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.
TEC's unique e-Learning (on-line training) 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 true cause(s) which are the human factors, then implementing effective 'controls' (barriers) to prevent or mitigate the consequences of human errors to downstream operations, customer or end-users.
The course covers in detail everything that is needed to develop, document and implement AS9100, AS13100, RM13010 and IATF 16949 conforming processes to address human factors in the manufacturing environment.
You will also learn how to harness 'practical psychology' to help motivate operators 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 and implement effective processes to address/prevent human factors in the manufacturing environment.
a downloadable (pdf) Delegate Workbook is included
Course details
Understanding human errors and human factors
What are human errors in aviation manufacture?
Exercise: examples of human error(s)
Human errors are the result of human factors
Test: Human errors and human factors
Human factors & Quality management principles
Test: matching human factors principles with their quality management equivalents
Understanding the scope of ‘manufacturing’ in standards
Quality management system requirements (AS9100, AS13100 & IATF 16949)
Documentation requirements for ‘scope’
Exercise: Evaluating your organisation’s statement of scope
Understanding an organisation’s mission, vision and values
Importance of mission and vision
Importance of values
Exercise: your organisation’s mission, vision and values
People and competency
Definitions of people/competency terminology
Exercise: defining an operator's competency
Organization structure and job descriptions
Organizational chart
Job descriptions
Important functions of a job description
Exercise: evaluating your own job description
Understanding authority, responsibility and accountability
Terminology
Authority
Responsibility
Accountability
Interrelationships between authority, responsibility and accountability
Test: explaining authority, responsibility, accountability, ethical behaviour and just culture
A first look at the sources and consequences of human errors
Sources of human errors
Consequences of human errors
Aircraft accidents and their consequences
Exercise: consequences of human error(s)
A first look at operator behaviour
Jens Rasmussen – operator behaviour and associated errors
Knowledge-based
Rule-based
Skill-based
Quiz: explaining the three types of operator behaviour
Operator movement between the types of behaviour
Exercise: operator movement between Knowledge, Rule and Skill modes
A first look at the causes of human errors
Distinguishing between human errors and nonconformities
The Ishikawa diagram – directed Brainstorming
Ishikawa/Fishbone diagram representing knowledge, rule and skill ‘framework’
Test: explaining the three types of operator errors
General classification of ‘operator errors’ (What happened)
Classifying ‘What happened’
Visualizing ‘What happened’ with an Ishikawa diagram
Test: classification of ‘types of operator errors’
Exercise: identifying ‘types of operator errors’ in a real-world situation
Errors resulting from failures in planning and/or execution
Understanding plans and actions
Understanding outcomes – success and error
Test: explaining failures in planning and/or execution
Exercise: Aloha Airlines Flight 243 – Error/Find & Fix
IAQG’s general “cause codes” for reported nonconformities
IAQG’s root-cause code initiative
IAQG’s 4-categories of human factor/root causes (including AS9100 & AS13100 requirments)
Exercise – Relating IAQG “cause codes” to the correct ‘perspectives’
The 'PEAR' Model
Methodologies for determining root causes/human factors
The 'two-stage' approach
Ishikawa diagram
5-WHYs
Aviation example – what the operator did/did not do
Exercise: investigation of the flight 5390 incident
Linking human errors to human factors
Defining human error
Understanding what happened
Commencing the search for human factors
Refining the search for human factors
Test: identifying relevant categories for directed brainstorming
Other models for determining human factors
Overview of models for Ishikawa/Fishbone diagrams
SCMH human factors categories – manufacturing-focused
Exercise: SCMH human factors categories
The ‘dirty dozen’ human factors – maintenance-focused
Exercise: United Airlines Flight 232 – identifying ‘dirty dozen’ human factors
The SHELL model – working environments-focused
Exercise: SHELL Model looking for ‘contributing causes’ and ‘influences’
Testing the validity of determined root causes/human factors
Rationale behind testing 'probables'
Scoring
IS – IS NOT test
Therefore test
Sherlock Holmes test
Occam’s Razor
Choosing between the tests
How are we performing? – KPIs, targets, results
AS9100 requirements for performance measures
Incidents of human errors/factors as KPIs
Personal assignment
Human factors and competency
Human factors and countermeasures
The 'three dimensions' of competency
Practical physiology, needs and motivation
The physiology of needs and motivation
Maslow's hierarchy of needs
Herzberg’s two-factor theory of motivation
Quiz: principles of ‘practical physiology’
Understanding how thoughts/feelings affect results/behaviour
Herzberg’s 'internalized' motivation
Tim Autrey’s "6-hour safety culture"
Understanding how you/organization can influence motivation
What you cannot do!
What you can do!
Cognitive Behavioural Therapies (CBT)
Quiz: Understanding thoughts/feelings, results/behaviour and motivation
Influencing behaviour with on-purpose/situational feedback
Focused feedback
Continual feedback
Implementing the TGR and TGW philosophy
Test: On-purpose/situational feedback, TGR and TGW
Planning and implementing countermeasures
Planning countermeasures
Generating behavioural countermeasures
Six Hats Thinking
Six Hats – questions for each colour
Risk evaluation of potential countermeasures
Implementing countermeasures
Quiz: Understanding terminology associated with countermeasures
Institutionalizing an effective TGR & TGW process
TGR – Things-Gone-Right
TGW – Things Gone Wrong
Accentuate the positive – eliminate the negative!
Boosting motivation with just culture & core principles
Quiz: Ethical behaviour and related operator qualities
Checklist of required actions
Personal assignment: human factors programme
Being proactive – differentiating between 'events' and 'hazards'
Understanding events/problems
Understanding hazards/failure modes
Methodologies for 'proactively' identifying/quantifying events/hazards
Proactive methodologies overview
The bow-tie model
Quiz: identifying the 'elements' of the bow-tie model
Failure Mode & Effects Analysis (FMEA)
PFMEA methodology
Targets for a PFMEA
Prerequisites for a PFMEA
Exercise: Sequence of steps in a PFMEA
Continual sustainable improvement
Review of the human factors 'models'
Ongoing facilitator responsibilities
Designing training programmes
Training goals
Training programme considerations
Factors to include in training programmes
Quiz: Key factors to be included in human factors training programmes
Applying the AS9100 'core concepts' to human factors
Final comments
Qualifications & benefits
The benefits of e-learning are numerous; not only are they extremely cost-effective but they provide students with convenience and flexibility as they embark on their learning journey. You can complete your training whenever and wherever you want, and at your own pace – and even have an anonymous ‘trial run’.
Companies do not have to tie-up entire teams at the same time as is the case with conventional classroom-based training.
The e-Learning course covers in detail everything that is needed to develop and implement effective processes to address/prevent human factors in the manufacturing environment.