A
Academie Nationale de L’Air et de L’Espace (ANAE), 125
Accidental death, criminal law and, 87–88
Accident investigation boards, 105
Accident report
formal, 105
in painting, 147–150 (see also La Méduse)
Accountability, 22–23, 31, 145; see also Incident
anxiety and, 132
blame-free system and, 132–134
failure stories and, 135
personal, discretionary space for, 131–132
stress and, 132
Accountability-free systems, 132–134
vs. blame-free systems, 132–134
Accusatory law, 99
Alternative dispute resolution (ADR), 144
Anecdotal evidence, 6
Anonymity, 70
Apology, 20
Appropriate/right action, 137–138
Aristotle, 139
Art of persuasion, 151–152; see also La Méduse
At-risk behavior, 2
Aviation safety groups issue joint resolution, 125–126
Aviation Safety Reporting System (ASRS), 70
B
Backward-looking accountability, 129, 135
Bad apple theory, 33, 42–46; see also Rule breaking
Bentham, Jeremy, 39
Black books, 42
personal accountability and, 133
vs. accountability-free system, 132–134
Bonhoeffer, Dietrich, 78
C
Case study
criminalization of human error
disciplinary rules within profession, 124–125
formal investigation beyond period of limitation, 120–121
industry responses to criminalization, 117–119
lobbying, prosecutorial, and media self-restraint, relying on, 121–122
prosecutor, part of regulator, 123–124
volatile safety database, 120
retributive/restorative just cultures
errors, 26
rule breaking
hindsight and culpability, 59–60
normal, technical professional error, 57–58
normative, culpable mistake, 58–59
outcome, worse, 60
safety reporting and honest disclosure
dose calculation, error in, 83–85
recorded miscalculation, reporting by nurse, 85–87
Christianity, 143
Code of Medical Ethics, 76
Competency over time in aviation and medicine, 45t, 46
Computer-based systems, 63
Confidentiality, 70
Conflict, ethical, 140
Consultation, 49
Consumer movement, 107
Contract ethics, 141
Control theory, 33, 38–40; see also Rule breaking
Convicted practitioner, 108
Corréard, Alexander, 148
Correctional systems, 108
Crime(s)
white-collar, 146
Criminalization, 16
Criminalization of human error
case study
disciplinary rules within profession, 124–125
formal investigation beyond period of limitation, 120–121
industry responses to criminalization, 117–119
lobbying, prosecutorial, and media self-restraint, relying on, 121–122
prosecutor, part of regulator, 123–124
volatile safety database, 120
consequences of criminalization
intention of professionals to commit crimes, 103
employing organizations, 103
evidence, summing up, 116
judge in Napoleonic law
adequate punishment, deciding, 101–102
breaking of laws, 101
judicial proceedings and justice, 113–114
judicial proceedings and safety, 114–115
prosecutor
safety investigations, 98
as truth-finder, 99
prosecutors and decision about crime, 109–113
tort (or civil) liability, 108–109
Criminal law and accidental death, 87–88; see also Safety reporting and honest disclosure
Criminal probe, 105
Crisis intervention, 103
Critical incident/stress management programs, 128
Culture, 144
D
Debriefing programs, incident, 128
De Chaumareys, Hugues Duroy, 148, 149–150, 151, 152
Defendant in trial, 95
Defensive posturing, 28
Disciplinary rules within profession, 124–125
Disclosure, 20
defined, 71
Disclosure and reporting, difference
overlapping obligations, 73–74
Discretionary space, for personal accountability, 131–132
Disinclination to report, 64
Domain expertise, role of, 119, 122, 123, 124
Duties, information about, incident and, 128
Duty ethics, 139–141; see also Fiduciary relationship
E
Epistemology of truthtelling, 78
Errors, 26, 44; see also Retributive/restorative just cultures
Ethics, 138
conflict, 140
contract, 141
golden rule, 143
utilitarianism, 142
virtue, 139
Eurocontrol rules, 68
Eurocontrol Safety and Regulatory Requirement (ESARR 2), 64
Evidence, 116
Evidence by analogy, 6
External control of behavior, 38
F
Failure, “true” account of, 145–147; see also Incident
Failure stories, accountability and, 135
Fear, 132
Feedback, 65
Fiduciary relationship, 139–140; see also Duty ethics
Fiduciary relationships, 23, 24
Flight Safety Foundation (FSF), The, 125
Forward-looking accountability, 129, 134–137
Fraud, 146
