Say what

Say what

A rule was not followed

So it feels a little more serious here. A rule or procedure was not followed, and this either led to an incident or increased the risk of an incident happening. Also, this goes against the basic safety agreement: We follow the best known procedures and practices to achieve our safety outcomes.

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This is the correct level if you find that a rule has not been followed because either the rule or procedure was not known, or (not unlikely) not clear enough / not understandable or contradictory with another rule. If that seems to be the case, click "next".

From the literature we could call this "unintended violations". They are the result of people not knowing how to apply procedures properly due to:

  • The use of complicated language
  • Many cross-references or internal inconsistencies and conflicting messages in the documents
  • Not taking the level of the user of the procedures into account

Sometimes people act as if there is no procedure at all, due to:

  • The procedures not being available
  • Lack of familiarity with the procedures

Wrong intersection


Explanation outcomes

You have now landed on one of the eight possible outcomes. Check the examples you may find. Do they match the behaviour of the person in question you were interpreting? If not, go back up and try a different branch. If yes, you may click the "next" button and get some suggestions what a good Just Culture follow up for this kind of behaviour is.


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