QC Book of Standards

Topic: 7 Steps of Human Error (Including Human Nature)

Jointly Developed and Approved by:

FCA: APAC, EMEA, LATAM, NAFTA, Global Quality, CNH, Comau, Magneti Marelli, Teksid

Rev 1
December 2016
 7 Steps of Human Error

What: Defines the 7 steps to approach Human Error

Where: Labor intensive areas, beginning with the area of priority, then
expanding

Why: To avoid moving to advanced steps before implementation of earlier

fundamental elements

When: Applicable at all levels and scores

How: Rigorous and sequential application of the steps

Who: Quality leads the methodology.

The main pillars involved are: WO, PD and SA

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 7 Steps of Human Error (Including Human Nature)

7) Re-apply Steps 5&6

Skill of people gets better
Advanced
O&R/HN changes/improves
(Sporadic)
6) Apply Non Specific Human Nature Approach
Emotional Load & 10 Common Features

5) Apply Specific approach by defect mode O&R

Repetitive Human Error is near zero

Intermediate
4) Apply systemic approach/s

(Repetitive)
Using cause pareto apply systemic action/s

3) Resolve advanced problems with advanced tools (Example: ATWTTP)

Investigation & solution of operators that make repetitive errors

2) Separate Repetitive and Sporadic

Basic Conditions
Eliminate Repetitive Defects (QG, Kaizens)
(Repetitive)
Effective feedback to operator when an error occurs

1) Measurement System for Human Error

Accurate Data

Ability to identify the people who generate errors

Proper application of TWTTP HERCA and alignment to
countermeasure 3
 Emotional Load

EMOTIONAL LOAD

YES

NO
K1 Activity type
Does the operator have to perform a check/inspection from another workstation.
Are there blind or difficult to see operations in the workstation?
Does the operator handle small parts < 25mm's (Small parts can cause stress to select, handle, & install)
Number of activities is excessive (pick, position, secure, connect) (excessive is determined locally)
K2 Working load
A Yellow ergonomic condition exists (is present now) for Posture (Examples: EAWS, Muri, ErgoPal)
A Yellow ergonomic condition exists(is present now) for Force (Examples: EAWS, Muri, ErgoPal)
A Yellow ergonomic condition exists (is present now) for Manual Handling (Examples NIOSH, SNOOK, Muri, ErgoPal)
A Yellow ergonomic condition exists(is present now) for Frequency (Examples: EAWS, OCRA, ErgoPal) (if applied)
Whole-body mechanical vibration (WBV) > or = 0.5 m/s^2 or a Mechanical vibrations to the hand-arm (HAV) > or = 2,5 m/s^2 (example impact guns)
K3 Anxiety load

Does the operator perform the job on a raised/lowered platform that changes level near the boundry of the operators movements during the work cycle?

In this workstation, does the cycle time exceed the takt time for any build configuration?
For this job is the average saturation above the limits (local or regional limits established)?
For this job is the average saturation below the limits (local or regional limits established)?
Are additional PPE required beyond the standard for the surrounding areas or are PPE required for life threatening injury
The team member must utilize a high number of tools to perform their job. Base criteria on takt time
Is access to the workstation limited (requires climbing up or down to access the station).
AA Quality issues can be generated from the station and NO Fool/Error/Mistake proof exists
K4 Surrounding conditions
Are Irritant, Harmful or Dangerous substances present that could effect the operator
Are Dusts or fumes present that are within legal levels, but not appreciated
Noise level in the station ( Lex 8h ) > or = 85 db ?
Workstation lighting that are within legal limits, but maybe considered tiring
Climate elements that add stress to the job are within legal levels, but not appreciated

All questions are weighted equally

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 10 Common Features

Ten Common Features

Y ES
NO
Selection Man cannot handle many pieces of information at the same time. Normally one at time

At the workstation is there information NOT necessary for the job?

Does the operator have to choose between two or more similar parts in a workstation ?

Is the identification of parts/trays/dunnage incomplete, or not clear? (Information the operator must work with)

Does the operator have similar alternatives to select from (trays/programs/tools)? (Selection causes stress)

Consciousness Human consciousness has its rhythm and it varies over time

Is there passive time(waiting) within the cycle time? Waiting time can lead to becoming distracted, loosing the rhythm of the job.

Does the operator have to remember too many operations?

Does the workstation need Visual Aid, SOP, other aids to guarantee critical to safety/quality are sustained?

Alertness Human alertness varies over time: Human beings cannot be attentive all the time

Is there a segment of the job that always requires heightened/special attention (for quality or safety)?

Illusion Human beings are liable NOT to be able to see things as they are

From the operators view point are there elements/activities prone to illusion?

The operator cannot see if the job was done properly/improperly

Guess and
Human beings tend to guess and/or be prejudiced positively or negatively when they see things
Prejudice
Are the worksheets of the workstation not clear; could two different operators understand the job differently?

Can the information showed on displays(machine, tool) and equipment be easily mistaken? (Operator cannot easily understand the information)
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 10 Common Features (Continued)

Forgetfulness People easily forget ; people easily forget if interrupted

Are there operations that are not 100% performed in the workstation 'optional' (not covered with sound/visual alert to bring attention to the operator of the change)?

Does this operation contain too many (example >=4 ) of parts that has to be assembled so there is a possibility that operator forgets?

Can an operation of the job be missed, and is not clear to the original operator or at a downstream check?

Are distracting activities in or near the workstation that can cause interruption: Examples: people crossing, vending machine, break area etc.?

Take a short cut,

Human beings are liable to take a short cut and or omitting things. Making a reflex movement
Omitting things

Can the job be done taking a shortcut (not hand start fastener, cleaning, sequence ) but is risk to quality or safety and the short cut is NOT clearly defined the "WHY"
in a visual aid?

Being influenced
by the physical Human beings are liable to be influenced by their physical condition
condition

Are the tools and other equipment in the station that are not simple and easy to use?
Does the station impose a physical limitation to any of the workers assigned to the station?

Being influenced
by the state of Being influenced by the state of mind
mind
Is the environment of the work area difficult for the operator causing loss of attention: Group dynamics, operator supervisor relationship, alienation, lack of
teamwork etc.

Visual direction It's diffi cul t to perceive thi ngs outs i de a rea where eyes a re di rected

Is information needed by operator out of line of sight of the activity at the time it is needed (display, instruments, Visual Aid)?
Is any operator assigned to the station not able to see the information due to physical differences (example height)

All questions are weighted equally

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 Tables for Emotional Load, 10 Common Features and Combined Stress

I TCF Ten common features level

LOW HIGH

FROM TO FROM TO
TCF (Ten common features )
10 CF SCORE

II K1+K2+K3+K4

LOW HIGH

FROM TO FROM TO
Emotional Load Score

Workplace
Combined Stress (*) From To unreliability NOTE
level
0 C
B
A
AA

Three evaluations are made:

10 Common Features
Emotional Load
Combined Stress
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 Scoring 10 Common Features and Emotional Load

The results for 10 Common Features and Emotional load are the sum of the yes
answers.

The ranges for 10 Common Features, Emotional Load, and Combined Stress are
developed in the plant.
Apply the checklist to known good stations, and known problem stations, and set the ranges

Note: The Combined Stress score is Emotional Load and 10 Common features together.
Consider that a work station that is at the border of the green range for 10 Common
Features, and at the border of the green range for Emotional load may be considered
yellow, orange or red when combined. This is due to the combined effect of the stresses.

As the plant improves, the ranges will need to be re-evaluated