Analysis Questions

Inspired by Gary Klein’s debriefing questions in Sidney Dekker’s The Field Guide To Understanding Human Error, below is a non-exhaustive list to help stimulate deep analysis. Ask “how” and “what” questions, rather than “who” or “why,” to discourage blame and encourage learning.

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Cues
  • What were you focusing on?
  • What was not noticed?
  • What differed from what was expected?
Previous Knowledge/Experience
  • Was this an anticipated class of problem or did it uncover a class of issue that was not architecturally anticipated?
  • What expectations did participants have about how things were going to develop?
  • Were there similar incidents in the past?
Goals
  • What goals governed your actions at the time?
  • How did time pressure or other limitations influence choices?
  • Was there work the team chose not to do in the past that could have prevented or mitigated this incident?
Assessment
  • What mistakes (for example, in interpretation) were likely?
  • How did you view the health of the services involved prior to the incident?
  • Did this incident teach you something that should change views about this service’s health?
Taking Action
  • How did you judge you could influence the course of events?
  • What options were taken to influence the course of events? How did you determine that these were the best options at the time?
  • How did other influences (operational or organizational) help determine how you interpreted the situation and how you acted?
Help
  • Did you ask anyone for help?
  • What signal brought you to ask for support?
  • Were you able to contact the people you needed to contact?
Process
  • Did the way that people collaborate, communicate, and/or review work contribute to the incident?
  • What worked well in your incident response process and what did not work well?