accident reports 104
see also safety data, protection of
accidents
changing interpretations of v–vi
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
discretionary space for individual action 80–82
forward-looking accountability 8–10, 83–4
adverse events see incidents
Air Law (Norway) 63
alternative dispute resolution (ADR) 146
aviation
case studies 25–33, 44–9, 71, 89, 94, 105–6, 150–151
criminalization of human error 87
line between acceptable and unacceptable acts 15–16
National Transportation Safety Board (NTSB) 95, 111
use of safety investigation reports 94
victims' view of trial 89
Aviation Safety Reporting System (ASRS) 62
Becker, Howard 128
Berlinger, Nancy 68
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
clinical trials in Argentina 121–2, 129
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
causal control 23
Chaumareys, Jean-Hugues Duroy de 122–5, 127, 129
Code of Medical Ethics (Ethical Opinions E-8.12) 67–8
compromise 32
criminal acts 118–19, 126–9, 153–6
criminalization of human error
complexity of incidents 109
employing organization's role 98–9
injustice resulting from 162–3
lawmakers' role 98
'Mara' nursing case study xi–xxiv
relationships, importance of 146–7
reporting of incidents, effects on 103–7, 110
safety, effects on 11, 110–111
triggered by lack of disclosure 33
and truth 152
Cronkite, Walter 154
culpability
persuasion of a particular viewpoint 122–6
data see safety data, protection of
debriefings 142
decency 33
defendants in legal action 91–2, 129
defense lawyer's role in legal action 95–6
disclosure
definition 64
just culture 33
protection of 69
Douglas, Mary 150
employing organization's role in legal action 98–9
empowerment of individuals to report risks 82
errors
normative errors 21, 35, 39–41
technical errors 21, 35, 36–8, 39–41
see also criminalization of human error
Eurocontrol Safety and Regulatory Requirement (ESARR 2) 53, 59
expert witnesses in legal action 97
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
Hidden, Anthony 44
Hull, Matty 66
"I'm sorry" laws 69
incidents
categorizing adverse events 73–5
criminalization of human error 87, 109
decision trees used to determine culpability 20–21
just culture, creation of 142
line between acceptable and unacceptable acts 15–18, 23–4, 25–33
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's role in legal action 96–8
judgment, use of
categorizing adverse events 73–5
line between acceptable and unacceptable acts 17–18, 23–4, 25–33, 131–3, 143–4, 145
just culture
categorizing adverse events 73–5
decision trees used to determine culpability 20–21
disclosure 33
discretionary space for individual action 80–82
ethical considerations 1–5, 79
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
organization's response to failure 6–8
relationships, importance of 145–7
safety data, protection of 131–3, 144
social construction of offenses 18–20
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
Lanir, Zvi 44
lawmakers' role in legal action 98
legal action
complexity of incidents 109
employing organization's role 98–9
injustice resulting from 162–3
lawmakers' role 98
'Mara' nursing case study xi–xxiv
relationships, importance of 146–7
reporting of incidents, effects on 103–7, 110
safety, effects on 11, 110–111
triggered by lack of disclosure 33
and truth 152
line between acceptable and
unacceptable acts
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
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
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 vs. legal criteria 79
hindsight, role of 42
mediation 146
multiple perspectives 117
reporting incidents 38, 52, 65
status, lack of 129
Merry, Alan 108
mistakes
categorizing adverse events 73–5
criminalization of human error 87, 109
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
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
Morreim, Haavi 82
multiple perspectives 32, 117–22
National Transportation Safety Board (NTSB) 95, 111
negligence
categorizing adverse events 73–5
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
'Mara' nursing case study xi–xxiv
social construction of offenses 18–20
non-punitive reporting systems 60–61
normative errors 21, 35, 39—41
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
professional disciplinary rules 139–40
proportionality 33
prosecutors
integration with regulator 138–9
relationships, importance of 146–7
protected reporting systems 61–3
Raft of the Medusa (Géricault) 122–6, 155, 156
Rasmussen, Jens 49
rational choice 149
relationships, importance of 145–7
reporting
consequences of 53
criminalization, effects of 103–7, 110
definition 63
features of successful systems 58–62
identifying report-worthy events 54–5
obligation to report 53
professional attitudes to 51–3
responsibility and accountability vii–viii
Rowe, Michael 88
safety data, protection of
consequences of exposure 53, 62–3, 93, 104
safety department 143
Savigny, Henri 124
Schmaltz, Julien-Désiré 122, 124
situational constraints 23
social construction of culpability 122–6
social construction of offenses 18–20
stress management programs 142
technical errors 21, 35, 36–8, 39–41
truth
and disclosure 67
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
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
willful violations
categorizing adverse events 73–5
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