Consequences
Because this has not happened before, your principle assumption remains that the procedures as specified normally work and are understood by everyone. Perhaps for this particular person the rules were not clear and well understood? Check out the subsitution test! In case there is no doubt, then obviously someone knew better than the system and deliberately deviated.
What are you correcting:
The person in question needs to understand how important it is that the operational practice follows the applicable rules. It is very important you do not let this opportunity slip, otherwise deviations and rule-breaking may quicky become the norm and your safety culture deteriorates. Were other workers already pointing out to their colleague he was violating the rules? You wish they had!
How are you correcting:
Assuming your procedures are in order you are definitely coaching the worker back on track of nominal behaviour. You could have him train the procedure again. Check if there is an 'attitude issue' with the person involved which could make things more difficult and could necessitate the first of correctional measures like a verbal warning.
Operating in the Dutch Caribbean, the pilot of a Britten Norman Islander took on passengers for a full load of his aircraft. The loadsheet reported precisely the maximum take-off weight. During the flight, one of the engines stopped. Instead of flying to the nearest airport, the pilot thought he could reach his destination airport on one engine. However, the aircraft was overloaded because it was company customary to estimate the weight of the passengers at 167 lbs per person.
The aircraft crashed in the sea. All passengers escaped and survived. The aircraft sank to the botten of the ocean. The pilot, most likely rendered unconscious because of the impact with the water, was killed.
Although he could not see the runway yet, the captain descended the aircraft below the minimum descent altitude because he was low on fuel and did not want to go-around.
The Maasstad Hospital at Rotterdam in the Netherlands experienced an outbreak of a nasty bacterium. The Klebsiellabacterium was first found in October 2010. Only late May of 2011 the hospital board admitted that there was a problem, took action and alerted neighbouring hospitals. Of the 115 infected patients 28 deceased. In three of these cases the infection was very likely the cause of death.
