- Error Management as Organisational...

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Error Management as Organisational Strategy Robert L. Helmreich 1 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. Errors Exacerbated Errors Mitigated Errors Missed Errors Trapped Higher Probability of Accident or Incident Higher Probability of Safe Flight Crew Response 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. 1 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 Medicine, with permission of Ashgate Publishing, Aldershot, UK.
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Helmreich 2 Error management recognises the inevitability of error and adopts a non-punitive stance toward inadvertent error. A refocused human factors training program integrates Crew Resource Management training into the error management philosophy is an essential component. CULTURE AND ERROR National culture and error . Flight operations occur within the context of three cultures – the national culture surrounding the organisation, the professional culture of aviators, and the company’s organisational culture. Some aspects of national culture increase the probability of safe flight while others increase risk. Figure 2 shows some of the positive and negative aspects
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This note was uploaded on 05/06/2011 for the course ECON 101 taught by Professor Jillmurray during the Three '11 term at La Trobe University.

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