The Culpability Matrix
When you consider the mix of variables in a workplace -- the individual workers and their constantly changing moods & attitudes, the workplace environment with its hazards, and the company culture with respect to safety -- it is unfortunately not a matter of whether there will be injuries, but when. A workplace can be made safer, but we haven't yet figured out how to make it perfectly safe. The goal is to seek continuous improvement.
Recently I saw an Associated Press report about an 83-year-old nun sentenced to nearly three years in prison for a nuclear plant break-in. She and two other individuals managed to break into the Y-12 National Security Complex in Oak Ridge Tennessee. They cut through three fences, strung banners, and spent more than two hours inside restricted areas before they were caught. This is no ordinary restricted area. According to the AP report, Assistant U.S. Attorney Jeff Theodore said they had “destroyed the mystique of the Fort Knox of uranium.” Clearly security failures were evident and the outcome affected Y-12 and DOE complex facilities nationwide.
Around the same time, I read a discussion on the VPPPA LinkedIn forum that asked the question, “Are we subliminally bullying employees into not reporting injuries?” This is something that should keep any safety professional awake at night. Let me apply an analogy: If you have ever had the unfortunate experience of a roof leak you can confirm that the initial drops of water progressively get more frequent and will not fix themselves. The failure of employees to report injuries will not make the problems that caused those injuries go away. Sooner or later the damn breaks. What are the consequences for an employee, perceived or real, for reporting a minor injury in your organization? Notice I said “reporting” the injury. In my experience most employees have found it easier and less of a hassle to not report.
I’d like to introduce you to an effective screening tool called the “Culpability Matrix.” The chart can be a useful tool to help determine culpability. As I have explained elsewhere on this site, there is a difference between accountability and culpability. Accountability means that one is responsible. Culpability means that one is worthy of blame.
The chart begins with the question of whether or not the employee intended the behavior and moves to intended consequences.
Recently I saw an Associated Press report about an 83-year-old nun sentenced to nearly three years in prison for a nuclear plant break-in. She and two other individuals managed to break into the Y-12 National Security Complex in Oak Ridge Tennessee. They cut through three fences, strung banners, and spent more than two hours inside restricted areas before they were caught. This is no ordinary restricted area. According to the AP report, Assistant U.S. Attorney Jeff Theodore said they had “destroyed the mystique of the Fort Knox of uranium.” Clearly security failures were evident and the outcome affected Y-12 and DOE complex facilities nationwide.
Around the same time, I read a discussion on the VPPPA LinkedIn forum that asked the question, “Are we subliminally bullying employees into not reporting injuries?” This is something that should keep any safety professional awake at night. Let me apply an analogy: If you have ever had the unfortunate experience of a roof leak you can confirm that the initial drops of water progressively get more frequent and will not fix themselves. The failure of employees to report injuries will not make the problems that caused those injuries go away. Sooner or later the damn breaks. What are the consequences for an employee, perceived or real, for reporting a minor injury in your organization? Notice I said “reporting” the injury. In my experience most employees have found it easier and less of a hassle to not report.
I’d like to introduce you to an effective screening tool called the “Culpability Matrix.” The chart can be a useful tool to help determine culpability. As I have explained elsewhere on this site, there is a difference between accountability and culpability. Accountability means that one is responsible. Culpability means that one is worthy of blame.
The chart begins with the question of whether or not the employee intended the behavior and moves to intended consequences.
If we apply the matrix to the story of the peace activists breaking into the nuclear facility, you can see that the behavior was intended. Yes, they knowingly violated requirements. The requirements are available, intelligible and posted. So, one can quickly move to the conclusion that this was an intentional violation.
Applying the matrix to the failure of a worker to report an injury, the first standout question after whether the behavior was intended is whether the employee intentionally violated a known requirement? Lacking any medical restrictions and assuming the requirements are “available, workable, intelligible and correct” we arrive at the “substitution test.” This is a critical juncture. The substitution test asks, “Given the identical set of circumstances, would a different employee act the same?” This is a critical part of this matrix. It is the last step where you can distinguish between a system-induced violation, negligence (calling for corrective measures), or a blameless error.
It is a fact that the three peace activists in my first example exposed systemic weaknesses in a top security nuclear complex and in a weird way deserve our thanks. The fact that it involved intentional sabotage should also carry consequences.
If your organization produces workers who fail to report even the most minor injury, you can apply this chart to find ways to encourage them to report such injuries in the future.
Applying the matrix to the failure of a worker to report an injury, the first standout question after whether the behavior was intended is whether the employee intentionally violated a known requirement? Lacking any medical restrictions and assuming the requirements are “available, workable, intelligible and correct” we arrive at the “substitution test.” This is a critical juncture. The substitution test asks, “Given the identical set of circumstances, would a different employee act the same?” This is a critical part of this matrix. It is the last step where you can distinguish between a system-induced violation, negligence (calling for corrective measures), or a blameless error.
It is a fact that the three peace activists in my first example exposed systemic weaknesses in a top security nuclear complex and in a weird way deserve our thanks. The fact that it involved intentional sabotage should also carry consequences.
If your organization produces workers who fail to report even the most minor injury, you can apply this chart to find ways to encourage them to report such injuries in the future.