Human Factors in MRO

Programme overview

TEC’s unique 2-day course focuses on the role of human factors in maintenance, repair and overhaul (MRO) operations. It addresses all of the requirements of AS9110:2016 Rev C and applicable regulatory requirements.

Understand why human errors occur in MRO operations, the appropriate 'model' to search for the root cause(s) must be used. Once the root cause(s) is found and conformed, effective ‘controls’ (barriers) must be implemented to prevent or mitigate the consequences of human errors to downstream operations or the customer. Lean how to use practical psychology to 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 AS9110:2016 Rev C conforming processes to address human factors in the MRO environment. The certification bodies will be auditing these topics as part of their routine surveillance and re-certification audits – so be fully prepared! The course is highly interactive and includes many individual and team exercises, Case Studies and quizzes.

Programme details

Interrelation of human factors with the quality management system

  • Human factors and Quality management goals and principles
  • Understanding the principles
  • Understanding the scope of ‘maintenance’ in AS9110:2016
  • 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
  • AS9110:2016 requirement for ‘competence’
  • clause 7.2
  • Establishing and maintaining competence
  • Individual exercise – defining an individual’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 MRO 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 maintenance operations sequence using a PFD
  • preliminary risk assessment
  • Sources of human factor causes – the ‘models’
  • Understanding the ‘design function’ in MRO operations
  • Additional AS9110:2016 QMS requirements -
  • 8.3.1
  • 8.3.3
  • 8.3.5
  • Team exercise – potential for human error in MRO design
  • The FMEA ‘road map’ – sequence of steps
  • Understanding failure mode – design and maintenance
  • 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

  • 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 goal achievement
  • Understanding how you/organization can influence motivation
  • KPI goal achievement and experiences
  • On-purpose situational feedback - mindset and perception
  • Influencing motivation with on-purpose/situational feedback
  • Understanding the TGR and TGW philosophy – responsibility
  • Institutionalize a sound TGR process
  • Institutionalize a sound TGW process
  • Accentuate the positive eliminate the negative!
  • The core principles to boost motivation
  • The need for MRO operator ‘awareness’
  • The need for ‘communications’
  • Team exercise – factors to include in processes and 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

Accountable managers, maintenance managers, management representatives and quality engineers and all levels of management responsible for developing, documenting, implementing and maintaining AS9110:2016 Rev C 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 maintenance organizations need to understand how they must develop, implement and maintain appropriate processes to effectively address human factors as part of their routine operations - with particualr reference to risk management and corrective actions.

TEC's practical 2-day course will empower organizations to demonstrate full conformity with AS9110:2016 Rev C requirements, meet aerospace customer expectations and comply with legislation and regulations.


Consideration of human factors is a mandatory requirement of AS9110:2016 Rev C. This course is specifically aimed at both (i) organizations who provide maintenance and continuing airworthiness management services, and (ii) OEMs when MRO operations are operated autonomously. The course is applicable to civil and military aviation products and services.

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 AS9110:2016 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.


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