Sequence of Process Steps not Respected

Cephissus

Involved In Discussions
#1
How would you use FMEA to ensure proper sequence of steps?

At the moment PFMEA studies the failure modes associated with each steps, but we found ourselves confused when somebody did the steps perfectly, just not in the right order. How would you tackle this?

Let's imagine a station in which an operator needs to manually stack 4 parts on to each other: A,B,C,D

We defined for him 4 functions at the Work Element level:
- Place part A on pallet
- Place part B on part A
- Place part C on stack AB
- Place part C on stack ABC


Now we already have clearly identified failures for each step, for ex:
- Doesn't place part B
- Damages part C
- Misplaces part D


but how would you handle the wrong sequence, for example: Placing C before B?

There are so many potential combinations to study. Is there a smarter and faster way to handle this?
 
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mattador78

Quite Involved in Discussions
#2
Surely you have covered Placing c before b by saying they haven't placed b. The principal is the same is not? or am I looking at it too simply
 

Steve Prevette

Deming Disciple
Staff member
Super Moderator
#3
I have worked in several environments where the sequence of steps performed can literally be the difference between life and death.

I would suggest one needs to consider:

1. Is this really a life or death (or significant damage) situation? What is the real outcome of performing the steps in the wrong order?​
1a - yes that may mean testing what are the POSSIBLE step combinations. If you have to go to a parts bin, get Part A and then add it to the assembly you are building, it is a bit hard to add part A before going to the parts bin.​
2. Why have people been performing them in the "wrong" order? Perhaps it really doesn't matter, or there is a compelling reason to do the work in a different order.​
3. Have you watched the task be performed (or even done it yourself)? Have you talked with the workers about the task?​
Given that you need to ensure steps are performed in the correct order, here are some applicable tools/ methods: (Note this is not an endorsement of the vendor(s), but google searches led me to these and I think they look valid)

Human Performance Tool Spotlight: Procedure Use and Adherence
Which Human Performance Tools aren't Human Performance Tools?
CDC - Hierarchy of Controls - NIOSH Workplace Safety and Health Topic [If you can physically make it impossible to do the steps in the wrong sequence, that is better than relying on memory - such as don't let the parts bin people give out Part B before giving out Part A, or an interlocking feature such as prevents you from putting a USB item into a USB port upside down]
Understanding procedural violations using Safety-I and Safety-II: The case of community pharmacies

Hope that provides some ideas.
 

GRP

Involved In Discussions
#4
How would you use FMEA to ensure proper sequence of steps?

At the moment PFMEA studies the failure modes associated with each steps, but we found ourselves confused when somebody did the steps perfectly, just not in the right order. How would you tackle this?

Let's imagine a station in which an operator needs to manually stack 4 parts on to each other: A,B,C,D

We defined for him 4 functions at the Work Element level:
- Place part A on pallet
- Place part B on part A
- Place part C on stack AB
- Place part C on stack ABC


Now we already have clearly identified failures for each step, for ex:
- Doesn't place part B
- Damages part C
- Misplaces part D


but how would you handle the wrong sequence, for example: Placing C before B?

There are so many potential combinations to study. Is there a smarter and faster way to handle this?
A fast way:

requirement: stack parts in order as per drawing xyz
failure mode: any or all parts out of order
effects: the highest severity as applicable to downstream processes, plant, customer, end user, govt regulations
control methods: as applicable

Notice I am not providing any substance from a process perspective, but suggesting a way to frame the situation in the pfmea.

A key aspect of pfmea is figuring out the depth of the analysis. Does it bring any value to put several people to investigate ALL possible outcomes of the wrong sequence? Wouldn't the organization be best served if you first try to answer Steve's question #2?

A smart and fast way would be to address why can ANY wrong sequence happen. Remember not to blame it on the operator, but rather work on why the process -designed as it is- fails to meet the requirement. Probably your process is manual and there is no error-proofing or mistake-proofing.

If this first general approach fails to mitigate risk, then you may have to pursue the combinations.

Just for the sake of it, I venture saying if a poka-yoke is not feasible, maybe you can put sensors/barriers before the bins to enforce the correct sequence. (And yes, it is always possible an operator can put the hand in the bin without taking the part, or they could take it, put it down, get the next one and stack it, and get the previous one, and so on...)

What do you think?And did you work it out?
 
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