Culpability. User Guide

Transcription

1 Culpability Decision Tree User Guide

2 Guidance for Using the Culpability Decision Tree This guideline provides instructions for using the Culpability Decision Tree in order to more objectively determine the relative culpability of the individual(s) involved when human error occurs. Use of the tool may also provide additional insight into the mindset of the personnel involved, the context of the situation, and the process, programmatic, organizational, and/or managerial/supervisory influences that may have affected decisions/behaviors. When used properly, the Decision Tree is designed to assist in drawing conclusions regarding relative culpability through use of a series of YES/NO answers to associated questions. Following is some additional guidance that may be used for further guidance/clarification. Q1 Were the actions as intended? At this point you are only concerned about behavior. In order to answer this question, you must know: a. the actions being evaluated b. the goal and how those actions are related to the goal c. the degree of success the individual had in executing the actions he/she planned to execute This is not an error. An intentional act causing negative consequences may be considered sabotage. The act is almost certainly an error since what he/she did is not what he/she intended to do. Q2 Were the consequences as intended? In order to answer this question, you need to know: a. the planned actions intended to achieve the goal b. how successful the actions were in achieving the goal c. the expected outcomes d. the actual outcomes (i.e., results) e. additional outcomes that occurred (if any), and whether those outcomes were considered/conceived of by the individual Page 1 of 9

3 Continue to Q3. Go to Conclusion C1. This was an intentional act (not human error). Q3 Were unauthorized substances used? The purpose of this question is to establish whether or not the individual was under the influence of alcohol or drugs known to impair performance at the time the actions were committed. Q4 Was there a medical condition? This question prompts you to determine if there was an actual medical condition that precipitated the individual using/taking the substance, albeit without authorization. While the substances used may be legal, for example alcohol or prescription drugs NOT prescribed for the individual involved, C2 is a potential conclusion due to the individual s violation of company expectations and policies. If the individual has a medical condition for which the substance was utilized, C3 should be the likely conclusion if (1) use of the substance contributed to the error, and (2) the individual was not in compliance with company policy for the use of such substances at the time the incident occurred Q5 Were there medical restrictions on the employee? If a medical condition had been reported to and acknowledged by the company, then there may have been medical restrictions imposed on the employee s job duties and tasks. Q6 Were restrictions clearly communicated and understood? If medical restrictions were in place, this follow-up question seeks to determine how well those restrictions were communicated to the individual involved, and whether they were properly understood. Page 2 of 9

4 The worker disregarded medical restrictions (C4) While medical restrictions were in place, a lack of awareness / understanding on behalf of the employee tends to indicate a system-induced violation (C5) NOTE: Conclusions C5, C7, C9, C10, and C11 tend to indicate that some aspect of the "system" contributed to the error. When answers to the questions in the Decision Tree lead to any of these Conclusions, an evaluation of associated process, programmatic, and organizational issues, as well as associated managerial/supervisory practices should be completed. Q7 Did the employee knowingly violate expectations? If it is established that the individual was aware of the expectations, but consciously elected not to conform to those expectations, then the answer would be YES Q8 Were expectations reasonable, available, workable, intelligible, and correct? To answer this question, you may need to evaluate the associated documentation, as well as seek input from the associated supervisor and/or other employees who are familiar with the task. The violation was induced by weaknesses in the organizational system (C7) This is a possible "reckless" violation Page 3 of 9

5 NOTE: It is appropriate here to recognize that most "violations" in the workplace are not initiated maliciously, but rather, either because the individual believes there is a "better" (quicker, easier, etc.) way of completing the work, or because the job cannot be completed if work instructions are followed verbatim. The primary motivation of workers is to get the job done. Whether C6 or C7 is the Conclusion reached, it may be appropriate to ask Q9 (the "Substitution Test") to (1) determine the extent of condition of such behaviors, and (2) the extent to which the "system" (organizational culture, etc.) played a contributing role. Q9 Does the situation pass the substitution test? The "substitution test" asks the following question: Would another appropriately-motivated and equally qualified individual have made the same choices / demonstrated the same behaviors at that time under the same conditions? The answer to this question is typically obtained by asking such "other" individuals in an environment that will yield frank and honest responses. Such answers may also indicate whether such actions have been condoned or become routine. While the system may have contributed to the error, failure of the substitution test places the individual s judgement outside the cultural norm under the conditions at the time of the incident. Deficiencies in training, assignment, etc. must now be asked per Q10. When the question passes the substitution test, it tends to diminish individual culpability; however, Q11 must now be considered. Remember that this may indicate a larger extent of condition of the associated behaviors. Page 4 of 9

