Performance Category

Description

Sub-Category

Evaluation

Comment

Ask the following questions for all categories:

1) Does it exist?

2) Did this cause the event?

3) Is something missing?

4) Is there an opportunity to correct?

5) Other thoughts to consider?

Policies and procedures

This category deals with the corporate policies and procedures.

System policies and procedures

1) Does the organization have a policy or procedure that applies?

2) Does the policy or procedure work?

3) If not what changes are needed?

Work direction

1) What was the work direction?

2) How was the work direction given? Verbally? In writing?

3) Do you have confirmation?

Performance Category

Description

Sub-Category

Evaluation

Comment

Communications

1) How did the parties communicate? Verbally or In writing?

2) Was "Third Part" communication followed?

Training

1) Does a training procedure exist? If not, why not?

2) Was the employee trained properly? If not, why not?

Quality Control

1) Is there a Quality Control program? If not, why not?

Barriers

1) Are there any barriers were the cause of negative results?

2) Do policies or procedures exist that are causing the problem?

3) Is there money available to fix the problem?

Human Performance

1) Do policies and procedures exist?

2) If not, will relevant policies and procedures be developed and implemented?

Performance Category

Description

Sub-Category

Evaluation

Comment

Ask the following questions for all categories:

6) Does it exist?

7) Did this cause the event?

8) Is something missing?

9) Is there an opportunity to correct?

10) Other thoughts to consider?

Policies and procedures

This category deals with the corporate policies and procedures.

System policies and procedures

4) Does the organization have a policy or procedure that applies?

5) Does the policy or procedure work?

6) If not what changes are needed?

Work direction

4) What was the work direction?

5) How was the work direction given? Verbally? In writing?

6) Do you have confirmation?

Performance Category

Description

Sub-Category

Evaluation

Comment

Human Performance, continued

3) If they exist will they be improved?

4) Did the person fail to follow training policies, and procedures?

5) Are there logical reasons for the failure of human performance?

Repeat Failure

1) Has this event happened before?

2) Why?

3) Why not?

4) What can be done to keep the same event from occurring again?

System Operation and Equipment

This section applies to how the system is performing or not performing. The same set of questions also applies to the pieces of equipment.

Operation Maintenance

1) Do policies and procedures exist?

Performance Category

Description

Sub-Category

Evaluation

Comment

System Policies and Procedures

2) If not, will relevant policies and procedures be developed and implemented?

3) If they exist will they be improved?

Design

1) Does a design problem exist?

2) Did the entity contact the equipment supplier or manufacturer?

3) Did this cause the event?

4) Is something missing?

5) Is there and opportunity to correct?

6) Any additional thoughts to consider?

Management Systems

1) Do policies and procedures exist?

2) If not will relevant policies and procedures be developed and implemented?

3) If they exist, will they be improved?

Performance Category

Description

Sub-Category

Evaluation

Comment

Defective Parts

1) Did parts fail? Why?

2) What improvements can be made?

3) Has the entity contacted the manufacturer? If no, why not?

Quality Control

1) Was the process inspected for flaws?

2) Was the work area inspected for problems?

3) Why not?

Training

1) Was staff trained properly?

2) If no, why not?

3) Any improvements needed?

4) Should the entity propose changes to the equipment supplier or manufacturer?

Repeat Failure

1) Why are the same mistakes occurring?

2) Any improvements needed?

3) Should the entity propose changes to the equipment supplier or manufacturer?

Performance Category

Description

Sub-Category

Evaluation

Comment

Human Performance

This area deals with the human element

Individual

1) Was the employee properly prepared to perform the tasks?

2) If not, why not?

3) What improvements can be made?

Team

1) Was the team adequately prepared to perform its work?

2) If not, why not?

3) What improvements can be made?

Management System policies and procedures

1) Do policies and procedures exist?

2) If not will relevant policies and procedures be developed and implemented?

3) If they do exist will they be improved upon?

Performance Category

Description

Sub-Category

Evaluation

Comment

Training

1) Does a training procedure exist? If not, why not?

2) Was the employee trained? If not, why not?

Communications

1) Did the parties involved communicate verbally or in writing?

2) Was "third part" communication followed?

Quality Control

1) Was the process inspected for flaws?

2) Was the work area inspected for problems?

3) Why not?

Work Direction

1) What was the work direction?

2) How was the work direction given? Verbally or in writing?

3) Did the employee confirm expectations?

Environment

1) Was the work environment bearable?

2) Was the work environment bearable?

Performance Category

Description

Sub-Category

Evaluation

Comment

Environment continued

3) Was the work load balanced?

4) Was the staff overworked?

5) Proper safeguards in place?

6) Were there other factors that exist that made it difficult to perform tasks?

Barriers

1) Are there any barriers that caused negative results?

2) Do policies or procedures exist that are causing the problem?

3) Does money exist that can fix the problem?

Repeat Failure

1) Why are the same mistakes occurring?

2) Are there any improvements needed?

3) Should the entity propose changes to the equipment supplier or manufacturer?

Performance Category

Description

Sub-Category

Evaluation

Comment

Corrective Action Plan

Repeat Failure

Cost to Correct

Lesson Learned

Should this event be shared with the industry?