Before sanctioning, you need to understand
When a non-conformance, incident, or accident occurs on the ground, the first instinct is often to find who is responsible. Yet the most useful question is not “Who did what?” but rather: “In what work situation did this action occur?”
Behaviors never arise by chance. They are strongly influenced by work organization, operational constraints, production targets, available resources, and the trade-offs made on a daily basis. When an operator adopts a non-compliant behavior, the most effective response is therefore not necessarily a sanction. The most effective response is first to understand the conditions that made that behavior possible — or even logical.
Non-compliant behavior is rarely the real problem
In the field, teams must constantly balance several demands:
- Meeting deadlines
- Maintaining quality
- Following procedures
- Preserving safety
These trade-offs are not always straightforward. In some situations, operators may bypass a safety rule to meet another expectation perceived as more pressing at that moment. Sanctioning only the observed behavior amounts to treating the symptom without treating the cause.
In-depth analysis of the situation often reveals the true reasons: organizational tensions, contradictory objectives, or constraints that were not visible at first glance. This is precisely where the real lever for improvement lies — and it is at the heart of the Understand phase of the CAP® Method developed by C2D Prévention.
Human error or system failure?
It is essential to distinguish between two types of deviant behavior:
Human error
Error is, by definition, unintentional. It results from a normal action carried out in a context that does not always allow the expected outcome to be achieved. Several factors can contribute to it:
- Fatigue or physical overload
- High cognitive load
- Insufficient or unsuitable training
- Complex work organization
- Degraded working conditions
Our brains constantly process multiple streams of information and rely on cognitive shortcuts — known as heuristics — to function efficiently. In high-pressure environments, these automatisms can lead to suboptimal decisions, without the person being fully aware of it. This is what neuroscience applied to risk prevention teaches us: the human brain is not defective — it functions as it was designed to function — and it is the organization’s role to adapt to it.
Psychologist James Reason, a leading authority on human factors, distinguished between two broad approaches to error: the person approach — which attributes the accident to the individual — and the system approach — which looks for the organizational and technical conditions that made the error possible¹. It is this second approach that enables truly effective and lasting prevention.
Deliberate violation
A violation, by contrast, is an intentional departure from a known procedure. It may be routine (a rule perceived as unsuitable), situational (an exceptional circumstance), or exceptional (a conscious risk-taking decision). Even in this case, the question remains the same: what, within the organization, made this violation possible or acceptable?
The INRS also points out that a workplace accident is never explained by a single cause, but results from a combination of interdependent technical, organizational, and human factors.
Sanctioning error does not remove its causes
In a context where error stems from systemic factors, sanctions do not act on the mechanisms that produced the event. Worse still, they can discourage people from reporting the difficulties they encounter on the ground. Safety management then becomes blind and biased.
Yet when an organization stops seeing its errors, it also loses its ability to learn. Safety improves when deviations are known, analyzed, and discussed — not when they become invisible.
This is the very principle of weak signals: those minor incidents, near-misses, or field reports that, if ignored or suppressed, accumulate silently until a serious event occurs. A culture of systematic sanctioning is the direct enemy of early detection.
Sidney Dekker, author of Just Culture: Balancing Safety and Accountability, puts it clearly: a just culture does not seek to shield individuals from all accountability, but to create an environment in which honest mistakes can be reported freely, so that the organization can learn from them.
Safety is built with work collectives
A safety policy cannot be effective if it is defined solely from the office. Operators and frontline managers possess irreplaceable knowledge of real work. They know where the difficulties lie, understand the trade-offs required, and can identify the situations that genuinely expose teams to risk.
Erik Hollnagel, a researcher in resilience engineering, distinguishes between Work-As-Imagined (work as prescribed in procedures) and Work-As-Done (work as it is actually carried out on the ground). The gap between these two realities is often at the root of non-conformances⁴.
Closing this gap requires involving field teams in defining the rules. Involving them in building expected behaviors makes it possible to establish more realistic collective standards that are better adhered to. When a collective participates in building its own safety, engagement is generally stronger and behaviors more durable.
This is precisely the logic that guides C2D Prévention’s support modules: co-constructing with teams, at every level of the organization, a safety culture rooted in the reality of the field.
Recognizing what works, not only what fails
Safety does not rest solely on the absence of accidents. It also rests on the thousands of adjustments made every day by teams to deal with the unpredictability of the field. These adaptations — what is known as managed safety — allow the organization to remain effective despite constraints, unexpected events, and variations in activity.
Yet these contributions are rarely visible or valued. When employees primarily receive feedback during deviations or errors, an imbalance sets in. Recognizing effective practices then becomes an essential lever for engagement. Valuing what contributes to safety is often more motivating than sanctioning what deviates from it.
This is one of the foundations of the BBS (Behavior-Based Safety) approach: observing, acknowledging, and positively reinforcing safe behaviors rather than focusing all attention on at-risk behaviors. Within Hollnagel’s Safety-II framework, the goal is precisely to learn from what works — not only from what fails.
Building a safety culture founded on trust
Lasting change does not rest on fear. It rests on buy-in.
A strong safety culture develops when:
- Teams understand the purpose of the rules
- They share common values around safety
- They feel heard when they report a difficulty
- Frontline managers fully play their role as Safety Leaders
Trust plays a decisive role here. When it exists, employees more readily discuss risky situations, report deviations before they become incidents, and participate more actively in improving working conditions. Safety then ceases to be an obligation to comply with. It becomes a collective responsibility.
This is exactly what the CAP® Method from C2D Prévention enables: a structured four-phase approach — Understand, Organize, Produce the infusion, Stay on CAP — to make safety culture an organizational reflex embedded at every level of the company.
Key takeaways
- When faced with non-conformance, the essential question is not: “Who is responsible?”
But rather: “What, within our organization, made this situation possible?” - Understanding real work, analyzing organizational and human factors, recognizing positive contributions, and building trust are far more powerful levers than sanctions alone.
- Because a high-performing, embedded safety culture is not built against teams. It is built with them.
Ready to move from reaction to prevention?
C2D Prévention supports organizations in analyzing the human and organizational factors that influence safety behaviors — and in establishing a lasting safety culture at every level of the organization.
Let’s talk about your situation → Contact C2D Prévention
Sources
Reason, J. (1990). Human Error. Cambridge University Press.
Reason, J. (1997). Managing the Risks of Organizational Accidents. Ashgate Publishing.
Reason, J. (2000). Human error: models and management. BMJ, 320(7237), 768–770.
INRS. Errors: causes, consequences and management approaches in occupational health and safety. INRS documentary portal.
INRS. Workplace accident analysis — The fault tree method. Document ED 6163.
INRS. The concept of factors in occupational risk prevention. Document ED 8004.
Dekker, S. (2007). Just Culture: Balancing Safety and Accountability. Ashgate Publishing.
Dekker, S. (2017). Just Culture: Restoring Trust and Accountability in Your Organization (2nd ed.). CRC Press / Taylor & Francis Group.
Hollnagel, E. (2014). Safety-I and Safety-II: The Past and Future of Safety Management. Ashgate Publishing.
Hollnagel, E. From Safety-I to Safety-II: A White Paper. NHS England / CPPS.