Chapter 3

Question 1

People who find themselves in the midst of an investigation of a bad outcome usually only want what to come out

Answer 1

• the truth

Question 2

What are influences generally associated with written and adopted policies, procedure and rules, they also include organizational culture issues

Answer 2

• System influences

Question 3

What is one critical reason to separate the team members when they write their original account

Answer 3

• Because each individual may have completely different perceptions of the same incident

Question 4

Once the appropriate reports, pictures, policies, training records, best practices documents, and the interview notes have been gathered, what is the next step

Answer 4

• to build an incident timeline

Question 5

What kind of approach should be taken to try to understand precisely why an individual or a team made the decision or series of decisions that led to what is viewed retrospectively as an undesired outcome

Answer 5

• holistic, systematic approach

Question 6

What do leaders who fail to take responsibility never achieve

Answer 6

• a just culture

Question 7

What kind of failure is it when initial operator education was inadequate or not completely relevant, the training was not up-to-date, the training was not provided in an appropriate style for the complexity of the subject, or training was delivered using a method that did not resonate with the student

Answer 7

• Education and training failures

Question 8

A just culture is about determining a cause for failure that satisfies what demand(s)

Answer 8

• the demand for accountability and the need for learning and improvement

Question 9

What enables individuals to perform without fear of retribution for honest mistakes

Answer 9

• Establishing a just culture and implementing a process for systemic cause analysis of accidents, errors, and mistakes

Question 10

For a just culture to work, what must personnel know about revealing an error

Answer 10

• that it’s paramount to the learning process and future safety of the organization and other personnel

Question 11

A systemic approach should perceive the accident as part of what, not as an individual or team failure

Answer 11

• the normal operational process

Question 12

Effective CRM requires what kind of communication

Answer 12

• open, honest, and respectful

Question 13

To establish a culture that embraces error as part of learning, team leaders must understand the fundamentals associated with what

Answer 13

• fair and comprehensive incident analysis