously to provide"holistic" picture of one's environment.Visual spatial skills. Holistic functions suchas dancing and gymnastics are coordinated
by the right hemisphere. Memory is storedin auditory, visual and spatial modalities.
CORPUS CALLOSUM
Connects right and left hemisphere to allowfor communication between thehemispheres. Forms roof of the lateral andthird ventricles.
Damage to the Corpus Callosum may result in "SplitBrain" syndrome.
CEREBRAL CORTEX
Cognition and memory.Prefrontal area: The ability to concentrateand attend, elaboration of thought. The"G t k " (j d t i hibiti )
Impairment of recent memory, inattentiveness,inability to concentrate, behavior disorders, difficultyi l i i f ti L k f i hibiti
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Basal Ganglia
FRONTAL LOBE
"Gatekeeper"; (judgment, inhibition).Personality and emotional traits.Movement:Motor Cortex (Brodman's): voluntary motoractivity.Premotor Cortex: storage of motor patternsand voluntary activities.Language: motor speech
in learning new information. Lack of inhibition(inappropriate social and/or sexual behavior).Emotional liability. "Flat" affect.Contralateral plegia, paresis.Expressive/motor aphasia.
PARIETAL LOBE
Processing of sensory input, sensorydiscrimination.Body orientation.
Primary/ secondary somatic area.
Inability to discriminate between sensory stimuli.Inability to locate and recognize parts of the body(Neglect).Severe Injury: Inability to recognize self.Disorientation of environment space.Inability to write.
Primary visual reception area.
Primary visual association area: Allows for
visual interpretation.
Primary Visual Cortex: loss of vision opposite field.Visual Association Cortex: loss of ability torecognize object seen in opposite field of vision,
"flash of light", "stars".
Auditory receptive area and associationareas.Expressed behavior.Language: Receptive speech.Memory: Information retrieval.
Hearing deficits.Agitation, irritability, childish behavior.Receptive/ sensory aphasia.
THE UNDER.ESTIMATED LIMBIC YOU
Olfactory and their different pathways.Hippocampi and their different pathways.
Limbic lobes: Sex, rage, fear; emotions.Integration of recent memory, biologicalrhythms. Hypothalamus.
Loss of sense of smell.
Agitation, loss of control of emotion. Loss of recentmemory.
Sub cortical gray matter nuclei. Processinglink between thalamus and motor cortex.Initiation and direction of voluntarymovement. Balance (inhibitory), Posturalreflexes.Part of extrapyramidal system: regulation ofautomatic movement.
Movement disorders: chorea, tremors at rest andwith initiation of movement, abnormal increase inmuscle tone, difficulty initiating movement.Parkinson's.
What makes o niq e Aptit des & Attit des
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LIMBIC
DRIVES
HIGH
MEDIUM
LOW
PURPOSE SOCIAL POWER SEXUAL TERRITORIAL SECURITY
FUNCTIONALPROGRAMS(INATEABILITIES)
PHYSICALDEXTERITY
INTELLIGENCE
MEMORY
LANGUAGE
ENERGY
SENSITIVITY
PHYSIQUE
ANGERCONTROL
What makes you unique Aptitudes & Attitudes
WHAT IS PROVIDED?
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WHAT IS PROVIDED?Training and Implementation Support using proven programs
First we create awareness of an error filled environment
Describe the negative aspects of the Limbic Responses
Implement a program to recognize and remove the errors
Calculate the cost of actual and potential errors
Implement programs to address the Ten defect areas to include
1. Simplified pictorial, tabular, procedures writing
2. Coaching and checking one another in error reduction
3. Improving accurate communication both individual & group
4. Creating a 1:400 error performance standard
5. Describing appropriate decisions & leadership6. Simplifying methods and equipment marking
7. Formally solving associated problems at all levels
8. Identifying and minimizing contributory system instabilities
9. Dealing with changes in processes and people