Course overview
We’ve all heard the excuse: “it’s down to human error” with the assumption that there’s nothing we can do about it. However, when any type of quality issue was caused by a person doing something incorrectly; there will be a deeper root cause of the incident. These precursors or preconditions are referred to as human factors.
Read recent CQI/IRCA technical articles by our Technical Director, Dr David Scrimshire –
Human factors in manufacturing – Part 1 ~ focused on methodologies to find the root causes (human factors) of human errors
Human factors in manufacturing – Part 2 ~ focused on methodologies to motivate people to avoid making human errors in the first place
TEC’s unique 2-day course focuses on understanding why human errors occur in manufacturing operations, selecting and using the appropriate 'model' to search for root cause(s), finding and proving the root cause(s), then implementing effective ‘controls’ (barriers) to prevent or mitigate the consequences of human errors to downstream operations or the customer. You will also learn how to use practical psychology to help motivate staff to do the right thing, first time and every time – and strive for continual sustainable improvement.
The course covers in detail everything that is needed to develop, document and implement AS9100, AS13100 and RM13010 conforming processes to address human factors in the manufacturing environment. The certification bodies will be auditing these topics as part of their routine surveillance and re-certification audits – so be fully prepared!
Course details
The course is highly interactive and includes many individual and team exercises, Case Studies and quizzes -
Interrelation of human factors with the quality management system
Human factors and Quality management goals and principles
Understanding the principles
Understanding the scope of ‘manufacturing’ in AS9100:2016
Understanding an organisation’s mission, vision and values
just culture and ethical behaviour
Creating a just culture and advocating ethical behaviour
Individual exercise – your organisation’s mission, vision and values
People and competency
Definition of competence and requirement for people
AS9100:2016 requirement for ‘competence’
Establishing and maintaining competence
Individual exercise – defining a person’s competency
Organization structure, authority, responsibility and accountability
Organizational charts and job descriptions
Important functions of a job description
Understanding authority, responsibility and accountability
Team exercise – evaluating your organization’s job descriptions
Understanding the consequences of human errors
The impact of human errors – the “error iceberg”
Human error – failures in planning and execution
Team exercise – consequences of human error(s)
Tutor illustration – consequences of human error(s)
Operator behaviour and associated errors
The skill, rule, knowledge ‘framework’ (Jens Rasmusssen – 1983)
Understanding the knowledge, rule and skill levels
Class review – explaining the three types of operator behaviour
Team exercise – moving between Skill, Rule and Knowledge levels
Operator behaviour and associated errors
Class review – explaining the three types of operator errors
Team exercise – explaining the three types of operator errors
Further classification of ‘operator errors’ (what happened)
Summary of ‘operator errors’
Class review – classification of ‘operator errors’ (what happened)
Team exercise – classification of ‘operator errors’ (what happened)
Looking for the causes of operator errors
Linking human errors to human factors (causes)
Understanding ‘events’ and ‘hazards’
Understanding the ‘before’ and ‘after’ requirements
introduction to the bow-tie model
Individual/team exercise – understanding clauses 8.1.1 and 10.2
Understanding the error – root cause – top event sequence
Relating human errors (what) to possible causes (why)
Team exercise – investigation of the flight 5390 incident
Understanding the three types of causes (reactive or proactive)
direct cause
contributing cause(s)
root cause(s)
Continue to ask “why did” and “why didn’t” questions
Basic tools to determine the causes of human errors – categorized as human factors
Overview of the process – eliminating/mitigating events/hazards
All tools are variants on ‘directed brainstorming’
Starting the search for human factors root causes
Directed brainstorming – the Ishikawa diagram
Looking for root causes with ‘directed’ brainstorming
Using the Ishikawa diagram and the 5-Whys tool in concert
IAQG’s general root cause ‘codes’ for nonconformities
understanding the IAQG root cause ‘codes’
IAQG’s human factors root causes
details of the IAQG’s human factors root causes
The PEAR Model to characterize human factors
SCMH root cause categories – manufacturing-focused
Team exercise – selecting and using the appropriate ‘model’
