Just Culture

Just Culture is an original concept to manage human errors in a complex system. The first implementations were made in aviation and nuclear industry, and we believe in the benefits of its extension to any business in manufacturing and services.

Basically, Just Culture uses human errors as a resource to constant improvement of the system, and the employees who generate these errors are motivated to collaborate honestly in the analysis of the way to prevent or to limit in the future that particular class of errors.
In the conventional culture, human errors lead to punishment and induce a defensive reaction in the guilty party, typically mystifying the incriminating facts. This mystification prevents a relevant analysis of the systemic causes of the errors, thus maintaining the error re-occurrence probability.
In the Just Culture, emphasis is given to the systemic analysis of the occurrence of errors, known as SOAM (Systemic Occurrence Analysis Method), based on the model of Professor James Reason (the University of Manchester) regarding the organizational accidents (1990).