Error Management as Organisational Strategy
Robert L. Helmreich
University of Texas Aerospace Crew Research Project
Austin, Texas USA
Errare humanum est.
An anonymous Latin saying, ‘To err is human’ still defines a universal characteristic of
our existence. While organisations can strive for a ‘zero error’ state, it is not an attainable goal.
So long as humans function in complex environments, errors will occur. And when under stress,
work overload, or work underload or boredom, the probability of error is increased. The best that
organisations can hope for is to manage error effectively, decreasing the probability of errors and
minimising their consequences (Helmreich & Merritt, 1998).
Psychologists have gained a thorough understanding of human error and its roots in
mental processes (Reason, 1990). However, the management of error in complex systems such as
aviation is an organisational task that cannot be achieved by dealing with psychological issues
alone. My goal is to describe organisational strategies for error management, of which Crew
Resource Management (CRM) is one important element and the vehicle for teaching error
management strategies to flight crews (Helmreich & Merritt, 1998, Reason, 1997).
WHAT IS ERROR MANAGEMENT?
By error management we mean the using all available data to understand the causes of
errors and taking appropriate actions, including changing policy, procedures, and special training
to reduce their incidence of error and to minimise the consequences of those that do occur.
Figure 1 shows the range of outcomes that crews may experience after an error is committed.
of Accident or Incident
of Safe Flight
Figure 1. Outcomes of error
University of Texas at Austin Human Factors Research Project: 225
Helmreich, R.L. (1998). Error management as organisational strategy. In
Proceedings of the IATA Human Factors Seminar
(pp. 1-7). Bangkok,
Thailand, April 20-22, 1998.
Research supporting this paper was supported by Federal Aviation Administration Grant 92-G-017, Robert
Helmreich, Principal Investigator. Figures are adapted from Helmreich & Merritt,
Culture at Work in Aviation and
with permission of Ashgate Publishing, Aldershot, UK.