Get the First Things, First

 

Make sure you start off with the right attitude.  We use the term inappropriate when we approach solving human performance issues because it takes away any moral judgment and just tries to examine the facts. 

"Just the facts, mamm" used to be one of my favorite Joe Friday teaching methods.  Our idea when we started evaluating people's performance was that most people want to do the right thing.  Sure, there are those that don't, but HUMAN doesn't really apply to them (that's what we call "intentional acts").  Intentional Acts are interrogated.  Inappropriate Actions are evaluated.

Isolate the "inappropriate action"

What makes an action "inappropriate"?

First and foremost, know what was supposed to happen in a given situation.  If you don't know what was supposed to happen, it will be almost impossible to determine which action was inappropriate for the actual situation.   Let's say that the appropriate steps were "A B C D E".  Let's look at some types of Inappropriate actions:

Omissions - This is kind of the antithesis so I'll mention it first.  An action was required for the situation, but was NOT taken.  

Using our example "A B C D E", this would be like "A B D E".

Out of Sequence - These are inappropriate because the correct action was taken, but it was not in the proper order with regard to other actions and the current situation.  

Example: "A B D C E"

Untimely Act - The correct action was taken in the proper order, but not within time constraints.  

Example: "A B         C D E"

Quantitative Deficiency - The action was correct, in the proper order, at the proper time, but was either too little or too much of the intended action (i.e., "The operator turned the valve two turns when he meant to turn it only one turn."). 

Example: "A B c D E"

Wrong Unit or Train - The action was correct, in the proper order, at the proper time, in just the right amount, but was performed on a incorrect train (when redundancy is in place) or unit (in the case of multiple standalone units).  

Example: "A B C D E -> Wrong Unit or Train"

Extraneous Act - The action was taken that had nothing to do with the current situation or process.  It was spontaneous or sporadic.

Example: "A B C 4 E"

How do I determine what was supposed to happen?

Look at procedures and administrative guidance, review training and qualification methods, and always talk to process experts.  Make yourself an event "chain" linking each action in the order required to successfully complete the process.  Add modifiers to any actions that will help you better evaluate the types discussed above (e.g., "Must be completely inserted").

Look for ways self checking can be used, but be careful. "Self Checking" errors can easily become a "dumping ground" for causes, covering up much more deeply rooted problems.  Learn from process experts how an individual, if he stopped to think through the action he was taking--its potential outcomes and expected outcome-- would have verified that the action was taken correctly based upon achieving the expected results.  Be aware of statements like, "He would have never known...", they point to bigger issues.  Look for barriers designed to prevent the error from occurring OR that should have prevented it from propagating to consequence once it did occur.  These barriers also had to fail.

And don't be fooled into believing, "there's no way a procedure could have been written for this situation," it reeks of improper assumptions and poor up front testing.  You would be utterly amazed at the wide variance of situations a procedure can be made to address, and if the actors knowingly moved into "unknown territory", that in itself tells you about the level of risk management knowingly or unknowingly may have encouraged.