Comments on: What a Coffee Cup Taught Me About Poka Yoke and Human Errors https://6sigma.com/a-coffee-cup-taught-me-about-poka-yoke-human-errors/ Six Sigma Certification and Training Fri, 28 Feb 2025 11:21:55 +0000 hourly 1 By: marlon https://6sigma.com/a-coffee-cup-taught-me-about-poka-yoke-human-errors/#comment-25865 Mon, 04 Jul 2016 12:41:19 +0000 https://opexlearning.com/resources/?p=12986#comment-25865 In reply to Mark Graban.

i just want to know something about that cup for my case study. any articles or sites about the cup please.

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By: Kimberly Newton https://6sigma.com/a-coffee-cup-taught-me-about-poka-yoke-human-errors/#comment-25864 Sun, 27 Sep 2015 02:20:37 +0000 https://opexlearning.com/resources/?p=12986#comment-25864 In reply to Paul Astle.

Very interesting sentiment. I work in a health care environment, and we deployed Six Sigma over 15 years ago, but what we do not have is a commitment to its practice. Leadership must be well versed in the practice, and committed to engage all employees in the value add.

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By: Mike Tatu https://6sigma.com/a-coffee-cup-taught-me-about-poka-yoke-human-errors/#comment-25863 Wed, 06 May 2015 22:33:25 +0000 https://opexlearning.com/resources/?p=12986#comment-25863 In reply to Chet Marchwinski.

Chet the handle is a handle, not a spout. The design of these cups are to make them stackable – look at the bottom of the cup – the notches on the outside line up with the “bumps” on the inside – and I suspect the bottom of the handle fits into the groove on the top – so these cups take up less space when you stack them and it allows air to circulate

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By: John Payson https://6sigma.com/a-coffee-cup-taught-me-about-poka-yoke-human-errors/#comment-25862 Tue, 01 Apr 2014 16:31:49 +0000 https://opexlearning.com/resources/?p=12986#comment-25862 In reply to John Payson.

And then there is this trouble——-

All of this trouble is sourced in what Deming pointed out as “sub-optimization”. Who said “if no ONE is responsible, then NO ONE is responsible”? P. Crosby? It is the crux of the matter.

The individual who CHOOSES the product to be implemented, never has to USE it THEMSELVES. They are not a “stakeholder”. Their only care is to again, meet the written job requirements.

So you end up with Point of Sale terminals that have 80% failure to read rates when cards are “swiped”. The individual who had criteria in hand to choose a “vendor” only had to put “guarantees and warrantee” in the contract, but did not have to worry about actual performance. That is a problem for the service department in the field.

You end up with “standard floor plans” for supermarkets put in place, with shelving locations that take no account for the fact that — in this building or that, there are support columns that end up blocking the aisle.

You end up with “customer service systems” that have “select 1 for x and 2 for y” and when you follow the directions you get to a point where NONE of the choices fit, so the “voice menu” just hangs-up.

You end up with a coffee cup that is stackable, storable in small space, light, easy to make—- in short does everything a modern coffee cup should do except deliver coffee to a human customer.

You have examples you will observe everyday.

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By: John Payson https://6sigma.com/a-coffee-cup-taught-me-about-poka-yoke-human-errors/#comment-25861 Tue, 01 Apr 2014 16:09:27 +0000 https://opexlearning.com/resources/?p=12986#comment-25861 This is a system problem, as are most. These are some examples of things that lead to such troubles– that are built into systems everywhere.
1. Lack of a product designer. Product is developed by a team, to requirements or specifications that are delegated out. A team leader facilitates and keeps the project on schedule. But NOBODY has a responsiblity to see that the Product will actually work or be any good. All of the effort is to get each of the specifications met. Without a designer—- it is likely that key specifications are NOT written up and are not part of development, and further it is likely that compromises will reduce the utility of the product. If you could see the wants list that made this cup happen, you will likely see that it meets or exceeds every listed requirement. Then look at what happens next because if the want or need isn’t listed explicitly— it won’t be addressed. These are the things the graphic points out.

2. List of wants by survey or by marketing committee delivered to the development team for realization of the product. The survey is a list of desirables, as are the wants that may be assembled by a marketing group. These are not engineers or designers with a holistic view of the complete product. They will list key points of interest, and leave the ASSUMPTION of the core needs of the product as just that, “assumptions” that of course “everybody knows that”. But these lists are passed on to Engineering functions who by nature will act precisely, and will have that precision enforced by budgets and economics— that if it is NOT on the LIst, then don’t do it. Again a true DESIGNER on the project would serve to stand up and point out what is missing. But if you hand a list of “wants” to the engineers— they are going to address those wants. Only. So you end up with a coffee cup that will do EVERYTHING on the list except deliver coffee to a human being for consumption— because that is the one thing that was never put in the specification— because of course everybody knows that is a core basic requirement and doesn’t need writing down or even discussion. Does it?

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By: Sandip Ghosh https://6sigma.com/a-coffee-cup-taught-me-about-poka-yoke-human-errors/#comment-25860 Thu, 16 Jan 2014 16:48:17 +0000 https://opexlearning.com/resources/?p=12986#comment-25860 Sometimes I wonder why the simple concepts of Lean are not introduced in high schools and Universities! These really are learning for life and need not be restricted to those who have some work relation to the factory! Would make life safer …even in our homes.

