Applying AcciMap and STAMP to the analysis of human error in complex manual assembly

Abstract

In sectors such as aerospace manufacturing, human errors in the assembly of complex products can negatively impact quality, productivity, and safety. Until now, the analysis of assembly errors has focused more on the immediate human-system interface and less on broader organizational factors. This article presents a case study-based analysis of assembly errors in the aeronautical industry using the systemic methods AcciMap and Systems-Theoretic Accident Model and Processes (STAMP). We seek to provide the company with elements to build a quality improvement strategy that considers human factors and ergonomics from a systemic perspective. The data and information necessary to conduct the analysis came from a project carried out at an aerospace manufacturing facility over a period of 12 months. The team had direct and recurrent access to primary data sources and communication with various stakeholders. A total of 31 influencing factors were identified with AcciMap at different levels within the manufacturing system. STAMP made it possible to model the sociotechnical control structure of the assembly process and identify several control flaws leading to hazards. The analysis shows that systemic methods require a high level of understanding of the manufacturing system and access to relatively high amounts of data and information. Therefore, direct contact with the field and stakeholders is crucial. Training quality specialists on systemic methods could support its use and help to close the gap between theory and practice. Globally, the field of quality in manufacturing could benefit from using systemic methods when deemed necessary.