FORM-SGQ-26 REV00 24/01/24

Human Error - Root Cause Analysis

TWTTP: The Way To Teach People
Failure / Error Data

Name of the Collaborator Area

Machine or workstation Sector

TWTTP: The Way To Teach People Root Cause of Suggested Method

(The way to teach people) Error of Solution
1. How do you perform this activity? (validate in the area if the activity is in accordance with the instruction of

work)
A) Employee described the activity in a way {"B":"Employee did not describe the activity","C":"Employee is unaware"}
clear, correct and objective, following the sequence in a clear, correct, and objective manner and/or the activity and its instruction
defined in the work instruction. skipped the stages. of work.

2. How do you know that you are doing your work correctly?
A) I follow the instructions in the Instructions of I follow my own experience and
C) Others
Work, LUPs or Visual Resources I perform self-control of activities

3. How do you know that you executed your work without problems or defects? LUP
A) Practice self-control, know the points Visual Resources
B) Showed doubts about the points LACK OF Training
operation keys and asks the leader for feedback C) Others
work keys. KNOWLEDGE / Operational
about the quality of the product. TRAINING Training in us
Procedures and
4. What do you do if you encounter a problem? Instructions
Service Order
B) This resolver alone the problem and/or
A) I immediately inform the leader or person in charge. C) Others
I'll inform my leader later, if he asks.

If one or more answers are different from A, Q2 must be filled in; otherwise, go to Q3.

1.2.1 Does the process (IT, LUP, POP) allow for this failure? YES NO

1.2.2 Caused by lack of training or insufficient training? YES NO

Was the operator away for more than 3 months? SIM NO

Has the operator been doing this work for less than 1 month? YES NO

HERCA : Human Error Root Cause Analysis

(Root cause analysis of human errors)
2.1 Does the process allow for mistakes or errors? YES NO

There are excessively complex, difficult activities or those that must be carried out with little YES NO
visibility?
2.3 Are there situations of low or lack of ergonomics in carrying out operations? YES NO Continuous improvement
WEAK PROCESS IT (Instruction of
2.4 Do the operations need to be described in a clearer, simpler, and easier to understand way? YES NO Work)

Is there any information missing in the work instructions or operational procedures? YES NO

Is visual management not very clear, incomplete, or even absent? YES NO

Are there basic conditions missing for tools / equipment? YES NO

PROBLEMS IN Poka Yoke
3.2 Are the tools/equipment suitable for performing the operation? YES NO EQUIPMENT AND (Error test)
INSTRUMENTS Continuous Improvement
3.3 All tools/equipment described in the instructions are available for the YES NO
collaborator at the workplace?

4.1 Are there problems caused by excessive workload? YES NO

4.2 Is the workstation organized in a less functional way and easily causes errors? YES NO

ENVIRONMENT OF Improvement
4.3 Is there a wrong organization of the materials stored at the workstation? YES NO Organization of the post
WORK of work
4.4 There are unfavorable conditions, such as poor lighting, inappropriate temperature, noise, etc. YES NO

4.5 There are labels/identifications with a similar appearance used at the workstation that YES NO
Can they generate errors?

Did the person voluntarily carry out the operation to sabotage? YES NO

ATTITUDE AND Coaching /

Is there a general lack of motivation? YES NO Development
BEHAVIOR of People
5.3 Did the collaborator show little pleasure with the specific operation they are performing? YES NO

OPL, Poka Yoke

6.1 Are there sources of distraction for the operators? YES NO
DISTRACTION Visual Resources,
FORGETTING Involvement of
Is the content of the work excessively repetitive? YES NO People

Does the employee have physical or health limitations/problems? YES NO Coaching

PROBLEMS
Involvement of
PERSONAL People
Does the employee have other problems? YES NO

Comments

Researcher Name Data

FORM-SGQ-26 REV00 24/01/24