I could have also titled this post “I screwed up!” or “Who Screwed Up? Me!” but we try not to point the finger of blame in the Lean mindset…. it's especially uncomfortable when you have to point it in the mirror.
I was trying to make a pot of coffee, same normal routine as usual. I got back out to the kitchen to pour my first cup and I noticed something was wrong. I hadn't pushed the filter basket all the way back in to its place above the coffee pot. Coffee had spilled out and all over the counter, leaving a mess and effectively ruining the pot of coffee (although the coffee that DID get into the pot was a surprisingly drinkable rich espresso type sludge). I won't claim I created “value” there.
The coffee pot was somewhat error proofed in that the pot has a “stop and serve” feature, a physical interlock that stops the flow of coffee when the pot and basket aren't engaged properly. But, with the basket out, water still flowed from the main reservoir and mixed with coffee grounds, flowing out over the basket edge onto the counter. The error proofing wasn't 100% sufficient (nor was it designed for that process defect, I'm sure).
Now looking back to prevention… is this an error I'm likely to make again? I don't know… I've made coffee hundreds of times on that maker and, if I made that mistake before, I don't remember it. Should I put up a large sign that says “Be Careful! Don't forget to snap the basket completely into place?” I'd argue no. Signs aren't effective error proofing and the world would be very visually cluttered if we to put up a sign for every possible thing that could go wrong (although lawyers might find that to be a good idea). That's often we react to problems in the workplace — let's put up a warning sign!
I could make a “checklist” that I walk through every time I make coffee to make sure I don't miss a step. Airline pilots (thankfully) have checklists that they HAVE to go through every time, regardless of how experienced they are.
I'll skip the 5 whys analysis since you might be sick of reading about this by now. I think my final conclusion:
Error proofing should protect us from our worst days.
Most of us don't think it's going to be us who makes the mistake. But if the mistake is possible (not error proofed), then it's likely to happen to most of us or any of us.
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