Title Page
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Name of Individual
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Address, Phone and E-Mail of Individual
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Document Number
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Conducted by
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Conducted on
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Location
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Signed by
Instruction
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Decision Tree for Unsafe Acts Culpability
To strongly support and foster the organisation’s Just Safety Culture the implementation of the below Decision Tree for Unsafe Acts Culpability is introduced. It is adapted from James Reason’s Decision Tree for Determining the Culpability of Unsafe Acts.
SwissPSA uses the decision tree when analysing an adverse event or error. This will help to identify how human factors and organisational system deficiencies have contributed to the event and thus helping the SwissPSA management discern between unintentional errors and conscious choices to disregard policy, procedures or protocols – and how to respond consistently in a Fair and Just manner.
The presumption of innocence applies and, in this sense, if uncertain err on the side of caution. Meaning the answer should then be in favour of the individual being under scrutiny.
The Substitution Test requires some further explanation:
If the answers to the Questions are „YES“, the problem is not necessarily the individual, but more likely the environment that would lead most individuals to that action. If the answer is „NO“, it is more likely that the individual being evaluated is more culpable and bears more accountability.
Furthermore, whatever the result of this analysis it is crucial to identify contributing system factors.
Deliberate Act Test
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Was the job understood?
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Was the action / act as intended?
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Where the results as intended?
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Malevolent or Willful Misconduct! - Immediate Action is Required!
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Continue with Incapacity Test on next page.
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Continue with Incapacity Test on next page.
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Continue with Incapacity Test on next page.
Incapacity Test
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Is there evidence of ill health, a medical condition, or substance abuse?
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Substance Abuse?
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Medical Condition OR Substance Abuse! - Immediate Action is Required
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Ill health or a medical condition?
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Was the individual aware of the ill health or medical condition?
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Medical Condition OR Substance Abuse! - Immediate Action is Required
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Continue with the third question of Compliance Test on the next page. Mark the first two questions with N/A.
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Continue with Compliance Test on next page.
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Continue with Compliance Test on next page.
Compliance Test
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Did the individual knowingly depart from policies, procedures, protocols or generally accepted performance standards?
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Where the policies, procedures, protocols, or performance standards available, understandable, workable, and clear?
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Is there evidence that the individual choose to take an unacceptable risk, OR has a trend in poor performance or decision making?
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Where there significant mitigating circumstances that justify the action / act in this case?
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Reckless / Grossly Negligent Behaviour! - Action is Required!
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Continue with the second question of Substitution Test on the next page. Mark the first question with N/A.
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Continue with the second question of Substitution Test on the next page. Mark the first question with N/A.
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Continue with Substitution Test on next page.
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Continue with Substitution Test on next page.
Substitution Test
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Would individuals in the same position / profession and with comparable knowledge, skills and experience act the same under similar conditions?
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Where there any deficiencies in related training, experience, resources, or supervision?
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Negligent / Careless Behaviour! - Action is Required!
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Continue with Violation History Test on next page.
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Continue with Violation History Test on next page.
Violation History Test
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Is there a history of violating policies, procedures, protocols or generally accepted performance standards?
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Repeated incident with similar root cause! - Action is Required!
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Blameless Error!
Possible System Induced Error.
Contributing System Factors
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Are there identified Contributing System Factors?
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What are the contributing Factors?
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Why are there no contributing Factors?
Conclusion & Summary
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Conclusion & Summary
Approval
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Date and time of approval
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Approver's signature