6 Q10 Were there deficiencies in training, selection, assignment, or experience? Training provides workers the appropriate behavioral skills, related knowledge, and attitudes needed to perform their job duties. Selection and assignment refer to considerations and processes used to hire people and assign them specific responsibilities and on-the-job tasks. Experience is knowledge, skill or practice derived from direct observation of or participation in events. Go to C8. If the substitution test was used (see the Note following Q8), the information gathered from the peer responses should be considered, at least in part, to help determine any level of negligence on the part of the individual. Go to Conclusion C9. Subsequent analysis should be directed at the specific deficiency in order to determine the associated systemic causes. Q11 Does the employee have a history of human performance problems? Have there been previous instances where the individual had this (or similar) performance problem(s)? While C10 indicates this to be a "blameless error", some type of correction is warranted, whether it be additional training, coaching, mentoring, etc. Be aware that a series of "human performance problems" by an employee may be an indicator that (1) there may be underlying personal / work related issues that have arisen, or (2) the individual is in a position not necessarily fitted to the best use of his/her skills and abilities. We have now enter the space of human fallibility, where it could simply have been the individual's 'unlucky day.' This being said, we are seeking a culture of self-reporting, and therefore now ask whether the individual self-reported. Page 5 of 9

7 Q12 Was the performance problem self-reported? Self-reporting can be in the form of the individual notifying management of an error, or if the individual acknowledged that an error was made when it was identified or pointed out by a supervisor or co-worker. Even though the error may be blameless (per C10), some remediation or mentoring may be appropriate within organizations actively promoting self-reporting At this level, the individual involved is deemed to have no culpability. There should be zero negative consequence to the employee. CONCLUSIONS C1 Intentional Act This was not an error; the behavior is possibly sabotage, malevolent damage, willful violation, etc. C2 Substance Abuse Without Mitigation Company procedures for dealing with instances of substance abuse should be initiated. C3 Substance Abuse With Mitigation Company procedures for providing mitigation when dealing with instances of substance abuse should be initiated. C4 Disregard of Medical Restrictions Company procedures for establishing and enforcing medical restrictions should be initiated. Page 6 of 9

8 C5 System Induced Violation This was a violation of medical restrictions that were not clearly communicated to or understood by the employee. While there is a substantial potential for individual culpability, system influences (lack of clarity, inadequate communication, etc.) upon the associated behavior(s) must be evaluated. C6 Possible Reckless Violation In a situation where the expectations, associated expectations and processes were correct and appropriate under the conditions at the time the error occurred, this could indicate the individual's disregard for "following procedure." When this conclusion is reached, ensure that the substitution test is considered as previously discussed (see the Note following Q8). Possible reckless violation C7 System Induced Violation When this conclusion is reached, an evaluation of associated process, programmatic, and organizational issues, as well as associated managerial/supervisory practices should be completed. C8 Possible Negligent Error This is an appropriate conclusion if another person (peer) would have foreseen and avoided bringing about the consequence. It suggests more individual culpability than a system-induced error. Corrective action should seek to understand why the individual did not recognize the potential consequence and why he/she believed his/her behavior was appropriate for the situation. C9 System Induced Error This was an error provoked by the system in which the individual was working. If there was a deficiency in selection and/or assignment, Page 7 of 9

9 further analysis should focus on the hiring process. Deficiencies in training or experience should analyze the training and qualification process for the individual s job position. Other parts of the system should be evaluated for related causes. C10 Blameless Error; Remediation May be Warranted In this case, the behavior (or history of this type of behavior) may warrant some form of remediation. Determining the performance mode of the error (skill-, rule- or knowledge-based) may serve to indicate the appropriate training or form of remediation needed. Analysis of organizational processes and management/supervisory practices should also be conducted. C11 "Blameless Error" When this conclusion is reached, there should be no overt consequences to the employee. Analysis of associated organizational processes and management/supervisory practices should be conducted to identify conditions that might have provoked the error, as well as any weaknesses in associated barriers/defenses that failed to prevent it / mitigate its consequences. Page 8 of 9