Index

accident reports 104

see also safety data, protection of

accidents

blame, reasons for 149–53

changing interpretations of v–vi

control and culpability 22–3

criminalization, effects of 110–111

decision trees used to determine culpability 20–21

line between acceptable and unacceptable acts 15–18, 23—4, 25–33, 131–3, 143–4, 145

perspectives viii–ix, 32, 115–22

persuasion of a particular viewpoint 126–9, 153–4

social construction of offenses 18–20

accountability

and blame 82–3

discretionary space for individual action 80–82

forward-looking accountability 8–10, 83–4

and outcomes 49–50

perspectives viii–ix

and responsibility vii–viii

and safety 8–10

through legal action 90–91

adverse events see incidents

Air Law (Norway) 63

alternative dispute resolution (ADR) 146

anonymity 61–2

anxiety 149–50

Ashley, James 159–63

aviation

case studies 25–33, 44–9, 71, 89, 94, 105–6, 150–151

criminalization of human error 87

hindsight, role of 41–2

line between acceptable and unacceptable acts 15–16

National Transportation Safety Board (NTSB) 95, 111

normative errors 39–40

prosecution test case 105–6

reporting events 51–2,53

reporting vs. disclosure 65–6

technical errors 36–7

use of safety investigation reports 94

victims' view of trial 89

Aviation Safety Reporting System (ASRS) 62

Becker, Howard 128

Berlinger, Nancy 68

blame 82–3, 149–53

Bonhoeffer, Dietrich 70–71

Bosk, Charles 35, 37, 38, 41

Buber, Martin 33

capacity constraints 23

case studies

aviation 25–33, 44–9, 71, 89, 94, 105–6, 150–151

British soldier killed by 'friendly fire' 66

child murder 1–2

clinical trials in Argentina 121–2, 129

dismissal of employees 7–8

firefighters 146

Israeli fighter jets shoot down Libyan airliner 44–9

La Méduse (Géricault) 122–6, 155, 156

Lot and his daughters (biblical story) 119–21, 127, 129, 155, 156

medical professionals xi–xxiv, 11, 22–3, 69–71, 82, 87, 91, 108, 116–17, 121–2, 129, 156–8

