But this time a small, non-technical complication was introduced. Specifically, the defect was discovered at the end of first shift. Employees on the first shift naturally assumed the person making the repair would purge the vessel before starting work. The second shift welder naturally assumed the vessel had already been depressurized and purged when he began the repair.

The combination of these two natural assumptions was fatal.

In hindsight, many proactive steps could have been taken – should have been taken – to prevent this possibility. In today’s more process-oriented times the principle of Poka Yoke would have been applied to error proof this operation.

One of our clients has adopted Lean Six Sigma technology as the basis of their safety initiative. Their accident records showed an interesting correlation – the vast majority of incidents occurred doing non-value added (NVA) work:

• Back injuries from lifting. Moving materials is by definition NVA. Reducing the need to move material, or at least using proper equipment to do it efficiently, reduces accidents.
• Trips and falls. This is often a result of clutter and can be solved with good 5S.
• Repairs and rework. Primary work is usually done with the correct tools and proper fixturing. Rework often uses cobbled-up holding devices or less well documented work methods. In addition, repairs are (hopefully) performed less frequently so employees are not as proficient with procedures.
• Reaching. Well engineered workplace design, and its close cousin of standard work, eliminates the need for reaching and, in particular, for twisting while holding a load.

Other Six Sigma tools can be used to analyze and prevent safety issues. For example, simple charting and Pareto analysis of near misses effectively anticipates accidents before they happen. Also, Failure Modes and Effects Analysis (FMEA) is a particularly good way to brainstorm the sources of possible injuries and to prioritize efforts to eliminate the root causes.

Progressive companies understand that the only acceptable goal for customer quality is Zero Defects. Safety performance needs to be considered with the same logic. While safety incidents may never be eliminated, particularly in very large companies, they can never be considered acceptable. There is no such thing as an “unavoidable work place accident”.

Do you have a success story (or failure) to contribute to the discussion? To add your experience follow the link to Our Blog.

Interested in more ways to improve operations and increase earnings at the same time? We invite you to download our white paper “Targeted Lean Six Sigma". You are also welcome to browse the list of free white papers and other articles at Free Resources.

If you have a topic that you would like addressed, or an Insight you would like to pass along, e-mail us at: Jack.Rink@rmdonovan.com

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