Just & Fair approach

Implementation Guide

SNCF
SAFETY P R I S M E
 THE JUST & FAIR APPROACH
GOALS OF THE APPROACH THE JUST & FAIR APPROACH…
The Just & Fair approach aims to create a …IS:
climate of trust that encourage feedback. By
promoting freedom to speak, this approach
• a complete approach, guided by a
methodology and tools to assist
provides a better understanding of system
management in taking the right decision.
strengths and weaknesses. Just & Fair • a guide to analyse the facts with goodwill yet
Following a safety event, this approach allows analysis with no complacency.
a processing of both: • a complementary approach linked to the
Just: by distinguishing the causes induced by analysis of Human and Organisational
the system and those related to the actors. Factors (HOF) carried out following a safety
Trust event.
& Fair: by providing a homogeneous • an approach promoted by management that
handling to similar situations. Acknowledgement contributes to the development of Safety
The approach also aims to recognise and Leadership.
promote exemplary behaviours that …IS NOT:
contribute to strengthen the safety level. Transparency
Freedom to • a penalty scale.
Ultimately, the approach aims to take speak • a search for culprits.
appropriate measures to prevent such • a moral judgment.
event from recurring and, in doing so, to • a substitute for the HOF analysis of an event
contribute to enhance the Safety Culture. • a screening approach for psychoactive
THIS BOOKLET… Feedback substances.
Learning • an approach limited solely to this guide.
... is a tool dedicated to the Just & Fair
approach. Its purpose is to guide you in the Improvement
processing of safety events in order to
determine the appropriate actions to prevent
To learn more about the process and the
similar event from occurring.
associated tools, scan the QR code
-1- (available in French language only):
5 KEY STEPS REQUIRED

about WHAT?
1 COLLECT FACTS AND ANALYSE ROOT CAUSES The approach applies to:
• All behaviours or acts that have had or may have an impact
on safety and are not expected or planned.
2 IDENTIFY THE BEHAVIOUR OR ACT • All areas of Global Safety (rail safety, occupational health safety,
security, fire safety, environmental safety and cybersecurity).
EVALUATE THE ACCEPTABILITY OR
3 UNACCEPTABILITY OF THE BEHAVIOUR OR ACT WHEN?
• The gathering of facts is done as quickly as possible after the
event.
TAKE APPROPRIATE MEASURES REGARDING THE
4 ACTORS, THE TEAM AND THE SYSTEM
• The other steps are carried out by taking the time necessary to
conduct an exhaustive analysis of the situation.

5 PROVIDING FEEDBACK TO ALL PARTIES INVOLVED HOW?

• With a goodwill and listening posture.
• Giving the benefit of doubt to the people involved.
• By being objective and open to everyone's points of view.
• By not anticipating the result during the analysis.

by WHOM?
• The process is carried out collectively.
Best practice • With the contribution of a HOF specialist.
Identify a J&F referent to ensure the • As much as possible, with the people involved in the safety
implementation of the approach. event at all stages of the process.

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 COLLECT FACTS AND ANALYSE ROOT CAUSES
1
DISTINGUISH BETWEEN SYSTEM-INDUCED AND OPERATOR-INDUCED CAUSES

SYSTEM-INDUCED CAUSES OPERATOR-INDUCED CAUSES

Negative factors Positive factors Negative factors Positive factors

 Rules / Procedures / Documentation  Knowledge

Unavailable Available
 Technical skills
Unenforceable Enforceable
Inappropriate for the situation Appropriate for the situation  Non Technical Skills (NTS)
Not understandable Understandable
Not up-to-date / Obsolete Up-to-date Lack of knowledge Adequate knowledge
Inconsistent to each other Compatible with each other Training gap Adequate training
 Equipment / technical installations Inadequate training received Appropriate training received
Unavailable Available Lack of experience Appropriate level of experience
Bugged or out of order Fully functional Inadequate soft skills Adapted soft skills
Unsuitable for the activity Suitable for the activity Technical skills gap Sufficient technical skills
Non technical skills gap Sufficient non technical skills
 Resources available
Insufficient time for the activity Sufficient time for the activity
Unavailable staff Available staff
Insufficient staff Sufficient staff
Inadequate skills (training, Adequate skills (training,
qualification, authorisation) qualification, authorisation) Best practices
 Organisation • Challenge the system and
Unsuitable for the activity Suitable for the activity managerial practices.
Not compliant with the plan Compliant with the plan
• Identify root causes based on the
 Environment and working conditions ( mood, atmosphere...)
HOF analysis of the safety event.
Uncomfortable (noise, weather...) Comfortable
Group pressure Collaborative helping
Unsafe local practices Safe group practices
Hierarchical pressure Hierarchical support
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 INDENTIFY THE BEHAVIOUR OR ACT
2
DISTINGUISH BETWEEN ERROR, VIOLATION AND EXEMPLARY BEHAVIOUR
WAT IS AN EXEMPLARY BEHAVIOUR?
It is a good practice, a behaviour or an act performed to guarantee a higher level of safety, even if it means breaking some rules.
Example: Airplane pilot Sully landing on the Hudson River in New York on January the 15th 2009.

