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Just Culture. “A Seat with A View”. Knowingly. Were the. Pass. History. Unauthorized. violate safe. actions as. substitution. of unsafe. N o. No. No. Yes. substance?. operating. intended?. test?. acts?. procedures?. Yes. No. Yes. Yes. No. Were procedures. Deficiencies in.
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Knowingly Were the Pass History Unauthorized violate safe actions as substitution of unsafe No No No Yes substance? operating intended? test? acts? procedures? Yes No Yes Yes No Were procedures Deficiencies in No Yes Were the available, training & Medical consequences workable, selection or condition? as intended? intelligible and inexperience? correct? Yes Blameless No No Blameless Yes error but Yes error No corrective Yes training, System- Possible counseling induced System- negligent Possible needed error induced error Substance reckless violation Substance abuse with violation Sabotage, abuse mitigation Diminishing malevolent without culpability damage, mitigation suicide, etc. Decision Tree for Determining Culpability of Unsafe Acts Reason, J., Managing the Risks of Organizational Accidents
The Four Behavior Concepts Human Error Negligent Conduct Reckless Conduct Knowing Violations