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Introduction
Approximately 88% of all workplace accidents and injuries can be traced back to unsafe acts, according to the foundational research of H. W. Heinrich.
While these behaviours might appear to be individual choices, deeper research, notably by safety expert Sidney Dekker, shows that about 90% of unsafe behaviours are actually caused by organisational factors, not the individual.
This means the real drivers of workplace safety lie in the systems, leadership and culture that shape behaviour. People tend to adapt to their environment, often unconsciously mirroring the norms and expectations around them. They simply want to fit in. So, if unsafe practices become routine or go unchallenged, even well-intentioned employees may adopt risky habits.
Therefore, to truly improve safety performance, a holistic approach is essential, one that focuses not only on individual responsibility but on creating a resilient, fair and learning-driven culture, as emphasised by Dr Tim Marsh.
This gap between individual behaviour and organisational influence is what the concept of Just Culture seeks to address. Developed by Professor James Reason, Just Culture provides a structured approach for understanding why people behave the way they do and how organisations should respond when things go wrong.
It moves the conversation beyond blame, focusing instead on learning, accountability and system improvement. By distinguishing between human error, at-risk behaviour and reckless actions, Just Culture helps create a fair environment where reporting is encouraged, learning is prioritised and safety becomes embedded in the organisational DNA.
The question is not if errors will happen, but how an organisation responds when they do.
A Just Culture provides a balanced approach to accountability. It recognises that while human error is inevitable, not all mistakes are equal and that learning, not punishment, should be the default response to most incidents.
Understanding Just Culture
What Is Just Culture?
Just Culture is a management philosophy that promotes accountability in a fair and transparent manner. It sits between a blame culture, where every error is met with punishment and a no-blame culture, where accountability is diluted. Instead, Just Culture evaluates actions based on behavioral intent and risk awareness. It differentiates between unintentional human error, at-risk behavior and reckless conduct, allowing organisations to respond in ways that are both just and constructive.
A healthy Just Culture encourages employees to speak up about errors, near misses and unsafe conditions. These reports are not only tolerated, they are valued as essential data for learning and systemic improvement. This openness leads to stronger risk controls, better process design and higher organisational resilience.
Origins and Evolution in Safety-Critical Industries
The roots of Just Culture can be traced back to the aviation sector, particularly following high-profile disasters where systemic issues were found to be major contributors. The work of Professor James Reason, especially his Swiss Cheese Model, helped establish the idea that failures are often the result of multiple, layered weaknesses rather than one individual's fault.
Building on this, Sidney Dekker introduced the concept of Restorative Just Culture, which places emphasis on healing, empathy and collective responsibility after an incident. These thought leaders have helped evolve Just Culture from a compliance-driven practice into a comprehensive strategy for managing operational risk and human performance.
Today, Just Culture is embraced by a variety of high-risk industries, including:
Healthcare, where it's used to encourage open reporting of medical errors.
Nuclear energy and chemical processing, where system reliability and staff vigilance are paramount.
Rail and maritime transportation, where accident investigations increasingly focus on latent organisational failures.
Core Principles: Fairness, Accountability and Learning
Just Culture rests on three foundational pillars:
Fairness: Employees must feel that they will be treated equitably when they report incidents. This involves applying consistent criteria to evaluate behavior and decisions, rather than assigning blame based on outcomes alone.
Accountability: Holding individuals responsible for their choices, especially when they knowingly violate protocols, is essential. However, this accountability must be proportional and free from scapegoating.
Organisational Learning: Errors are inevitable, but they can also be invaluable. A Just Culture seeks to understand what happened and why, using insights to strengthen systems and prevent recurrence.
These principles work in collaboration to foster an environment where safety is everyone’s responsibility and improvement is continuous.
The Three Behaviours in Just Culture
Understanding how to respond to incidents begins with categorising behavior correctly. Just Culture outlines three main behavioral categories:
Human Error: Unintentional Mistakes
This is the most benign category. Human error includes slips, lapses and oversights, unintentional acts that typically arise from fatigue, distraction or miscommunication.
These are not acts of negligence but symptoms of deeper systemic issues such as flawed processes, poor training or inadequate resources.
In a Just Culture, the response to human error is not punishment but support. Organisations should ask:
What led to the error?
Were safeguards in place?
Can training or system design be improved?
Common responses might include procedural redesign, refresher training or increased staffing. The key is not to stigmatise the individual but to strengthen the process.
At-Risk Behaviour: Risk Not Recognised
At-risk behavior involves choices that increase risk, often because the person is unaware of the hazard or believes the risk is justified. Examples include shortcutting a safety step to save time or using a tool incorrectly due to habit or convenience.
While there may be no intent to cause harm, these behaviors require intervention. Responses may include:
Coaching to raise risk awareness
Discussions about why the behavior occurred
Revisiting standard operating procedures (SOPs)
Importantly, leadership must model the right behaviors themselves (Leading by Example). If frontline staff see managers violating rules without consequence, they may emulate those choices.
Reckless Behaviour: Conscious Disregard
Reckless behavior is a willful choice to ignore known safety protocols or engage in risky conduct with full awareness of the potential consequences. This might include:
Operating machinery while impaired
Ignoring lockout/tagout procedures
Concealing a safety incident
In these cases, disciplinary action is warranted. A Just Culture does not excuse reckless behavior, but it does ensure the response is consistent, well-documented and free of bias. The aim is not retribution, but protection of the broader team and reinforcement of core values.
By clearly distinguishing these behaviors, organisations can make informed decisions that uphold accountability while maintaining trust. This classification system also empowers employees to report issues, knowing their actions will be fairly evaluated rather than reflexively punished.
This breakdown also aligns with the HSG48 guidance from the UK Health and Safety Executive, which categorises unsafe behaviours into errors and violations, offering a useful complement to the Just Culture model:
Five Practical Tips to Improve the Just Culture Within Your Organisation
Creating and nurturing a Just Culture requires deliberate, ongoing effort. Here are five practical tips you can begin implementing today:
Lead by Example: Ensure leadership consistently demonstrates the values of transparency, fairness and accountability.
Clarify Behavioural Expectations: Communicate clearly about the differences between human error, at-risk behaviour and reckless conduct.
Encourage Reporting Without Fear: Implement anonymous reporting systems and reinforce that honest reporting leads to improvement, not punishment.
Regular Training and Communication: Provide ongoing education on Just Culture principles through workshops, toolbox talks and case-based learning.
Review and Learn from Incidents: Analyse incidents using behavioural frameworks and share learnings across teams to build organisational resilience.
If you're ready to start building a Just Culture in your organisation, we’re here to help. Get in touch with us to explore how we can support your journey toward a safer, more accountable workplace.
