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Human Factors in Root Cause Analysis

When developing a corrective action, the most critical step is the identification of the root cause of the problem. There are several tools used for this analysis — 5 Why’s, 8D, data analysis, fishbone diagrams, brainstorming, FMEA’s (Failure Modes and Effect Analysis), and other statistical tools. These are all valuable and effective methods, but problems arise when it comes down to the belief that someone “just made a mistake”. The dreaded human error classification.

It has been understood that identifying the root cause as human error is not acceptable and the CAR (Corrective Action Report) will likely be rejected by customers or management. However, the fact remains that humans make mistakes; they do so because they are human. Human factors are the underlying causes of human error. Whenever human error is the cause of a nonconformity, look for human factors as an underlying cause.

Human factors have been studied for some time in the aerospace industry. Now, human factors have been added to the AS9100 standard as part of Corrective Action. Although human factors are not specifically mentioned in the other ISO standards, it is beneficial to consider them when doing root cause analysis.

There have been 12 Human Factors (the dirty dozen) identified and adopted by the aviation industry. A 13th human factor is also listed and that will be reviewed at the end.

  1. Lack of Communication – A lack of necessary information being exchanged between relevant parties.
  2. Complacency – Complacency is caused by a lack of sufficient stress.
  3. Lack of Knowledge – Performing a task correctly takes knowledge and skill. Even experienced workers might try to perform a task they are not trained for, resulting in nonconformities.
  4. Distractions – Something that shifts one’s focus from the task at hand.
  5. Lack of Teamwork – Failure to work together to complete a shared goal or task. It also includes cooperation with others. Without teamwork all jobs are more difficult.
  6. Fatigue – Physical or mental exhaustion that affects work performance. This is a common issue with people working ten- and twelve-hour shifts.
  7. Lack of Resources – Not having sufficient people, equipment, time, etc. to complete a task.
  8. Pressure – Organizations sometimes create a “crisis environment” where workers are under constant pressureto work harder and faster.
  9. Lack of Assertiveness – Failure to speak upor document concerns about instructions, orders or the actions of others.
  10. Stress – Stress is the subconscious response to demands on a person. A certain amount of stress is good, but excessive stress can have negative effects.
  11. Lack of Awareness – Failure to recognize a potential problem situation and predict negative results.
  12. Norms – Unwritten rules of behavior that develop over time; organizational culture.

This is a good list but not exhaustive. There are additional human factors that can impact performance.

13. Attitude – Frequently an underlying cause of human error. A positive or negative attitude will positively or negatively impact work performance.

In summary, human factors are the underlying causes of human error. Too often human error is diagnosed as lack of knowledge and retraining is the only corrective action. As the list above indicates there are other human factors that will not be improved by training. Potential corrective actions include redesigning a process and improving the work environment or working conditions. Whatever human factor is identified an appropriate corrective action needs to be determined to address the factor or factors identified.

Want to learn more about how root cause analysis can benefit your company? Contact Insyte Consulting for more information.

Phil Celotto, Insyte Consultant pcelotto@insyte-consuting.com

Phil helps WNY companies improve their operations through the implementation of lean manufacturing practices and ISO quality management systems. In addition to Insyte, Phil has worked at Hughes Aircraft, Carleton Technologies and SoPark Corporation in the engineering and operations fields. His experience includes positions as Project Engineer, Systems Engineer and Operations Manager. Phil is a certified Lean practitioner from SME/AME, has ISO 9000 and ISO 13485 Provisional Lead Auditor certifications and is an active member of APICS. He holds an MBA and a Bachelor of Science in Mechanical Engineering from the University at Buffalo.


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