ATTACHMENT B

CULPABILITY ASSESSMENT DIAGRAM[1]

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Were actions intended? / This question helps determine the person’s intent relative to the person’s immediate objective. If the actions were not intended (“I meant to push button “A,” but somehow pushed Button “B.”), then a slip or lapse occurred. If the answer is “NO,” proceed to the question regarding procedures and expectations.
Were consequences intended? / If the person intended to perform the action, but not the consequence, then the action is more likely a mistake or a possible routine violation or shortcut. If the answer is “NO,” proceed to the next question regarding expectations. However, if the answer is “YES,” then the performance situation does not involve an honest mistake, but a deliberate, malevolent act intended to cause harm.
Intentional act to cause harm / Performance involves a willful act intended to cause harm. A disgruntled worker whose purpose is to undermine or destroy the employer’s efforts, accomplishments, or products usually carry out workplace sabotage. Immediate management attention is required. There may be broad ramifications to person’s actions.
Explore performance management ... / Typically, individuals receive penalties in a progressive fashion usually in the order of verbal warnings, written warnings, and eventually termination. Disciplinary action is sometimes necessary. Occasionally, termination is the best option for unruly individuals, who can be a troublesome and dangerous influence to the rest of the workforce. However, disciplinary action can seriously damage the perception of trust, respect, and fairness if handled uncaringly. But, if the performance problem seriously threatens safety and reliability, then risking undesirable side effects to stop the behavior immediately is warranted. [2]
Knowingly violated procedures or expectations? / A violation involves a conscious decision on the part of the individual to bend or break the rules. Did the individual recognize the risk of the action, and what was the individual’s “intent” in light of the risk? The answer is “YES,” if the individual was aware of the expectation, but consciously chose not to conform to it.
However, a person’s care or rigor of execution of an expectation sometimes “drifts” from the written standard to something different than intended by management. The current practice may have become acceptable by the lack of correction by managers or supervisors. The “violation” or shortcut may have become the workgroup’s norm-a routine violation-and the individual may not have consciously violated the written expectation. If so, a “NO” answer should be considered, and the substitution test evaluated next.
Were procedures or expectations available, intelligible, workable, and correct? / Proper procedures and reasonable expectations are to be sensible, logical, and practical for the work situation. The procedure or expectation may not accurately match the work situation, requiring the individual to work around the situation to get the job done. Such work situations tempt the individual to make a judgment call in the field. Managers and supervisors develop procedures and expectations with imperfect knowledge of all work situations that workers could possibly encounter. A procedure or expectation for a particular situation may, if fact, create an unsafe condition, and it would be prudent for the person to “violate” the expectation to avoid the obvious consequences. If it can be argued that the individual was attempting to achieve the desired outcome, but the situation rendered the expectation or procedure unsuitable, then a “NO” answer is appropriate. If the answer is “NO” or cannot be established, then the error or violation may have been system induced.
However, if procedures and expectations were readily available, workable given the work situation, intelligible, and correct, and communicated to the individual, then “YES” is a proper response, and the individual is culpable for a possible reckless violation.
Possible reckless violation / Recklessness involves taking a deliberate and unjustifiable risk—one that is foreseeable and where a bad outcome is likely though not certain. Obviously, the justification for any action depends on 1) its value to the organization and emphasis leadership places on it and 2) the probability of foreseeable and harmful consequences. Although not as serious as sabotage, management attention to such acts requires immediate action and investigation.
System-induced violation / People perform within a system designed to facilitate the accomplishment of the organization’s mission and goals. The system comprises the technology, organizational processes and procedures, standards, values, and beliefs, among others used by management to govern people’s behavior and practices in the facility. Deficiencies with one or more of these organizational factors likely created the conditions for violation. The quality and usability of procedures require further scrutiny, the sensibility or suitability of the expectation(s) in question needs review, or management or supervisory practices are questionable.
At this point, it seems appropriate to apply the substitution test to substantiate the culpability of the individual once deliberate non-compliance has been eliminated as a factor in the event
Passes the
substitution test? / This question acknowledges that even the best make mistakes at times. The analyst can apply a simple mental test by asking him/herself the following question: ‘In the light of how events unfolded at the time as perceived by the individual in real time, could one or more motivated, comparably qualified and experienced individuals make the same kind of error under similar circumstances?’ If the answer is “probably,” the answer is “YES,” and assigning blame will obscure systemic or organizational deficiencies.
