Building a Reliable Organization: The Evolution of Error-intolerance in the FAA.

Previous High Reliability Organizational (HRO) research reveals that some organizations demonstrate the ability to use high-risk technologies to routinely conduct operations with little or no error. A 76-year longitudinal case study examines five major historical aviation legislative periods that evaluate seven nonincremental and incremental policy actions to determine the role of policy change and implementation in shaping error-intolerance within the FAA's air traffic control services. It was found that ATC service evolved as part of a larger policy-agency-industry error-intolerant system. A conceptual systems model was constructed to explain how legislative oversight, agency regulatory programs, and industry operations combine into an extremely redundant structure that operates with extremely low error rates. A scale has been constructed capable of measuring and improving error-intolerance for policy and organizational levels of government, but has promise for use in performance improvement in private and non-profit sectors as well.