The ‘dirty dozen’ human factors – maintenance-focused
Directed brainstorming – continuing the search for root causes
Team exercise – refining the search for the root cause (engine failure)
The SHELL model focused on working environments
Team exercise – looking for ‘contributing causes’ and ‘influences’
Team exercise – mitigating the environment effects on the operator
Refining the search for human factor root causes
5-WHYs – the basic concept
5-WHYs – looking for root causes from different perspectives
Team exercise – the engine has stopped
FTA (Fault Tree Analysis) using Boolean logic
Example of Boolean logic – focus on what was not done
Verifying human factor root causes
Verify the root cause – the “therefore test”
IS – IS NOT structured questioning
Verify the root cause using the “IS – IS NOT test”
Team exercise – verifying root cause using the “therefore test”
Systematizing and quantifying root cause(s) relating to human factors and other sources
Understanding failure mode and effect analysis
Analysing the manufacturing sequence – PFD
Sources of human factor causes – the ‘models’
Analysing the design function – P-diagram
The FMEA ‘road map’ – sequence of steps
Understanding failure mode – design and production
Understanding the effect (impact) of a failure mode
Quantifying severity of a failure mode
Determining the cause(s) of failure modes
Quantifying the likelihood (occurrence) of failure mode
Risk ‘tolerability’ matrix (aka ‘heat’ map – S & O)
Understanding controls (barriers)
Determining the RPN (Risk Priority Number)
Team exercise – the tyre is flat
Using FMEA ‘principles’ to quantify human factors
Mitigation – prevention and recovery
Identifying ‘controls’ (barriers) using the bow-tie model
Designing effective controls (barriers)
Implement effective actions
Re-evaluate the actions action taken
Team exercise – the flat tyre ~ recommended actions
Continual sustainable improvement "how to make it happen"
Reflect on the words of W Edwards Deming
The four stages of competence – the need for training
The ‘three dimensions’ of competency
Event or Hazard performance KPIs and targets
S-M-A-R-T goals
Can practical psychology help with motivation?
The psychology of motivation
Maslow (hierarchy of needs)
Herzberg (motivator-hygiene theory)
Herzberg’s data and conclusions
Understanding how thoughts/feelings affect results/behaviour
KPI achievement creating 'experiences'
mindset and perception
Understanding how you/your organization can influence motivation
KPI performance-based on-purpose situational feedback
Influencing motivation with on-purpose/situational feedback
Understanding the TGR and TGW philosophy – responsibility
Institutionalize a sound TGR process
Institutionalize a sound TGR process
Accentuate the positive eliminate the negative!
The core principles to boost motivation
Team exercise – factors to include in processes & training programmes
Checklist of required actions
Applying the ISO 9001:2015 core concepts to human factors
risk based thinking
process approach
plan-do-check-act
Extended Q & A session
Who should attend
Quality managers, Accountable managers, Quality engineers and all levels of management responsible for developing, documenting, implementing, managing and maintaining AS9100:2016 Rev D conforming processes to address human factors.
Six Sigma 'belts' and Continual Improvement practitioners who want to incorporate human factors into their 'future-state' initiatives. The course is particularly useful for supervisors who have to manage operators on a day-to-day basis.
All aerospace/defence production organizations need to understand how they must develop, implement and maintain appropriate processes to effectively address human factors as part of new product introduction (APQP & PPAP) and nonconformity & corrective action.
TEC's practical 2-day course will empower organizations to demonstrate full conformity with AS9100:2016 requirements, meet aerospace customer expectations and comply with legislation and regulations.
Deliverables & benefits
Consideration of human factors is a new and mandatory requirement of AS9100:2016 Rev D. This course is specifically aimed at both (i) Make-to-print, and (ii) Design-and-make organizations.
All aerospace/defence organizations need to understand how they must develop, implement and maintain appropriate processes to effectively address human factors in a proactive and reactive manner.
TEC's practical 2-day course will empower organizations to demonstrate full conformity with AS9100:2016 requirements, meet aerospace customer expectations and comply with legislation and regulations.
This course is classified as ‘structured’ for continuing professional development (CPD) purposes by the CQI/IRCA. It contributes 16-hours to the required 45-hours of appropriate CPD for QMS Lead Auditors.