Another way to evaluate the substitution test is to personally ask the individual’s peers, ‘Given the circumstances that prevailed at that time, could you be certain that you would not have committed the same or similar action?’ Again, if the answer is “probably not,” then “YES” is the proper response to the substitution test.
If the individual does not pass the substitution test, then the performance problem is specific to the individual or the work setting.
Deficiencies with work setting, training, selection, resources, or incentives? / If factors exist regarding the work setting, the person’s training, qualification, selection, resources, or incentives relevant to the job, then there is likelihood that the unsafe act was organizationally-induced. Proficiency, experience, fatigue, and fitness for duty are other factors to consider. A person may be qualified and experienced, but may not have performed the task recently enough to stay current with its demands. If no deficiencies exist with the work setting, training, selection, resources, or incentives, then a possible negligent error is considered.
Possible negligent error / Negligence involves bringing about a consequence that a ‘reasonable and prudent’ person would have foreseen and avoided. A reasonable person would have been aware of the potential consequence and avoided the act. There is much less culpability associated with negligence than with recklessness. This is a situation where the person’s intent was honorable, but his or her action, in retrospect, was unwise. Usually, there are extenuating circumstances that may explain why the person was unaware of the potential consequence; “Why did he or she think it was the correct action to take?” Absentmindedness, which varies considerably between individuals, may have played a role. However, it must remain clear that absentmindedness has nothing to do with ability or intelligence.[3] Depending on the preponderance of evidence, some form of training, counseling, or disciplinary action may be appropriate.
System-induced
error / The conditions associated with the person’s actions were shaped by organizational processes or the prevailing culture—the system. Error precursors possibly existed in the job site during performance that provoked the error. For instance, when the control room reduces the number of concurrent maintenance activities, and the work control process does not adapt the maintenance schedule to the new tempo, craft people will be tempted to hurry through their work to stay on schedule. While hurrying through a work activity, the worker makes a mistake.
Also, the severity of the consequences is the outcome of flawed defenses, not the individual’s action or lack of action. In significant events, organizational weaknesses diminished the integrity, robustness, or presence of defenses.
History of performance problems? / This question helps determine the focus of performance improvement. Either improve the individual’s performance in the current position, or consider other career options that he or she may be more suited to. The process of selecting people for the job may be suspect in that the wrong person may have been place in a job the person is unsuitable for. The person may not have the aptitude—innate capability, ability, or talent—necessary for the job in question. Discipline should not be an automatic response.
People’s personal error rates, and how they err, varies widely but consistently.[4] List any history of performance problems or disciplinary action for this employee that differ from the current problem, but that may constitute a pattern of poor performance, (if relevant). The individual may be a habitual or repeat offender. History may be limited to some standard period of time previous to the occasion under scrutiny.
System-induced error, with remediation / If the person has a history of unsafe acts or errors, it probably indicates the need to consider performance management options, which may include alternate career options, the need for counseling or special training for the individual.
If the error was system induced, identify the organizational contributors. Most blameless errors contain system-induced elements. Identification and resolution of the conditions that provoked the error can be addressed using the corrective action program.
Performance problem self-reported? / All persons involved in or having knowledge of a human error or mistake to:
·  promptly report the error to one’s immediate supervisor or other appropriate authority
·  cooperate in any resulting investigation, and provide input to or assist in determining corrective actions
However, if the individual avoided reporting the error for fear of retribution, there may be concerns regarding the organization’s management style or the immediate work group’s norms and values.
Evaluate relevant organizational processes, standards, and related management / supervisory practices. / The challenge here is to identify how the organization shaped the individual’s behavior. The key is identifying those specific job-site conditions that influenced performance, whether error precursors or other factors. Knowing how a process, standards, or culture influenced worker behavior offers insight into how to improve the particular process or value.
A self-assessment of related processes and cultural factors or a performance gap analysis offer methods to isolate the specific organizational contributors to the particular performance issue.

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[1] Adapted with permission from Dr. James Reason’s Managing the Risks of Organizational Accidents, Ashgate Publishing Limited, 1997, pp.205-213. The above version of the Culpability Assessment Diagram is based extensively on the Human Error Investigation Tool used at Diablo Canyon Power Plant.

[2] Geller, E., The Psychology of Safety, How to improve behaviors and attitudes on the job, CRC Press: Boca Raton, 1996, p.174-176.

[3] Reason, J. Managing the Risks of Organizational Accidents. Ashgate Publishing Limited, 1998, p.211.

[4] Reason, J. Managing the Risks of Organizational Accidents. Ashgate Publishing Limited, 1998, p.211.