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Toolkit:Safety and Justice/Consequences 4

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Consequences
You again.png
Hey! It's your man again! Does he have a problem following the rules? Have you established his competence for the job? Who trained him? Did you make sure the procedures were clear and unambiguous and fit for the job?

What are you correcting

If the same person is found deviating from known rules and procedures an number of times, you need to go a little deeper. It could be that your training methods are not effective or that rules and procedures are too complex. On the other hand, it could be that the person simply misses the competency to be able to operate at the required level or that there is is bigger issue related to his or her attitude. In these cases you need to address how it is that people that do not meet the competence levels are put in this position, or you need to address the issue of professional attitude. When it comes to professional attitude, a key thing to observe here is the person's reaction to being corrected. Being corrected can be painful, and you need to take that into account, but if somebody is open for this correction there is usually not a real problem. If somebody refuses to be open for this correction however, the problem is more serious and it might well be that this is a more serious case.

How are you correcting

At this point it is important to address the issue completely and deeply. What is the pattern here? Take a person out of the operational proces until you either feel confident that he or she has demonstrated the competence and/or attitude that give the organization the confidence that he or she can function again.

Be mindful of the fact that you are not talking to an evil person here: we all sometimes struggle to learn something, and we all fall into the temptation of ego sometimes (be honest!). But low competence and pretending to be better than you are, or better than your peers or superiors, simply has no place in a high reliability team.

Take a critical look at your training and selection process. Check your supervisor's ability to handle ego-related issues or to judge somebody's competence correctly and fairly. It is not fair or "nice" to put somebody in a job that is above his or her competence!

Examples
Explanation consequences
Now you are at the level of the Just Culture consequences that we are suggesting.

If you feel these consequences are not appropriate, maybe you could consider going back up the navigator and trying some other branches.

Substitution Test
The Substitution Test helps to assess how a peer would have been likely to deal with the situation.

Johnston (1995), a human factors specialist and an Aer Lingus training captain, has proposed the substitution test. When faced with an event in which the unsafe acts of a particular individual were clearly implicated, the judges should carry out the following thought experiment. Substitute for the person concerned someone coming from the same work area and possessing comparable qualifications and experience. Then ask: 'In the light of how the events unfolded and were perceived by those involved in real time, is it likely that this new individual would have behaved any differently?' If the answer is 'probably not' then, as Johnston (1996:34) put it, 'apportioning blame has no material role to play, other than to obscure systemic deficiencies and to blame one of the victims'. A useful variant on the substitution test is to ask of the individual's peers: 'Given the circumstances that prevailed at the time, could you be sure that you would not have committed the same or a similar type of unsafe act?' If the answer again is 'probably not', then blame and punishment are inappropriate.