We have been off the Bulletin Board recently. There just haven't been
enough hours in the day - either in Austin or Paris. We have been forwarded
some of the interesting interchanges about error management and wanted to
add our two cents worth.
Why fiddle with CRM?
Over the past years, our group has noted several things in evaluating the
impact of CRM training. First, not all participants react favorably and
some decry it as pop psychology aimed at ameliorating a variety of
interpersonal problems. Second, many pilots queried have lost sight of its
original focus on 'pilot error' (Merritt & Helmreich, 1996). Third, the
export of CRM programs from the US to other cultures has not been terribly
successful (Helmreich & Merritt, 1998). Motivated by concerns associated
with the non-operational nature of some curricula and the association with
aspects of "pop psychology," some organizations have dropped the CRM label
from their programs in favor of a label such as "Human Factors Training"
and have advocated a general abandonment of the CRM name because of its
negative associations with these earlier approaches. Many organizations
have developed their own names and acronyms for CRM and this remains a
means of identifying the training with the particular organization. Because
of the global implementation of CRM programs, it would probably lead to
considerable confusion if the name were suddenly abandoned. One possibility
is to describe the programs as Error Management CRM (EMCRM) as a means of
stressing the operational focus of contemporary programs and to
differentiate them from early forms of training. Regardless of the label,
the important point is to stress the focus of CRM on training issues that
contribute to effective flight management.
We sought a rationale for CRM that might be universally acceptable and
still faithful to the original intent of programs. We first suggested a
fifth generation of CRM based on error management to fulfill this need at
an IATA Human Factors Seminar in Warsaw in 1995 and have since tried to
expand on the concept (Helmreich, Merritt, & Wilhelm, in press-a). When we
talk about the evolution of CRM, we are not suggesting that the programs
have gone through progressive stages in every organization. Rather, we are
recognizing the fact that programs developed at different times over the
last twenty years do have systematic and recognizable differences.
We feel that CRM is a viable and successful approach to human factors
problems, but still recognize that it is regarded in some quarters as a
failed enterprise since accidents attributed to CRM failings continue to
plague the industry (more on this later).
What do we mean by error and error management?
These definitions govern our discussion of error and error management:
Human error. Human error is defined as action or inaction that leads to
deviation from crew intentions or situational requirements such as
policies, regulations, and standard operating procedures. Errors may lead
to inadvertent violations of rules and are an inevitable result of human
limitations. On the other hand, willful violation of rules and procedures
is not error and cannot be tolerated by any organization. How an
organization deals with error and violations is a critical element of its
culture. Thus, the success of a program is dependent on whether or not it
is congruent with the organizational culture. This is why developers need
to have an accurate understanding of the organizational culture while
developing programs. Errors in the operational context tend to reduce the
margin of safety and increase the probability of accidents of incidents
(Helmreich, Merritt, & Wilhelm, in press-b).
Error management. James Reason (1997) defines error management at the
organizational level as having two components, error reduction and error
containment. Error reduction consists of measures taken to limit the
occurrence of errors while error containment consists of the measures taken
to limit adverse consequences. Error management at the crew level is
defined as actions taken either to reduce the probability of errors
occurring (error avoidance) or to deal with errors committed either by
detecting and correcting them before they have operational impact (error
trapping) or to contain and reduce the severity of those that become
consequential (error mitigation). It is also possible for crew actions to
exacerbate the consequences of error.
What is different about CRM focused on Error Management?
In many ways CRM as error management is a refocusing of basic CRM concepts
and behavioral strategies, which are now identified as error
countermeasures. However, the justification and some of the global
curriculum topics do differ. Since pilots' professional cultures show a
considerable degree of denial of personal vulnerability to stressors. (For
example, a high percentage of pilots believe that their decision making is
unaffected by emergency conditions. This false since of invulnerability is
likely to make them less accepting of the need to utilize the resources of
the crew in emergencies). It is important that limitations of human
performance be credibly presented as part of training, including the
inescapable fact that human error is inevitable and ubiquitous. The nature
of human error should also form a part of basic training, and be revisited
in recurrent. Both of these should be illustrated with data from aviation
experience.
Most CRM training has addressed the avoidance of error or recovery from
external, catastrophic failures (e.g., UAL 232). In the new iteration an
explicit concern needs to be on recovery from error, whatever its source.
Another shift in training for involves the qualification of instructors and
evaluators. Historically, they have focused attention on their role as
error detectors (Tullo, in press). They must expand their role to train and
reinforce recovery from error and the management of inevitable errors. In
the new approach, instructors and evaluators need preparation to
concentrate on assessing and reinforcing error management strategies.
Another element that has not been stressed in many programs is making the
position and role of CRM in organizations explicit. It is not a single fix
for human error. Rather, it is a part - a critical part, but still only a
part - of an organizational commitment to error management that includes
building and nurturing a safety culture. When CRM is positioned and
described correctly, we should see fewer criticisms of the CRM because it
has not eliminated human nature and human failings. In summary, CRM as
error management is part new and part repackaging. Initial results from
organizations that have made the transition are very positive.
References
Helmreich, R.L., & Merritt, A.C. (1998). Culture at work: National,
organizational, and professional influences. Aldershot, United Kingdom:
Ashgate.
Helmreich, R.L., Merritt, A.C. & Wilhelm, J.A. (in press-a). The evolution
of Crew Resource Management. International Journal of Aviation Psychology.
Helmreich, R.L., Merritt, A.C. & Wilhelm, J.A. (in press-b). Applying
Resource Management Across Organizational, Professional, and National
Cultures. In E.Salas, C.A. Bowers, & E. Edens (Eds.). Applying Resource
Management in Organizations: A Guide for Training Professionals. Hillsdale,
NJ: Erlbaum.
Merritt, A.C., & Helmreich, R.L. (1996). CRM: I hate it, what is it?
(Error, stress, culture). In Proceedings of the Orient Airlines Association
Air Safety Seminar. Jakarta, Indonesia, 123-134.
Tullo, F. (in press). Instructor/evaluator training in error management. In
R.S. Jensen (Ed.), Proceedings of the Ninth International Symposium on
Aviation Psychology. Columbus, OH: The Ohio State University.