213: Individual Issue
Definition/Typical Issues
Did the worker's physical or mental well-being, attitude, mental capacity, attention span, off-the-job sleeping practices, substance abuse, etc., adversely affect the performance of the task? Was the problem the result of the individual not being capable of performing the task or not wanting to do his or her job?
Note 1: The Personnel Performance Issue; Individual Issue (#213) node should only be used when the problem is isolated to one individual. If other personnel have difficulty performing the same task under similar circumstances, then other portions of the Root Cause Map™ should be used to code the issue.
Note 2: There should be management systems in place to detect and correct most (if not all) individual performance issues BEFORE an incident occurs. Therefore, the failure or absence of the management systems should be coded as well.
Note 3: Consider coding under the Personnel Hiring Issue (#209) node because there should be management controls to ensure that employees possess the required job capabilities prior to being hired. Also consider coding under the Supervision During Work Issue (#192) or Detection of Individual Performance Issue (#212) nodes because supervision should detect this problem.
Note 4: Code as Personnel Performance Issue; Individual Issue (#213) only. The 10 nodes beneath Individual Issue (#213) are included to provide the investigator with an understanding of the types of problems that might be categorized as Personnel Performance Issue; Individual Issue (#213). However, the investigator should NOT include these cause nodes in the investigation report.
Examples
Example 1
- An operator failed to close a valve after completing a transfer. The operator was not paying attention to the level of the tank into which the oil was being transferred. The operator had a history of not paying attention to his work. He had been involved in several other incidents during which he had left his job or was not performing his job requirements. Other operators performed these same job tasks with no problems.
Example 2
- A mechanic came to work drunk. He did not look visibly impaired, so no one did anything to stop him from going to work. Later, while operating a crane, he dropped the load, damaging production equipment.
Example 3
- A middle-aged worker's vision had deteriorated but she was too vain to wear her prescription glasses at work. As a result, she misread the DCS screen values and improperly operated the equipment.
Typical Recommendations
- Ensure that job requirements are complete, including required physical/perceptual capabilities.
- Provide reasonable accommodations for coworkers with sensory/perceptual limits.
- Review employee screening and hiring processes to ensure that the individuals who are hired have the required reasoning capabilities.
- Inform and encourage workers to take advantage of employee assistance programs.
- Disciplinary policies should be used to reinforce compliance with company rules and policies:
- Discipline needs to be fair, impartial, prestated, sure, and swift
- Enforcement needs to be consistent
Cross-References
| Maritime Element(s) | |
|---|---|
| Node ID | Node Name |
| 249 | Individual Issue |