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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.

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Just Culture Overview

Just Culture classifies behaviors into three categories, each with a different organizational response:
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.

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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.

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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.

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Document Decision Rationale

Thorough documentation of the decision rationale is essential for consistency, defensibility, and regulatory compliance. For each decision tree question, document:
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.

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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.

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Record Follow-Up Actions

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Case Statuses

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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.
Last modified on April 11, 2026