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YES NO Were the actions intended? Evidence of illness or substance abuse? Knowingly violated safe procedures? Would it pass substitution test? History of unsafe acts? Were the consequences as intended? Known medical condition? Were procedures available, workable, intelligible, correct, and routinely used? Deficiencies in training, selection or experience? Blameless error Substance abuse without mitigation System induced violation Blameless error corrective training, counseling indicated Sabotage, malevolent damage Substance use with mitigation Pass organizational substitution test? Possible negligent behavior System induced error Did procedures lack critical safeguards and support? Blameless, system induced error w/ possibly reckless system traits Pass gaming test? Possible reckless violation Blameless individual error yet negligent organizational deficiencies Diminishing Culpability