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Team Performance Module navigation.
Module Introduction
Lesson Goals
Team Use
Decision Making
Team Types
Development
Goals
Motivation
Performance
CRM
Human Error
CRM Model
Systemic Model
Error Management
CRM Effectiveness
Module Summary
Course Conclusion
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Team Performance Module > Human Error - 2 of 6
 
 


Human Error - CRM Systemic Error Model

CRM is the embodiment of the systemic approach to human error. Both humans and systems are fallible; latent conditions exist within the environment--Errors Happen! If we cannot prevent all human error, then, we must concentrate on error management to eliminate errors before they lead to an accident or adverse event--or at the very least, to limit the “consequences” of error. Further, the resolution of safety issues is through correction, not through punishment or discipline--except in cases of intended harm.

The following illustration provides an example of an unintended, human error. The controller fails to detect a readback error. The error chain continues with the controller's late response to the Short-term Conflict Alert warning and an incorrect command for Flight ABC123 to "turn right." The result is a loss of separation minima and a potential mid-air collision.

visual demonstration of error chains also known as cascades
Accidents are usually caused by more than one error event.
Multiple events create"error chains" or "error cascades."*

*Illustration adapted from European Air Traffic Management, "The Human Error in ATM Technique (HERA-JANUS)," Edition 1.0, p10.

  
 

   

  
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