When the balance is clear and the judgment is out, now is the time to follow up and maintain or create that Just Culture!

The goal is to improve the workforce morale and performance.

Recognizing exceptional behaviour is an important element in a just culture.

Improving the system effectively demonstrates a high level of skill. This should be recognised and rewarded.

Becoming a teacher is a major milestone in the development of a professional.

Working effectively with a system, and working it well, is no trivial achievement.

Do the routine test first

Hm! You must be puzzled and want to know WHY this happened.

O dear… Is it him again? Why can he not understand how this system works…!

Did you see this before?

First time it happened... okay, let's dig in and go deeper.

It is him again... Yes, he does have a problem following rules. 

Either your rules are not clear or your safety culture is down.

A rule was knowingly NOT applied

Because this has not happened before, your principle assumption remains that the procedures as specified normally work and are understood by everyone. 

Yes, he does have a problem following rules.

Your safety culture is down and no-one is correcting this.

Personal gain at play!