1. 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Out of Date?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