By following this guide, you will classify behaviors using the Just Culture decision tree, document case outcomes, and track quarterly statistics to maintain a non-punitive reporting culture.
Who should read this: Safety managers and admins who evaluate
safety events and determine appropriate organizational responses.
The accountable executive should understand the framework to
support consistent application.Prerequisites: Safety manager or admin role. Familiarity with
the Just Culture Framework
reference is recommended. Just Culture Overview
Just Culture classifies behaviors into three categories, each with
a different organizational response:
| Behavior Type | Description | Response |
|---|
| Human Error | Inadvertent action; the person did not intend the outcome. Slip, lapse, or mistake. | Console. Support the individual. Fix the system. |
| At-Risk Behavior | Conscious choice to deviate, but the person did not recognize or underestimated the risk. Drift, normalization of deviance. | Coach. Help the person see the risk. Remove incentives for the behavior. |
| Reckless Conduct | Conscious disregard of a substantial and unjustifiable risk. The person knew the risk and chose to proceed. | Discipline. Remedial action proportional to the conduct. |
Just Culture does not mean no-blame culture. Reckless conduct requires accountability. The
framework distinguishes between behaviors that deserve system-level fixes and behaviors that
require individual-level remediation.
Open a Case from an Investigation
Just Culture cases are typically initiated after a safety event has been reported and investigated. You can open a case from two places:
- From the Just Culture page: Navigate to Safety > Just Culture and create a new case, then link it to a safety report or investigation.
- From an investigation: While reviewing investigation findings, create a Just Culture case linked to the investigation to formally classify the behavior involved.
In both cases, the case is linked to the source record for traceability.
Work the Decision Tree
The decision tree implements James Reason’s Culpability Decision Tree, adapted for aviation SMS. It follows two paths — an error path and a violation path — determined by the first question.
Step 1: Open the Just Culture page
Navigate to Safety > Just Culture. The page displays three tabs: the interactive decision tree, the case log, and quarterly statistics.
Create a new case and link it to the relevant safety report or investigation. Enter the employee reference and incident reference for tracking.
Step 3: Question 1 — Were the actions as intended?
The first question determines which path the evaluation follows:
No (Error path): The actions were unintended — a slip, lapse, or honest mistake. The individual did not mean to perform the actions that led to the event. Proceed to Question 2.
Yes (Violation path): The actions were deliberate, but the outcome was not intended. The individual chose to deviate from the expected procedure. Proceed to Question 4.
This question asks about the actions, not the outcome. Almost no one intends a negative safety
outcome. The question is whether the person intended to do what they did — not whether they
intended the result.
Step 4: Question 2 (Error path) — Was there a deficiency in training, experience, or supervision?
If the actions were unintended, determine whether the system contributed:
Yes: The error resulted from inadequate training, insufficient experience, unclear procedures, or lack of supervision. This is a system issue. Classification: Human Error. Response: Console.
No: The individual had adequate training and resources. Proceed to Question 3.
Step 5: Question 3 (Error path) — Would a similarly trained and motivated individual make the same error? (Substitution test)
Apply the substitution test: if you replaced this individual with a reasonable peer of similar training and experience, would they likely have made the same mistake?
Yes (System failure): The error reflects a system trap or design flaw that would catch most people. Classification: Human Error. Response: Console. Focus on fixing the system.
No (Individual factor): Something specific to this individual contributed to the error. Classification: At-Risk Behavior. Response: Coach. Provide additional training or support.
Step 6: Question 4 (Violation path) — Does the individual have a history of unsafe acts or prior violations?
If the actions were deliberate, assess the individual’s safety record:
Yes (Pattern): A pattern of repeated violations exists. Proceed to Question 5.
No (Isolated): This is an isolated deviation. Proceed to Question 6.
Step 7: Question 5 (Violation path, pattern) — Did the individual knowingly accept a substantial and unjustifiable risk?
For individuals with a pattern of violations, determine whether the behavior was reckless:
Yes (Reckless): The individual was aware of a substantial, unjustifiable risk and consciously chose to proceed. Classification: Reckless Conduct. Response: Discipline.
No: Despite the pattern, the individual did not consciously accept an unjustifiable risk. Classification: At-Risk Behavior. Response: Coach. Address the pattern through targeted intervention.
Step 8: Question 6 (Violation path, isolated) — Would a reasonable peer in the same situation have made the same choice? (Substitution test)
For isolated violations, apply the substitution test:
Yes (System issue): The procedural deviation is common among peers, suggesting the procedure may be impractical or poorly designed. Classification: Human Error. Response: Console. Fix the procedure.