Freedom-of-information legislation, 70, 105
French Revolution (1792), 149
G
Géricault, Theodore, 147, 149, 150, 151
Goal conflicts, 47
Golden rule ethics, 143
versions, 143
Guilt-phase, 9
Guilty knowledge, 74
H
Hidden, Anthony, 55
Hinduism, 143
Honest disclosure, safety reporting and, see Safety reporting and honest disclosure
Honest mistakes, 2
reporting of, 69
Human errors, 2
criminalization of (see Criminalization of human error)
Human faculty, 53
I
Imagination, 53
Incest, 146
Incident, 127; see also Accountability
accomplishments after, 128–130
accomplishments before, 127–128
appropriate/right action, 137–138
backward-looking accountability, 129, 135
bad relationships and, 144
critical incident/stress management programs, 128
debriefing programs, 128
ethics and, 138–143 (see also Ethics)
forward-looking accountability, 129, 134–137
as free lesson, 128
importance of reporting, 128
individuals in systems and, 131
discretionary space for personal accountability, 131–132
information about rights and duties, 128
responsible circumstances for, 136–137
retraining of practitioner after, 128
safety-critical information sharing, 130
staff safety department, 127–128
stigmatization of practitioners, 128–129
Individuals in systems, 131
discretionary space for personal accountability, 131–132
Industry responses to criminalization, 117–119
Informal teaching, 42
Information, 14
Information (reported) into wrong hands, 70–71
Insensitivity, 27
Intention of professionals to commit crimes, 103
Intervention, active, 66
Investigation (formal) beyond period of limitation, 120–121
Islam, 143
Israeli intelligence, 57
J
Judaism, 143
Judge in Napoleonic law; see also Criminalization of human error
adequate punishment, deciding, 101–102
breaking of laws, 101
Judicial authorities stopping an investigation, 105k
Judicial proceedings
Judicial proceedings after incident, 115
Judicial proceedings with regulatory work, 115
Jury selection, 101
Justice, 144, 145; see also Restorative justice; Retributive justice
lack of, 127
K
Killen, Ray, 137
L
Labeling theory, 33, 34–38; see also Rule breaking
Lanir, Zvi, 56
Law breaking, 101
Law enforcement officials in investigations, 104
Leaders, 50
Learning review, of incident, 129–130
Learning theory, 33, 40–42; see also Rule breaking
Legal action, 124
Legal process in Supreme Court, 90
Legal system, 87, 107–108; see also Criminalization of human error
Legitimacy, 8
Le Journal des Débats, 148, 149
Libya, 57
Line-reporting mechanism, 67
M
Malpractice claims, 109
Media, role of, 97
Medical professionals, 77
Micro-management, 49
Mistake, 56
Morality of truth-telling, 78
Motivation, 132
N
National laws, 63
Near-miss reporting systems, 67
Needs of victims, 14
No-blame culture, 3
Noncompliant patient, 65
Nondisclosure, 74
Normal, technical professional error, 57–58
Normative, culpable mistake, 58–59
Normative errors, 29–31; see also Retributive/restorative just cultures
November Oscar 747 case, 131, 141
O
to disclose information, 72
disclosure vs. reporting, 73–74
to report, 72
to report mistakes and problems, 62–63
Offender, 23
Operational organizations, 104
Opportunity, 14
Organizational community, 14
Organizational disclosure or reporting, 73
Organizational learning, reporting and, 64–65
Organizational practices, 20–21
Organizations, 72
employing, 103
Overlap in rules, 49
Overreactions, 49
P
Painting, accident report in, 147–150; see also La Méduse
Peer support, 16
Penalty-phase culpability, 9
Personal accountability
blame-free systems and, 133
discretionary space for, 131–132
Persuasion, art of, 151–152; see also La Méduse
Phronesis, 139
Plato, 143
Political pressure, 96
Practical consequences, 95
stress and isolation of, 115
Preexisting trust, 118
Procedural justice, 8–10; see also Retributive just culture
Professional codes, 64
Prosecutor
and decision about crime, 109–113
safety investigations, 98
as truth-finder, 99
Protected reporting system, 70
Protection of safety data, 120, 122
Psychological consequences, 95
R
The Raft of the Medusa; see La Méduse
Rasmussen, Jens, 60
Rational choice theory, 38
Rational systems with irrational outcomes, 88–89
Realism, 150
Realist paintings, 150; see also La Méduse
Recklessness, 2
Reflex, 55
