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.

中文翻译：

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应用 AcciMap 和 STAMP 分析复杂手工装配中的人为错误

在航空航天制造等行业，复杂产品装配中的人为错误会对质量、生产力和安全性产生负面影响。到目前为止，对装配错误的分析更多地关注直接的人机界面，而不是更广泛的组织因素。本文介绍了使用系统方法 AcciMap 和系统理论事故模型和过程 (STAMP) 对航空工业中的装配错误进行基于案例研究的分析。我们寻求为公司提供要素，以建立从系统角度考虑人为因素和人体工程学的质量改进战略。进行分析所需的数据和信息来自一个在航空航天制造设施中进行的为期 12 个月的项目。该团队可以直接和经常访问主要数据源并与各种利益相关者进行沟通。在制造系统的不同层次上，共识别出 31 个影响因素。STAMP 可以对装配过程的社会技术控制结构进行建模，并识别导致危险的几个控制缺陷。分析表明，系统方法需要对制造系统有高度的了解，并需要访问相对大量的数据和信息。因此，与该领域和利益相关者的直接联系至关重要。就系统方法培训质量专家可以支持其使用并有助于缩小理论与实践之间的差距。在全球范围内，制造质量领域可以在必要时从使用系统方法中受益。