No (Individual choice): A reasonable peer would not have made this choice. Classification: At-Risk Behavior. Response: Coach. Help the individual understand the risk.
Step 9: Review the classification
The decision tree highlights the resulting behavior category (Human Error, At-Risk Behavior, or Reckless Conduct) and the recommended response (Console, Coach, or Discipline). Review the classification before proceeding.
Document Decision Rationale
Thorough documentation of the decision rationale is essential for consistency, defensibility, and regulatory compliance.
For each decision tree question, document:
| Element | Description |
|---|
| Question answered | Which question in the tree was evaluated. |
| Answer selected | Yes or No, with the specific label (e.g., “No — Error path”). |
| Reasoning | Why you selected this answer. Reference specific facts from the investigation, training records, or safety history. |
| Evidence consulted | What data sources informed your answer (investigation findings, witness statements, training records, prior safety history). |
Document your reasoning as you work through the tree, not after. This prevents retroactive
rationalization and ensures the rationale reflects your actual thought process at each step.
Determine Organizational Response
Based on the classification, determine and document the appropriate organizational response:
The individual made an unintended error. The appropriate response focuses on the system, not the individual:
- Support the individual — acknowledge the error without blame, offer support.
- Analyze the system — identify what system conditions contributed to the error (procedure design, workload, distraction, interface design).
- Implement system fixes — create a CPA if the system issue is significant enough to warrant formal tracking.
- Share lessons — communicate the learning opportunity (without identifying the individual) through safety bulletins or committee discussions.
The individual made a choice that increased risk. The appropriate response addresses the behavior through coaching:
- Discuss the risk — help the individual understand why the behavior was risky, without shaming.
- Remove incentives — identify and address organizational factors that incentivized the at-risk behavior (time pressure, reward systems, cultural norms).
- Provide training — targeted training on the specific risk area.
- Monitor — follow up to verify behavior change.
- Create a CPA if the at-risk behavior reflects a broader organizational pattern.
The individual knowingly accepted a substantial, unjustifiable risk. The appropriate response includes accountability:
- Follow organizational policy — apply the disciplinary process defined in your organization’s policies.
- Proportional response — ensure the disciplinary action is proportional to the conduct, not the outcome.
- Document thoroughly — record the basis for the disciplinary decision with references to the decision tree evaluation.
- Preserve non-punitive reporting — ensure the discipline is clearly linked to reckless conduct, not to the act of reporting.
Record Follow-Up Actions
Step 1: Define response actions
Based on the classification and organizational response, define specific follow-up actions:
| Action Type | When to Use |
|---|
| System improvement | Console outcomes — fix procedures, training, or equipment that contributed to the error. |
| Coaching session | Coach outcomes — document the coaching plan, topics, and timeline. |
| Training assignment | Coach outcomes — assign targeted training via Safety > Training. |
| CPA creation | Any outcome where a formal corrective or preventive action is warranted. |
| Disciplinary action | Discipline outcomes — follow organizational disciplinary procedures. |
Step 2: Create linked CPAs (if applicable)
If the case identifies systemic issues that warrant formal tracking, create a CPA from Safety > CPAs > New and link it to the Just Culture case.
Once the assessment, response, and follow-up actions are documented, close the case. Closed cases are retained as part of the SMS record per 14 CFR 5.97.
Case Statuses
| Status | Description |
|---|
| Open | Case created; evaluation not yet started. |
| In Progress | Decision tree evaluation underway. |
| Closed | Assessment and response documented. |
Review Quarterly Statistics
The Just Culture page displays quarterly statistics that track
your organization’s behavior classification patterns:
- Distribution by category — percentage of cases classified
as human error, at-risk, and reckless.
- Trend over time — whether the overall pattern is shifting
toward more or fewer at-risk and reckless classifications.
- Response effectiveness — whether coaching and system
improvements are reducing repeat occurrences.
These statistics are valuable for safety committee reviews and
management review meetings. A healthy safety culture typically
shows a high proportion of human error classifications (indicating
open reporting) and a low proportion of reckless conduct.
If your organization has zero reports classified as at-risk or reckless, it may indicate
under-reporting or reluctance to escalate — not necessarily a perfect safety culture. Discuss
reporting patterns in your safety committee.
Just Culture Framework
Complete reference for behavior categories, decision tree questions, and case fields.
Submit a Safety Report
How non-punitive reporting supports Just Culture.
Manage Investigations
Investigations that feed into Just Culture evaluations.
The Four Pillars
How Just Culture supports the Safety Policy pillar.
