File #2680: "2019_Book_TheJustCulturePrinciplesInAvia.pdf"
Text
1|Preface|7
1|Contents|9
1|Chapter 1: Origin and Development of a `Just Culture´|11
2|1.1 From Human Error to a `Safety Culture´ and a `Just Culture´. Reason´s Model|11
2|1.2 Just Culture´ in Aviation|18
3|1.2.1 Application of `Just Culture´ Principles to the Aviation Sector|18
3|1.2.2 Relationship Between `Just Culture´, Safety Investigation and Occurrences Reporting|22
2|1.3 `Just Culture´ in Healthcare|27
3|1.3.1 Application of `Just Culture´ Principles to the Healthcare Sector|27
3|1.3.2 The Brief Relevance of a `Just Culture´ in the Field of Medical Responsibility in the Italian Legal System: From the `Ba...|30
2|References|42
1|Chapter 2: The Legal Definition of `Just Culture´ in Aviation|55
2|2.1 Legal Concept and Definition of ``Just Culture´´ in Aviation|55
3|2.1.1 At International Level|56
3|2.1.2 At European Level|64
3|2.1.3 At National Level (Italian Legal System)|72
2|2.2 Considerations on the `Just Culture´ Common Definition|73
2|References|75
1|Chapter 3: Legitimate and Illegitimate Behaviour in Aviation|79
2|3.1 The Fine Line Between Acceptable and Unacceptable Behavior|79
2|3.2 Current Definitions of `Wilful Misconduct´ and `Gross Negligence´|81
2|3.3 Towards a Common Legal Definition of `Gross Negligence´ in Aviation|86
2|References|91
1|Chapter 4: `Just Culture´ Versus `Blame Culture´ in Aviation|93
2|4.1 The Differences Between `Blame Culture´ and `Just Culture´ in Aviation|93
3|4.1.1 The Linate Disaster|96
3|4.1.2 The Überlingen Disaster|99
3|4.1.3 The Gonesse Disaster|101
2|4.2 The Implications of Criminalization|103
2|4.3 Justice Versus Aviation Safety with Regard to Safety Investigation and Occurrence Reporting|104
2|References|107
1|Chapter 5: From a `Blame Culture´ to a `Just Culture´ and Back: The Italian Experience in the Aviation Field|111
2|5.1 An Italian Trial Inspired by `Blame Culture´ Principles: Aftermath of the ``Monte dei Sette Fratelli´´ Disaster|111
2|5.2 The Consequences of the Supreme Court Judgement on the 2004 Cagliari Fatal Accident|118
3|5.2.1 The ANSV Recommendations No. 3/28-04/6/A/09 and No. 4/28-0476/A/09|119
3|5.2.2 The NOTAM A/4785|120
3|5.2.3 The ENAC Circular ATM-07|120
3|5.2.4 The Italian Legislative Decree No. 133/2014|122
2|5.3 The Italian Legal System Following the Changeover from a `Blaming Culture´ to a `Just Culture´|123
2|5.4 From the (EC) Regulation No. 216/2008 to the Italian Legislative Decree No. 173/2017: A Step Backwards in the Framework of...|124
2|References|131
1|Chapter 6: Final Remarks|135
2|References|137
1|References|138
1|Contents|9
1|Chapter 1: Origin and Development of a `Just Culture´|11
2|1.1 From Human Error to a `Safety Culture´ and a `Just Culture´. Reason´s Model|11
2|1.2 Just Culture´ in Aviation|18
3|1.2.1 Application of `Just Culture´ Principles to the Aviation Sector|18
3|1.2.2 Relationship Between `Just Culture´, Safety Investigation and Occurrences Reporting|22
2|1.3 `Just Culture´ in Healthcare|27
3|1.3.1 Application of `Just Culture´ Principles to the Healthcare Sector|27
3|1.3.2 The Brief Relevance of a `Just Culture´ in the Field of Medical Responsibility in the Italian Legal System: From the `Ba...|30
2|References|42
1|Chapter 2: The Legal Definition of `Just Culture´ in Aviation|55
2|2.1 Legal Concept and Definition of ``Just Culture´´ in Aviation|55
3|2.1.1 At International Level|56
3|2.1.2 At European Level|64
3|2.1.3 At National Level (Italian Legal System)|72
2|2.2 Considerations on the `Just Culture´ Common Definition|73
2|References|75
1|Chapter 3: Legitimate and Illegitimate Behaviour in Aviation|79
2|3.1 The Fine Line Between Acceptable and Unacceptable Behavior|79
2|3.2 Current Definitions of `Wilful Misconduct´ and `Gross Negligence´|81
2|3.3 Towards a Common Legal Definition of `Gross Negligence´ in Aviation|86
2|References|91
1|Chapter 4: `Just Culture´ Versus `Blame Culture´ in Aviation|93
2|4.1 The Differences Between `Blame Culture´ and `Just Culture´ in Aviation|93
3|4.1.1 The Linate Disaster|96
3|4.1.2 The Überlingen Disaster|99
3|4.1.3 The Gonesse Disaster|101
2|4.2 The Implications of Criminalization|103
2|4.3 Justice Versus Aviation Safety with Regard to Safety Investigation and Occurrence Reporting|104
2|References|107
1|Chapter 5: From a `Blame Culture´ to a `Just Culture´ and Back: The Italian Experience in the Aviation Field|111
2|5.1 An Italian Trial Inspired by `Blame Culture´ Principles: Aftermath of the ``Monte dei Sette Fratelli´´ Disaster|111
2|5.2 The Consequences of the Supreme Court Judgement on the 2004 Cagliari Fatal Accident|118
3|5.2.1 The ANSV Recommendations No. 3/28-04/6/A/09 and No. 4/28-0476/A/09|119
3|5.2.2 The NOTAM A/4785|120
3|5.2.3 The ENAC Circular ATM-07|120
3|5.2.4 The Italian Legislative Decree No. 133/2014|122
2|5.3 The Italian Legal System Following the Changeover from a `Blaming Culture´ to a `Just Culture´|123
2|5.4 From the (EC) Regulation No. 216/2008 to the Italian Legislative Decree No. 173/2017: A Step Backwards in the Framework of...|124
2|References|131
1|Chapter 6: Final Remarks|135
2|References|137
1|References|138