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By: Michel Baudin https://6sigma.com/a-coffee-cup-taught-me-about-poka-yoke-human-errors/#comment-25859 Thu, 16 Jan 2014 14:03:34 +0000 https://opexlearning.com/resources/?p=12986#comment-25859 With its unsightly bumps and nooks, the “fancy cup” you show is not even pretty, which makes you wonder what the designer had in mind. The issues you bring up, however, are more about usability engineering in Don Norman’s sense, than Poka-Yoke.

A properly designed handle is self-explanatory in that any user who has never seen a cup will immediately understand what it is for. But it doesn’t make the cup mistake-proof: there is nothing physically preventing you from pouring coffee onto it while it is upside down.

Usability engineering, including is about controls that look and feel distinctive to the touch — as opposed to rows of identical buttons — that give you feedback when you have activated them, that have shapes that naturally lead you to use them properly, that respect cultural constraints in the meaning of shapes and colors, etc. Applying these principles in designing human interfaces reduces training costs and the risk of errors, It is valuable, but it does not prevent errors.

Incidentally, why do so many cultures, including Japan and China, use cups with no handles? An alternative to handles to avoid burning your fingers is the double-walled cup, and I have seen some from China. Otherwise, I have resorted to the Arab way of holding a handleless tea cup: between my thumb on the bottom and my index finger on the rim.

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By: Chet Marchwinski https://6sigma.com/a-coffee-cup-taught-me-about-poka-yoke-human-errors/#comment-25858 Thu, 16 Jan 2014 13:51:03 +0000 https://opexlearning.com/resources/?p=12986#comment-25858 I think your friend got it wrong, Pete. The “handle” is obviously a spout. Your friend was supposed to hold the cup in his palm and pour the coffee down his throat. Much more efficient than sipping. This cup has kaikaku-ed coffee drinking! (great article)

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By: Raj https://6sigma.com/a-coffee-cup-taught-me-about-poka-yoke-human-errors/#comment-25857 Thu, 16 Jan 2014 04:02:21 +0000 https://opexlearning.com/resources/?p=12986#comment-25857 I tend to agree with Martin Sala.

I see some uses of the stubs on the inside bottom of the cup, and the matching slots on the outside, which will make it very useful for stacking the cups – less space being occupied.

I am sure its use was not for drinking coffee or any beverage; just that the coffee shop proprietor thought he would look cool if he served coffee in such a cup! I see such utensils (made of stainless steel generally) which the mothers use to feed milk to infants, where they may not be able to hold and drink with a sipper.

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By: Mike Peacock https://6sigma.com/a-coffee-cup-taught-me-about-poka-yoke-human-errors/#comment-25856 Wed, 15 Jan 2014 22:32:27 +0000 https://opexlearning.com/resources/?p=12986#comment-25856 Great analogy Pete! Processes are great when designed well. Management often demands process to be followed and if individuals do not, then they are penalized – so therein exists built-in conflict. I’ve never seen a process written in stone – so they are made to be changed! It is also great to know that there are indeed coffee/Coke drinkers in SLC – I was one!

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By: Martin Sala https://6sigma.com/a-coffee-cup-taught-me-about-poka-yoke-human-errors/#comment-25855 Wed, 15 Jan 2014 22:20:08 +0000 https://opexlearning.com/resources/?p=12986#comment-25855 Someone is making the assumption that this cup is a LEAN disaster, but is it? Upon first viewing, I thought – Wow! what a clever cup for pouring and drinking! Then, the internal nubs provide an excellent defense against the ceramic material frictionally binding and causing the cup to fracture. This cup is a great design, however, its use must be questioned. So, lets beat up the proprietor of the bistro and not the design team: they probably delivered “The Cup of the Year!”

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By: Paul Astle https://6sigma.com/a-coffee-cup-taught-me-about-poka-yoke-human-errors/#comment-25854 Tue, 14 Jan 2014 01:07:20 +0000 https://opexlearning.com/resources/?p=12986#comment-25854 Great article Pete. Poka Yoke is such a simple but powerful concept. Coupled with DMAIC or DMADV it’s the ultimate process control. It’s such a pity that more Healthcare providers aren’t bought into Six Sigma for their continuous improvement programmes. Just think of the lives that could be saved and the millions saved in clinical liability case costs.

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By: Mark Graban https://6sigma.com/a-coffee-cup-taught-me-about-poka-yoke-human-errors/#comment-25853 Mon, 13 Jan 2014 12:04:22 +0000 https://opexlearning.com/resources/?p=12986#comment-25853 Yeah, we shouldn’t make people feel stupid for making en error that’s caused by the system. For example, we shouldn’t blame a person for showing up at the wrong Toyota plant entrance for a tour when the directions and signage are non-existent:

I wrote about this just today: http://www.leanblog.org/2014/01/toyota-tour-thoughts-yes-they-have-opportunities-for-kaizen/

As for the medical errors… there is a new study that says the number is 400,000 a year, not 44 to 98k. It’s really frightening that the main failure modes in healthcare aren’t being addressed fasts enough.

http://journals.lww.com/journalpatientsafety/Fulltext/2013/09000/A_New,_Evidence_based_Estimate_of_Patient_Harms.2.aspx

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