murder of civil rights activists 12–13

oil refinery safety 84

parking offense 18–20

police shooting 159–63

causal control 23

Chaney, James 12–13

Chaumareys, Jean-Hugues Duroy de 122–5, 127, 129

Christie, N. 127–8

civil law 111–12

Code of Medical Ethics (Ethical Opinions E-8.12) 67–8

Cohen, Stanley 156, 157

compromise 32

confidentiality 61–2

consequentialism 2, 4–5

control and culpability 22–3

criminal acts 118–19, 126–9, 153–6

criminalization of human error

complexity of incidents 109

consequences of 112–13, 152–3

defense lawyer's role 95–6

effects of 11–12, 77

employing organization's role 98–9

injustice resulting from 162–3

judge's role 96–8

and justice 11–12, 108–9

lawmakers' role 98

'Mara' nursing case study xi–xxiv

objective view 115–17

prosecutor's role 92–5, 96

purpose of 87, 107–8

relationships, importance of 146–7

reporting of incidents, effects on 103–7, 110

safety, effects on 11, 110–111

suspect's role 91–2

tort liability 111–12

triggered by lack of disclosure 33

and truth 152

victim's role 88–91

Cronkite, Walter 154

culpability

and blame 82–3

decision trees, use of 20–21

and hindsight 35, 41–50

persuasion of a particular viewpoint 122–6

psychological research 22–3

data see safety data, protection of

debriefings 142

decency 33

decision trees 20–21

defendants in legal action 91–2, 129

defense lawyer's role in legal action 95–6

deontology 2, 3–4

deviance 153–4

disciplinary rules 139–40

disclosure

definition 64

ethical obligation 67–8

importance of 40–41, 66–7

just culture 33

protection of 69

vs. reporting 63–6

risks of 68–9

discretion 80–82

domain expertise

approaches to 134–41

just culture 131–3, 145

Douglas, Mary 150

duty of care 2, 3–4

employing organization's role in legal action 98–9

empowerment of individuals to report risks 82

errors

hindsight, role of 35, 41–50

normative errors 21, 35, 39–41

technical errors 21, 35, 36–8, 39–41

see also criminalization of human error

ethics 1–5, 65, 69–71, 79

Eurocontrol Safety and Regulatory Requirement (ESARR 2) 53, 59

expert witnesses in legal action 97

fiduciary duty 3–4

financial compensation for victims 90–91

financial penalties 142

forward-looking accountability 8–10, 83–4

fraud 121

freedom-of-information 62–3, 104

Galison, P. 151

Gephart, R.P. 74

Géricault, Theodore 122, 124–6

Goodman, Andrew 12–13

Hidden, Anthony 44

hidden curriculum 68–9

hindsight 35, 41–50, 132

honesty 69–71

Hull, Matty 66

"I'm sorry" laws 69

incidents

blame, reasons for 149–53

categorizing adverse events 73–5

control and culpability 22–3

criminalization of human error 87, 109

decision trees used to determine culpability 20–21

hindsight, role of 35, 41–50

just culture, creation of 142

and legal action 110–111

line between acceptable and unacceptable acts 15–18, 23–4, 25–33

normative errors 35, 39–41

perspectives viii–ix, 32, 115–22

persuasion of a particular viewpoint 126–9

social construction of offenses 18–20

technical errors 35, 36–8, 40–41

see also case studies

judge of instruction 137–8

judge's role in legal action 96–8

judgment, use of

categorizing adverse events 73–5

and hindsight 41–50

line between acceptable and unacceptable acts 17–18, 23–4, 25–33, 131–3, 143–4, 145

outcomes, influence of 41–50

reporting events 54–5

just culture

advantages of 78–9

blame, reasons for 149–53

categorizing adverse events 73–5

control and culpability 22–3

creation of vi–vii, 73–5

decision trees used to determine culpability 20–21

disclosure 33

discretionary space for individual action 80–82

domain expertise 131–3, 145

ethical considerations 1–5, 79

failure of 12–14

features of 8–10, 31–3

forward-looking accountability 8–10, 83–4

legal action, effects of 11–12, 77

line between acceptable and unacceptable acts 15–18, 23–4, 25–33, 131–3, 143–4, 145

organizational justice 75–6

organization's response to failure 6–8

relationships, importance of 145–7

safety data, protection of 131–3, 144

second victim, care of 76–8

social construction of offenses 18–20

staggered approach to 141–5

systems and adverse events 80

justice xi–xxiv, 11–12, 89–90, 108–9

Killen, Ray 13

King, Martin Luther 13

La Méduse (Géricault) 122–6, 155, 156

labeling theory 153–4

Lanir, Zvi 44

lawmakers' role in legal action 98

learning-by-doing 36–8

legal action

complexity of incidents 109

consequences of 112–13, 152–3

defense lawyer's role 95–6

effects of 11–12, 77

employing organization's role 98–9

injustice resulting from 162–3

judge's role 96–8

and justice 11–12, 108–9

lawmakers' role 98

'Mara' nursing case study xi–xxiv

objective view 115–17

prosecutor's role 92–5, 96

purpose of 87, 107–8

relationships, importance of 146–7

reporting of incidents, effects on 103–7, 110

safety, effects on 11, 110–111

suspect's role 91–2

tort liability 111–12

triggered by lack of disclosure 33

and truth 152

victim's role 88–91

line between acceptable and

unacceptable acts

approaches to 134–41

just culture 15–18, 23–4, 25–33, 131–3, 143–4, 145

Lot and his daughters (biblical story) 119–21, 127, 129, 155, 156

'Mara' nursing case study xi–xxiv, 22–3, 69–71, 87, 91, 108,116–17, 129, 156–8

media scrutiny 8–9, 92

mediation 146

medical professionals

case studies xi–xxiv, 11, 22–3, 69–71, 82, 87, 91, 108, 116–17, 121–2, 129, 156–8

categorizing adverse events 73–4, 75

control and culpability 22–3

criminalization of human error xi–xxiv, 11, 87, 91, 108, 116–17

disclosure, requirement of 67–8

empowerment of individuals to report risks 82

ethics of honesty 69–71

ethics vs. legal criteria 79

hidden curriculum 68–9

hindsight, role of 42

mediation 146

moral panic 156–8

multiple perspectives 117

reporting incidents 38, 52, 65

status, lack of 129

technical errors 37, 38

Merry, Alan 108

mistakes

blame, reasons for 149–53

categorizing adverse events 73–5

control and culpability 22–3

criminalization of human error 87, 109

decision trees used to determine culpability 20–21

hindsight, role of 35, 41–50

line between acceptable and unacceptable acts 15–18, 23–4, 25–33, 131–3, 143–4, 145