ATTENTION
Was it an exemplary behaviour?
ERROR = UNINTENTIONAL ACT
VIOLATION = VOLUNTARY ACT
NO YES

Was the behaviour or act done deliberately? Praise the behaviour

NO YES

Error Violation Is this behaviour expected?*

Promote good practice and consider

NO YES if it is worth integrating this
behaviour into established practices

Follow up on step 2 Follow up on step 2 Proceed directly to step 4 Proceed directly to step 5
page 5 page 6 page 9 page 10

* A behaviour can be considered exemplary because it has allowed a situation to be remedied, but can also be considered as undesirable
given the fact that it is not the agent’s but the system's responsibility to prevent or remedy this situation. Such exemplary behaviour is hence
evaluated as undesirable when we want to avoid putting other agents in a similar situation.
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 IDENTIFY THE BEHAVIOUR OR ACT
2
QUALIFY THE NATURE OF THE ERROR
Could another agent with the
ERROR Did the agent take Was the agent
same skills and comparable
= any drugs or YES performed similar acts
NO qualifications have behaved
UNINTENTIONAL psychoactive or had similar behaviour
the same way in similar
ACTION substances? in the past?
circumstances?

YES NO YES NO

Did he have a Does the involved agent Were the system’s

medical have a lack of training or expectations realistic and
prescription? experience? reasonable in this context?**

NO YES NO YES NO YES

Error with abuse Error with abuse

Potential error by System-induced Error due to lack of
without mitigating with mitigating Single error
negligence error training or support
circumstances circumstances

* If necessary, describe the situation with peers including any contextual factors and then raise the question: ‘ How would you have acted in a
similar context? Could you have made the same error? ’. Assess the work habits and any factors that might have 'trapped' the agent.
** Review the negative factors identified in step 1 and enquire about the causes induced by the system with the following questions:
• Were the procedures available, understandable, applicable, and appropriate to the activity?
• Did the environment or context (atmosphere, disrupted situation) favour the observed behaviour?
• Was the technical equipment fully functional?
• Was the organisation adapted and were the resources adequate?
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 IDENTIFY THE BEHAVIOUR OR ACT
2
QUALIFY THE NATURE OF THE VIOLATION
VIOLATION = VOLUNTARY ACTION Deliberate consequences? YES

NO

Could another agent with the

Did the agent Did he act under the
same skills and comparable Did he act in
take any influence of the work
NO qualifications have behaved in NO the interest of NO
psychoactive environment or the
the same way in similar the company?
substances? hierarchy?
circumstances?

YES YES YES YES NO

Did he have a Were the system's expectations of

Did he act with personal motivation or
medical the agent realistic and reasonable
with carelessness or gross negligence?
prescription? in this context?**

NO YES YES NO YES NO

Violation with
Violation with abuse Violation with intent to
abuse without Potential violation System-induced Violation by
with mitigating harm (malevolence)
mitigating by negligence violation negligence
circumstances
circumstances
* If necessary, describe the situation with peers including context and then raise the question: ‘ How would you have acted in a similar context?
Could you possibly have committed the same violation?’. Assess the work habits and factors that could have 'trapped' the agent.
** Review the unfavourable factors identified in step 1 and enquire the causes induced by the system with the following questions:
• Were the procedures available, understandable, applicable, and appropriate to the activity?
• Did the environment or context (atmosphere, disrupted situation) influence the observed behaviour?
• Was the technical equipment fully functional?
• Is it the system that forced the agent to choose between several conflicting demands (double binding)?
• Was the organisation appropriate and the means sufficient?
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 EVALUATE THE ACCEPTABILITY OR UNACCEPTABILITY OF THE BEHAVIOUR OR ACT
3
DEFINE THE LEVEL OF ACCEPTABILITY RELATED TO THE OPERATORS

If the result of step 2 is:

Use of psychoactive Use of psychoactive

Violation with intent
substances without substances with Violation by
to harm Error by negligence Single error
mitigating mitigating negligence
(malevolence)
circumstances circumstances

Review the causes collected in Step 1 and use the following questions to evaluate the acceptability of the
behaviour or act from the operator's perspective:
• Could another agent have acted in the same way in similar circumstances? Do peers consider this behaviour appropriate for
a professional in the industry?
• Does the safety event reveal a latent ‘trap’ in which other agents could fall too?
• Did the organisation put in place contribute to the occurrence of the safety event?
• Was the agent aware of the potential impact on safety or other possible Best practice
impacts (on reputation, regularity, etc.)? Do not let consequences
• Was the agent being transparent? Did he/she spontaneously report the information? influence your assessment.
• Was the agent collaborative during the investigation and analysis?
• Does the agent show any guilt or remorse?
• Is this safety event a source of learning for the group or the system?
• Did the agent have a duty to be exemplary? The more influential an agent is, the more he / she should be exemplary.
(Raise this question in the case of a violation by a manager, trainer, person with safety duties, etc.)

