We Should Have Tried Mistake-Proofing…

            You don’t usually hear a lot of talk, even in lean circles, about poka-yoke, also known as mistake-proofing. Everybody tries 5S, and there are lots of other lean tools that have probably achieved greater prominence. I’m not sure if this is because many companies don’t bother with mistake-proofing, or simply don’t bother talking about it. Maybe they don’t regard it as important.

But there’s a company in Canada that I’ll bet has begun looking for ways to prevent mistakes, even if they’re not familiar with lean principles.

According to a recent news report from Reuters, a worker at Nova Chemicals Corp. in Corunna, Ontario, accidentally tripped a switch that shut down the factory’s entire manufacturing process, halting production and forcing two weeks of repairs.

The 1,000-employee plant is one of Canada’s largest plastics facilities, capable of supplying up to 40 percent of the country’s primary petrochemical market.

As a result of the incident, Nova says it will be unable to fulfill contracts for shipments of propylene and some other products, with delays extending through two quarters. Company officials estimate this will reduce profits by $11 million.


The switch in question exists so that anyone seeing a serious problem can shut down production. It was triggered by a contractor’s employee installing a structural steel platform. WHY he hit the switch is not yet clear, and Nova is conducting an investigation.

Let’s assume for the moment this worker did not press the button simply for the fun of it. At least for now, let’s say he meant to do something else and hit the wrong switch.

Maybe he was careless. Maybe he wasn’t paying as much attention as he should have. But I also have to believe that the switch wasn’t marked as clearly as it might have been, and perhaps was too easily accessible.

The best way to solve problems is to prevent them from occurring in the first place. Perhaps this story can serve as a wake-up call for those companies that have not made mistake-proofing a priority.

Otherwise, we’re likely to see more stories about $11-million-dollar mistakes.


1 comment:

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