215: Mental Capabilities Issue*
*This node is for descriptive purposes only. Code only to Personnel Performance; Individual Issue (#213).
Definition/Typical Issues
Was the problem caused by inadequate intellectual capacity? Does the person frequently make wrong decisions? In general, does the person have difficulty processing information? Is the difficulty isolated to this one worker?
Was the problem caused by lack of attention? Does the individual involved in this occurrence frequently "daydream"? Is the person distracted easily? Is the person's ability to maintain vigilance frequently below minimum standards? Is the difficulty isolated to this one worker?
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 made a mistake in a calculation and added too much material to the mixer. The operator had frequently made errors with calculations and appeared to have problems with numbers. Other operators did not have difficulty performing these tasks.
Example 2
- An operator missed several steps in a procedure. The operator was unable to clearly understand the procedures because they were written at a sixth-grade level and he could only read at a second-grade level.
Example 3
- An operator failed to stop a transfer, resulting in a tank overflow. The operator had a history of being distracted easily and losing track of the next step in the process.
Example 4
- A technician in the field ran out of a water-based cleaner. Someone nearby was using gas to run a lawn mower. Instead of going back to the truck to get the water-based cleaner, the technician put some gas on a rag and used it. The operator's hair was burned when the rag contacted a hot bearing, starting a fire.
Typical Recommendations
Review employee screening and hiring processes to ensure that the individuals who are hired have the required reasoning capabilities.
Note 1: A review of the human factors engineering for the process (see Human Factors [#146]) is also appropriate to accommodate a wider spectrum of mental capabilities. For example:
- Can the displays be redesigned to reduce the need to perform calculations?
- Can procedures and supervisor resources be provided to assist workers in performing the task?
Cross-References
| Version 10 Element(s) | |
|---|---|
| Node ID | Node Name |
| 211 | Reasoning Capabilities LTA |
| Maritime Element(s) | |
|---|---|
| Node ID | Node Name |
| 251 | Poor Reasoning |