UNACCEPTABLE ACCEPTABLE

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 EVALUATE THE ACCEPTABILITY OR UNACCEPTABILITY OF THE BEHAVIOUR OR ACT
3
DEFINE THE LEVEL OF ACCEPTABILITY OF THE SYSTEM

If the result of step 2 is:

System-induced System-induced Error due to lack of

violation error training or support

Review the causes collected in Step 1 and use the following questions to evaluate the acceptability of
the agent's behaviour or act from the system's standpoint:
• Could the safety event have had more serious consequences or other more significant impacts?
• Is the organisation, the context, the situation exceptional or recurrent?
• Does the safety event reveal a latent "trap“ in which other agents could fall too?
• Was it possible to work differently in this situation / context / environment / working conditions?
• Was the safety event predictable? Could it have been anticipated or is it surprising?
• Were the system’s expectations of the people involved realistic and reasonable (i.e., sufficient and appropriate training,
available resources, available staff, available time, applicable procedures, etc.)?
• Were the working conditions acceptable?
• Did the organisation put in place generate significant or unconsidered risks?
Risks for which no protective barriers are provided?
• Could the people involved have warned, avoided or remedied the situation? Best practice
Do not let consequences
influence your assessment.

UNACCEPTABLE ACCEPTABLE

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 TAKE APPROPRIATE MEASURES REGARDING THE ACTORS, THE TEAM AND THE SYSTEM
4
PREVENT THE EVENT FROM RECURRING
ATTENTION
It is up to the analysis team to identify the measures needed to prevent the event from happening again. Make sure that every decision is
compared with similar cases to ensure a fair process.

Undesirable exemplary The error or violation is

The error or violation is assessed as unacceptable
behaviour assessed as acceptable

Assess whether measures are necessary to ensure that the Take measures to prevent the Assess whether the sanction is
safety event does not recur event from happening again useful in addition to other actions

Context Operational management

 Environment, working conditions:  Organisation adapted to reality

lighting environment, noise exposure,... Sanction is necessary if it is the only way to:
 Managerial practices: safety leadership,
 Equipment, tools, technical equipment: on-site presence, exemplarity,… ❑ solve the problem
available, in good working order, suitable
for the activity,...  Rules, documentation, procedures: ❑ prevent the event from happening again
available, appropriate, understandable, up
 Resources available: available time, staff, to date, applicable and coherent ❑ enforce the fundamentals
equipment...
❑ discourage overt cover-ups
Operational activity / the protagonist(s) Strategic management

 Work experience, training: knowledge,  Orientations, decisions, arbitrations at

technical and non-technical skills, the entity level: risk analysis, Common
qualification, authorization,... Safety Method (CSM),... If a checkbox is ticked, consider the sanction
and possibly initiate the disciplinary
 Feedback and alert on strategic business procedure
 Psychological and physiological choices
condition: support, planning,...

J. Reason's model

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 PROVIDING FEEDBACK TO ALL PARTIES INVOLVED
5
PROVIDING FEEDBACK AND EXPLAINING TO BUILD TRUST

ATTENTION
Building trust is based on understanding and adherence to treatment outcomes.

1 2 3 4
Review the facts and Explain the decision taken. Present the measures Explain what these
information collected Using the provided tools, taken and the measures have
from all parties explain the path of questions associated action plan. prevented, are
involved in the event. which has led to the conclusion preventing and
whether the observed behaviour will prevent.
or action is acceptable or
unacceptable.

Best practice Best practice ITEMS TO BE PRESENTED

Give feedback to the Explaining the decision is
larger team by an essential step for the • Synthesis of the facts collected in Step 1.
explaining the decision success of the process. • Main organisational factors identified in step 1.
and measures taken. • Main Human Factors identified in step 1.
• Result of the behaviour or action analysis from the flowchart
in step 2.
• Results and evaluation criteria for assessing the
acceptability of the behaviour or action (step 3).
• Actions taken and lessons learned for the system (step 4).

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In case of a safety event, the appropriate

SNCF - Direction Sécurité Groupe – 2 place aux Étoiles – 93 200 SAINT-DENIS

Guide d’application de la démarche Juste & Équitable version 2 - juillet 2022
question to ask is not:
‘What penalty should I apply?’ but
‘What actions do I need to take, at system
level and for the operators, to ensure that
the event does not happen again?’
This is the only way we can improve to ensure
a high level of safety.