Consequences 2

Consequences 2

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O dear... Is it him again? Why can he not understand how this system works..! Repeating errors are a problem because it is an indication that in some way learning is not taking place. If the repeating pattern centres around an individual it is really important to take a closer look.

What are you correcting

Before jumping to conclusions, you need to check how this person was declared competent for the job. Where was he trained and was that up to date? Did he have the right tools, materials, instructions, enough time etc?

If the person is working in a situation which is beyond his competence, mistakes, slips and lapses are waiting to happen.

If slips and lapses show a consistent trend, you could indeed question competence for this type of job. If mistakes are consistent, more training / coaching is justified. At the same time, you should look at how the organization creates the situation whereby people who are not competent to the task are put at work. Here you should look at the planning process, the instructions management gives and perhaps bigger or personal consequences that managers are trying to avoid with this situation ("He was the only person I had so I let him do the job otherwise I would have looked bad").

If it turns out that the person in question refuses to take input and integrate learning that is the key issue to be addressed. In a just culture everybody can make mistakes, but refusing to share, learn and improve are a real no-go.

How are you correcting

You should really go into these situations with the intention of discovering the pattern. If the organization stops learning things are wilfully put at risk. Find the pattern that makes this situation recur, and share the learnings without blame.

However, when it turns out the the repeating event is caused by somebody wilfully not changing his or her ways, you should consider taking this person out of harm's way by removing him or her out of the process until a change has happened.

Manager should be trained on recognizing and correcting these patterns.


Implants infection

Monitoring a CTG

Separation minimum

Auto-throttle connection

Forgetting a clearance

This is your captain speaking


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.


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