Contents
Case Study: When Does a Mistake Stop Being Honest?
Chapter 1 Retributive and Restorative Just Cultures
Difficulties and Fairness in Retribution
Breaking The Rules to Get More Recruits: Some Say Cheating Needed to Fill Ranks
Summarizing and Managing the Difficulties with Retributive Justice
Who Was Hurt, and What Are His or Her Needs?
Identifying the Obligations to Meet Needs
Comparing and Contrasting Retributive and Restorative Approaches
Neither Retributive nor Restorative Justice “Lets People Off the Hook”
Retributive and Restorative Forms of Justice Deal Differently with Trust
Can Someone or Something Be Beyond Restorative Justice?
Technical Errors: Errors in a Role
Normative Errors: Errors of a Role
Chapter 2 Why Do Your People Break the Rules?
Violations Seen from This Bench Are Just Your Imagination
Stupid Rules and Subculture Theory
Hindsight and Shooting Down an Airliner
A Normal, Technical Professional Error
The Worse the Outcome, the More to Account For
Chapter 3 Safety Reporting and Honest Disclosure
Reporting to Managers or to Safety Staff?
The Successful Reporting System: Voluntary, Nonpunitive, and Protected
What If Reported Information Falls into the Wrong Hands?
The Difference between Disclosure and Reporting
The Risks of Reporting and Disclosure
The Ethical Obligation to Report or Disclose
A Nurse’s Error Became a Crime
Criminal Law and Accidental Death
Rational Systems that Produce Irrational Outcomes
Chapter 4 The Criminalization of Human Error
Do First Victims Believe that Justice Is Served by Putting Error on Trial?
Are Victims in It for the Money?
Safety Investigations that Sound Like Prosecutors
The Prosecutor as Truth-Finder
Determining Whether Laws Were Broken
The Consequences of Criminalization
Most Professionals Do Not Come to Work to Commit Crimes
Is Criminalization Bad for Safety?
But Isn’t There Anything Positive about Involving the Legal System?
Without Prosecutors, There Would Be No Crime
Judicial Proceedings and Justice
Judicial Proceedings and Safety
Industry Responses to Criminalization
Response 2: The Volatile Safety Database
Response 3: Formally Investigate Beyond the Period of Limitation
Response 4: Rely on Lobbying, Prosecutorial, and Media Self-Restraint
Response 5: Judge of Instruction
Response 6: The Prosecutor Is Part of the Regulator
Response 7: Disciplinary Rules within the Profession
Chapter 5 What Is the Right Thing to Do?
Before Any Incident Has Even Happened
After an Incident Has Happened
Not Individuals or Systems, but Individuals in Systems
A Discretionary Space for Personal Accountability
Blame-Free Is Not Accountability-Free
Forward-Looking Accountability
Ask What Is Responsible, Not Who Is Responsible
What Is the Right Thing to Do?
Not Bad Practice, but Bad Relationships
There Is Never One “True” Story
The “Real” Story of What Happened?