Most problems and accidents involve human activity at some point or other. Often, this activity is right at the point of occurrence, and people at the sharp end are usually operating under difficult or confusing circumstances. They make decisions and take actions that, in hindsight, prove to be "wrong" in some way. Then, after something "bad" happens, we perform an investigation and find these "human errors"... and all too often, we stop there without really considering all the factors that shaped the undesired outcome. This article discusses a new tool that has been developed (by me) to help investigators find these factors so they can be used as starting points for root cause analysis.
I developed this tool because I was not satisfied with the existing tools that I have seen. Invariably, these tools were too simplistic, too complicated, or too proprietary. I also wanted something that would be easy for me to remember and reproduce, so that I wouldn't have to carry around some kind of reference document. Finally, I wanted a comprehensive tool that included a wide variety of factors that I have found (through experience) to be important. It should be noted, however, that this tool should not be treated as a comprehensive model for human performance! It is only a tool to help an investigator remember important factors to be considered; it cannot be used to judge the importance of any specific factors. Nevertheless, I have found this tool to be quite useful in my own work, especially during the investigation phase of root cause analysis.
The tool is basically a phrase consisting of first-letter mnemonics that can be used to recall a set of four categories, each containing five separate items, for a total of twenty individual factors. The basic mnemonic is "AC/DC - CHEST PAINS, FRIES & STEAK." Yes, this seems silly. Even sillier is the visualization I use to trigger recall of the entire mnemonic - basically, I picture an overweight, balding man with a pony-tail (kind of like Comic Book Guy from the Simpsons), wearing a too-tight, black AC/DC concert shirt, and clutching his chest with one hand while his fast-food bag (containing a super-sized order of french fries and a steak sandwich) falls from his other hand to the floor. (My apologies to any AC/DC fans reading this - I hope this doesn't describe you.)
So, that's the entire mnemonic, including a cheesy visualization for enhanced recall. The first part - "AC/DC" - provides the four categories that define the structure for the rest of the phrase. It is expanded thusly:
The remaining words in the phrase are associated with each of the above categories, in the order provided, e.g., CHEST is associated with Activity, PAINS with Culture, and so on. The expansions and explanations for each of these words are provided below.
That's the entire tool. I find it useful because I can use it to rapidly generate the list of 20 factors anytime I need to, without reference to any kind of book, report, or user aid. I've used it many times to structure interviews, and/or guide my other evidence-collection efforts. I can't claim that all important factors, for all types of events, are included - but I do believe that the factors included in the tool are among the most important for investigating human performance events and problems. I've reviewed the breadth of coverage by comparing the complete set of factors to a number of well-established tools (such as MORT and the Savannah River Root Cause Map), and I don't believe there are any significant gaps.
I hereby release this tool for free usage by anyone that finds it to be useful. You may even reproduce this tool in published works. However, I require that you do not claim it as your own in any published work, and that you reference this web page as the original source. Finally, I request that you leave a comment on this web page if you use the tool - let me know how it worked for you, or if you have suggestions to improve it.
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Bill Wilson © 2004-2010