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?
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| 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?
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| 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?
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| 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?
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| 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?
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| 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?
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| 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?
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