Rehabilitative purpose of justice, 108
Relationships
bad, 144
fiduciary, 139–140 (see also Duty ethics)
good, 144
importance of, 144
Reporting
defined, 71
incident, importance of, 128
to managers/safety staff, 66–67
organizational learning and, 64–65
Reporting rate, keeping up, 65–66
Reportworthiness, 64
Resilience theory, 33, 50–53; see also Rule breaking
Responsibility
dominant view, 135
prospective sense of, 135 (see also Forward-looking accountability)
Restoration
defined, 1
forgiveness, restoration and, 19–21
restorative justice steps
obligations to meet need, 16–19
Restorative justice, defined, 12
Restorative theory, and injustice elimination, 24–25
Retraining, of practitioner after incident, 128
Retribution
defined, 1
difficulties and fairness in, 6–7
shades of, 2
breaking of rules for recruitment, 7–8
difficulties with retributive justice, managing, 10–12
retribution, difficulties and fairness in, 6–7
substantive justice, 7
Retributive justice, criticism for, 25
Retributive/restorative just cultures
case study
errors, 26
comparing and contrasting
restorative just culture
forgiveness, restoration and, 19–21
restorative justice steps, 13–19
restorative theory
and injustice elimination, 24–25
retributive just culture
breaking of rules for recruitment, 7–8
difficulties with retributive justice, managing, 10–12
retribution, difficulties and fairness in, 6–7
substantive justice, 7
retributive justice
criticism for, 25
Right/appropriate action, 137–138
Right of appeal, 9
Rights, information about, incident and, 128
Risks of reporting and disclosure
ethical obligation to report or disclose, 76
protection of disclosure, 77
Royal Aeronautical Society in England (RAeS), 125
case study
hindsight and culpability, 59–60
normal, technical professional error, 57–58
normative, culpable mistake, 58–59
outcome, worse, 60
overview, 34
subculture theory, stupid rules and, 46–50
Rule creep, 49
Rule enforcement, 49
S
Safety, 30
Safety-critical industry, 11
Safety-critical information sharing, 130
Safety-critical work, 130, 131
Safety data, protection of, 120
Safety inspection, 105
Safety investigations, 98
Safety-related data, 105
Safety reporting and honest disclosure
case study
dose calculation, error in, 83–85
recorded miscalculation, reporting by nurse, 85–87
criminal law and accidental death, 87–88
disclosure and reporting, difference
overlapping obligations, 73–74
legal process in Supreme Court, 90
obligation to report mistakes and problems, 62–63
protected reporting system, 70
rational systems with irrational outcomes, 88–89
reported information into wrong hands, 70–71
reporting and organizational learning, 64–65
reporting rate, keeping up, 65–66
reporting to managers/safety staff, 66–67
risks of reporting and disclosure
ethical obligation to report or disclose, 76
protection of disclosure, 77
voluntary reporting, 68
Savigny, Henri, 148
Second victims, 14–16, 95–96, 142
Self-criticism, 28
Seniority, reward for, 51
Sharpe, Virginia, 135
Silence, 74
Social support, 16
Societal or professional trade-offs, 112
Staff-based reporting mechanisms, 67
Staff safety department, 127–128
Stakeholders, 121
Statistical analysis, 43
Stigmatization, of practitioners involved in incident, 128–129
Stupid rules and subculture theory, 46–50
Subculture theory, 33
stupid rules and, 46–50 (see also Rule breaking)
Subordinate, 29
Substantive justice, 7; see also Retributive just culture
Systematic evidence, 6
Systems, individuals in, 131
discretionary space for personal accountability, 131–132
T
Technical errors, 26–29; see also Retributive/restorative just cultures
Technical professional error, 57–58
Tort law, 109
Tort (or civil) liability, 108–109
Training, 45
between professional and client, 139–140 (see also Fiduciary relationship)
Truth and Reconciliation Commission, 12
Truth-finder, prosecutor as, 99
Truth-telling in professions, 78
U
Utilitarianism, 142
V
Verbal guidance, 28
Victims, 13–16; see also Restorative just culture
for monetary compensation, 95
Virtue ethics, 139
Virtues, 139
Volatile safety database, 120
Voluntary reporting, 68
W
Weber, Max, 89
White-collar crimes, 146
Willful violations, 3
Willingness to report, 69
Work-to-rule strike, 51