Human error management

Abstract

The focus of this research is safety critical systems management set within the context of a series of Lean brown field manufacturing case studies. The thesis is founded upon a human factors perspective of quality/safety management and the perceptions of over 800 workers drawn from 4 corporately owned aero repair & overhaul UK sites. Traditionally, human factors and aviation research has focused upon aircraft operations, where pilots and to a lesser extent air traffic controllers, have increased their ability to make safety critical decisions based on improved levels of team situational awareness. No literature exists to demonstrate the same potential from a front line operations perspective of aircraft maintenance engine overhaul, especially, within the context of Lean operations. The research hypothesis is problem driven and theory building using a cross-case comparative method involving both qualitative and quantitative data collection. Data was analysed using a non-parametric design and seeks to extract differences in quality attitudes. Results show the most significant barrier to quality and safety effectiveness, originates from management planning and workplace control. This is a condition that was found to be perpetuated by a lack of understanding for how to transition from traditional craft based engineering, towards a more lean approach within the context of Total Quality Management (TQM) literatures. The study shows corner cutting is a precondition of leadership and its front line engineering resource namely; self-managed teams. Results also demonstrate that people do not intentionally make mistakes, but generally do, because of operations system pace/instability of material flow. The researcher therefore concluded with a challenge to design new ways of neutralising latent error conditions before the safety critical events breach the quality systems defence mechanisms at each case study concerned