Here's how you can learn effectively from mistakes in manufacturing operations.

Um erro é a oportunidade de fazer melhor o que você está fazendo atualmente! Se há espaço para acontecer um erro, é possível que a análise de risco não tenha sido realizado com a abrangência necessária. Volte ao início e recomece! Aprenda com essa oportunidade e ensine os outros. Dessa forma haverá um circulo de aprendizado que partiu de um erro/oportunidade.

Errors can appear in value stream through a number of sources. An error may occur at any stage in the value stream. An error may occur in an equipment, in the raw material, in the process or during human intervention as well. In todays times the use of advanced technology has improved the manufacturing quality of almost every process to a greater extent. Almost every error avoidable, can be corrected and almost every process can be improved & optimized. It is evident that it is not only the technology which makes a manufacturing process great and error-free. A good team that own the process also plays an important role in the quality. A great workforce coupled with use of great technology makes a manufacturing process great and error-free.

To my mind, there are a few items to learn from the mistakes in the manufacturing process: - Behavior in front of errors - we need to have the right reaction when errors are revealed. Consider them as opportunities for improvement - Having the right approach. If the problem is complex and/or critical, it takes structured problem solving approach such as 8D so that there is a structured team-based approach and we don't jump to superficial causes and solutions. - If the errors seem human related, Human and Organizational Factors need to get analyzed. - Identify and implement lessons learned and make sure that the corrective actions are permanent, simple and efficient

The errors always are in the production lines, and these errors show up in different aspects, could be: Method / Material / Machinery / Men power (4M's). So, in my personal point of view is work in the prevention, and analyze the errors independently if they are minimum, any application works the most important is create the team and be constantly analyzing and sharing the lessons learns with the team that need to be involved.

Keep asking “why” until you understand. Too many times people look to a procedure or process to solve the issue. Ironically, it was a procedure/process that failed. Understand the failure then write a problem statement. The problem statement reinforces that you truly understand the failure. Then give the problem statement to everyone involved in the process/procedure and request feedback.

Ask why until you get to the root cause. Then update all procedures and work instructions accordingly. The error more than likely was something missed in the procedure. A lessons learned type meeting to discuss what happened and how to correct it, is something that we always do.

Uma vez identificado um erro, é essencial realizar uma análise completa para descobrir suas causas subjacentes. Técnicas como os "5 Porquês" são muito úteis nesse processo. Por exemplo, se um defeito no produto for detectado, pergunte repetidamente "por que" ele ocorreu, aprofundando-se em cada resposta até chegar à causa raiz do problema. Esse método ajuda a garantir que as soluções implementadas abordem a causa real, em vez de apenas tratar os sintomas superficiais.

Its been my experience as a manufacturing specialist and trainer when errors are identified a team must be formed, this team must include every person involved in the process! when changes are made you need every ones input. the people doing the job have the best insight and are your best resource to overcome mistakes and implement changes.

Depois de identificar a causa raiz de um problema, é crucial implementar mudanças eficazes para prevenir erros futuros. Isso pode incluir a atualização de procedimentos operacionais padrão, investimentos em novos equipamentos ou fornecimento de treinamento adicional para a equipe. É fundamental comunicar claramente essas mudanças e garantir que todos os envolvidos compreendam e adotem as novas práticas. Isso facilita uma transição suave e aumenta a eficácia das medidas preventivas implementadas.

Develop and execute a plan to address the identified causes. Make necessary adjustments to processes and systems.............

After identifying the root cause, The corrective actions and Implementing changes should be transparently implemented at all levels. All the Records should be documented, and necessary procedures should be updated. All records should be maintained as knowledge packages based on the PDCA cycle, including control equipment, mistake-proofing, necessary training, etc. In our organization, from the time of the failure occurrence, the problem-solving process information is displayed visually at the location of the failure. This ensures that all individuals involved in the process are informed and understand the situation. Through our change management process, we oversee the facilitation of information transfer and adaptation to new procedures.

At the initial stage implementation in any process or operation can take some time for setting up. One has to have proper map of operations stage by stage,by using engineering concept we can implement small small process at a time. But after implementation give some time for the results not to accept sudden success in process line or any other plans, must have proper data records of before and after implementation results, according to it one should take steps consulting with superior and also by training employees. Lots of implementation time to time can also affects the manufacturing process give some time for process and you will indirectly can learned from it and understand loophole.

As part of the pin pointing, you MUST have demonstrated you can turn the issue on and off at will. Failure to do this leaves you open to justified criticism if the issue returns. It goes without saying that the communication must be made with the additional monitoring in place for a significant time period (weeks or months rather than hours). There are few things that impact any engineering professionals career than the ‘half a job’ moniker so take the time to ensure the issue has been resolved.

Monitoring of results after implementing changes is crucial for the effectiveness of corrective actions. Immediate and continuous monitoring ensures that solutions not only address the current issue but also prevent future problems, demonstrating a commitment to continuous improvement. Using KPIs related to the mistake to track progress is a practical approach. This ensures that monitoring is objective, measurable, and focused on the critical aspects of the problem. We have also defined indicators for the process of following up on corrective actions. The idea of making further adjustments if necessary indicates a flexible and adaptive approach to problem-solving. This shows that the process is dynamic and responsive to changing conditions.

Track the effectiveness of implemented changes using real-time data and analytics. Ensure that the solutions are working as intended.

I’ve mentioned previously about monitoring so have copied over. Additional monitoring must be in place for a significant time period (weeks or months rather than hours). There are few things that impact any engineering professionals career than the ‘half a job’ moniker so take the time to ensure the issue has been resolved.

The most important lesson to be learnt is to not say it unless you really mean to embrace it. To do this effectively you must be 100% certain that you have all of the contributing root causes understood with proven corrective actions and monitoring systems in place. You need to be focussed on knowing you have the root cause and not symptoms of it. Most issues have more ‘issue predecessors’ that are buried in history. Nothing can make the heart sink more than ‘we had that issue years ago’ so do the digging needs to be early and thorough.

Go thru the PDCA cycle quickly and learn from what you have done to make things better and solve problems. This is a great way to get team members involved in learning and problem solving.

Document and share the insights gained from each mistake with your team. Encourage others to learn from these experiences....

🌍 What CI principles did I employ as a Global Director in P&G manufacturing? Lean Manufacturing: Streamlines processes, eliminates waste, and saves costs. Six Sigma: Reduces variability for higher quality and consistency. TQM: Focuses on customer satisfaction and involves all employees. Data-Driven Decisions: Uses analytics for informed decisions and improvements. Employee Empowerment: Encourages contributions to process improvements. Sustainability: Aligns improvements with sustainability goals. Cross-Functional Collaboration: Ensures comprehensive, coordinated improvements. Technology: Uses automation and IoT to enhance processes. Customer Focus: Committed to exceeding customer expectations. Resilience: Adapts quickly to market changes.

Always look for ways to enhance processes. Use the feedback loop from previous steps to drive ongoing improvements...........

Looking over the overall steps initially taken versus potential modifications to the existing method can nurture creativity and efficiency improvements not originally seen. This promotes things like time methods studies and fault tree analysis which could improve the amount of time taken to do things as well as look for more efficient routes which could reduce complexity and RPN (risk priority numbers) which could tributes to the past errors.

If you have approached the issue in an “A3” style approach you effectively gone through the steps to address the issue. Next steps are following up on sustainability steps potentially using Pareto charts to see if problems are returning to the same area or cascading to the next area