normative errors 21, 35, 39—41

perspectives viii–ix, 32, 115–22

persuasion of a particular viewpoint 126–9, 153–4

social construction of offenses 18–20

technical errors 21, 35, 36–8, 40–41

moral panic 156–8

Morreim, Haavi 82

motivation 81–2

multiple perspectives 32, 117–22

National Transportation Safety Board (NTSB) 95, 111

negligence

categorizing adverse events 73–5

control and culpability 22–3

decision trees used to determine culpability 20–21

definitions of 17–18

line between acceptable and unacceptable acts 15–18, 23–4, 25–33, 131–3, 143–4, 145

'Mara' nursing case study xi–xxiv

social construction of offenses 18–20

Nietzsche, Friedrich 151–2

non-punitive reporting systems 60–61

normative errors 21, 35, 39—41

objective view 115–17

organizational justice 75–6

organizations 6–8, 75–6, 142–4

outcomes, influence on judgment 41–50

Pellegrino, E.D. 80

perspective from which the incident is viewed

alternative viewpoints viii–ix, 32, 115–22

La Méduse case study 122–6, 155, 156

persuasion of a particular viewpoint 126–9, 153–4

persuasion of a particular viewpoint (rhetoric) 126–9, 153–4

political pressure 92–3

power, use of 33, 129

Price, Cecil 12–13

professional disciplinary rules 139–40

proportionality 33

prosecutors

integration with regulator 138–9

judge of instruction 137–8

relationships, importance of 146–7

role in legal action 92–5, 96

test cases 105–6

protected reporting systems 61–3

Raft of the Medusa (Géricault) 122–6, 155, 156

Ramstead, Keith v, viii–ix

Rasmussen, Jens 49

rational choice 149

Reason, J.T. 20–21

regulation 8–9, 110, 138–9

relationships, importance of 145–7

reporting

consequences of 53

criminalization, effects of 103–7, 110

definition 63

vs. disclosure 63–6

encouraging reporting 55–6

features of successful systems 58–62

identifying report-worthy events 54–5

importance of 40–41

non-punitive systems 60–61

obligation to report 53

professional attitudes to 51–3

protected systems of 61–3

recipients of reports 56–8

voluntary systems 59–60

responsibility and accountability vii–viii

rhetoric 126–9, 153–4

Rowe, Michael 88

safety 8–10, 110–111

safety data, protection of

approaches to 134–41

consequences of exposure 53, 62–3, 93, 104

just culture 131–3, 144

and reporting 61–2

safety department 143

safety investigations 93—4

Savigny, Henri 124

scapegoats 149–53

Schmaltz, Julien-Désiré 122, 124

Schwerner, Michael 12–13

second victim 76–8

Sharpe, Virginia 9, 83–4

Sherwood, Christopher 159–63

situational constraints 23

Snook, Scott 150–151

social construction of culpability 122–6

social construction of offenses 18–20

stress management programs 142

suspects 91–2, 129

technical errors 21, 35, 36–8, 39–41

tort liability 111–12

trust 56, 142–4

truth

and disclosure 67

ethics of honesty 69–71

legal action 152

'Mara' nursing case study xi–xxiv

multiple perspectives vs. one true account 119–22

prosecutor's role in legal action 94–5

utilitarianism 2

Vaughan, Diane 150

victim's role in legal action 88–91

'view from below' 32

'view from nowhere' 115–17

voice of the parties involved 32, 88–9

volitional behavior control 22–3

volitional outcome control 23

voluntary reporting systems 59–60

Walker, Andrew 66

Weber, Max xxiii

White, H.B. 152

Wilkinson, S. 25–31

willful violations

categorizing adverse events 73–5

control and culpability 22–3

decision trees used to determine culpability 20–21

line between acceptable and unacceptable acts 15–18, 23–4, 25–33, 131–3, 143–4, 145

social construction of offenses; 18–20

witness impact statements 88