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Just Culture_Julie Morath

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

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Just Culture_Julie Morath