ATTACHMENT B
CULPABILITY ASSESSMENT DIAGRAM1
Start:
Were
actions
intended?
Knowingly
violated procedures
or expectations?
No
Yes
Yes
No
Were
procedures or
expectations
available, intelligible,
workable, and
correct?
Deficiencies
with work setting,
training, selection,
resources, or
incentives?
No
Were
consequences
intended?
Passes the
substitution
test?
No
Yes
History of
performance
problems?
No
Performance
problem was
self-reported?
Yes
No
Yes
Yes
No
Possible
reckless
violation
Intentional act
to cause harm
System-induced
violation
No
Yes
Yes
Possible
negligent
error
System-induced
error
System-induced
error, with
remediation
System-induced
error
Evaluate relevant organizational
processes, standards, and related
management / supervisory practices.
Explore performance management
options befitting the performance
problem up to and including
disciplinary action.
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.
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.
1
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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
2
Geller, E., The Psychology of Safety, How to improve behaviors and attitudes on the job, CRC Press: Boca Raton,
1996, p.174-176.
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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 noncompliance 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
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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 organizationallyinduced. 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
3
Reason, J. Managing the Risks of Organizational Accidents. Ashgate Publishing Limited, 1998, p.211.
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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 selfreported?
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.
4
Reason, J. Managing the Risks of Organizational Accidents. Ashgate Publishing Limited, 1998, p.211.
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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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