Which conditions are obviously contributing to the symptoms? Basic Checks Was the Standard Operating Procedure being followed properly? Is the Operator correctly trained and do they have the skills to do this job? Is the equipment configured with the standard settings for this job? Do the raw materials meet the required specifications for the job? Has the problem been safely contained? Is the difference between the current & required conditions understood? Have obvious solutions been identified and tried? MAN Skills Experience METHOD SOP’s One Point Lessons MACHINE Condition Settings MATERIAL Specification Out of Date? Current Condition Is there an obvious cause? (look upstream and downstream) This problem occurred because of….? Which conditions are obviously contributing to the symptoms? CC Current Target Condition Revert to Standard Conditions Is the settings correct? Are procedures being followed? TC Target Condition Incremental Improvements Repair Equipment Problems Restore Standard Conditions Define The Problem Solution Hierarchy Mistake Proofing There are four approaches... Effectiveness Forced Control makes it impossible to make a mistake. Shut Down when rejects are found, Supervisor re-starts. Warning by use of sounds or lights or both Sensory Alert by use of colour, sound, vibration, visuals, 5S. Verify New Process How have we eliminated the problem? Did our countermeasures work? Have we verified elimination of the problem has been achieved? Do we need to update procedures? Do we need to train people to the new methods and machine settings? Are training records up to date? Do we need to review our Preventative Maintenance plans? Are Risk Assessments required? How will we audit and sustain the changes we have made? Eliminate the root cause to prevent the issue from re-occurring again. How has the solution been tested? How will it prevent re-occurrence? Elimination Substitution Isolation Effectiveness Engineering Controls Administration Controls Personal Protective Equipment