# Just Culture *Tom Geraghty · Safety & Human Error, Power* Examines why Just Culture — first developed in James Reason's 1997 Managing the Risks of Organisational Accidents, extended to healthcare by David Marx, and deepened by Sidney Dekker — so often fails to 'stick' in practice. 'Just' means justice, not 'only', and crucially it aligns with restorative rather than retributive justice: Dekker frames the choice as backward-looking and retributive versus forward-looking and change-oriented. A just culture balances accountability with learning, treating people with fairness and compassion on the premise that humans will inevitably make mistakes and that punitive responses obstruct improvement. The article threads in local rationality (people act in ways that seem rational given their context, and the opposite stance is the fundamental attribution error), the work-as-imagined vs work-as-done gap, blametropism, and the restorative reframing of accountability as 'giving an account' rather than assigning fault — centring who was harmed, what they need, and whose obligation it is to meet those needs (including the 'second victims', the staff involved). The Elaine Bromiley case anchors the argument. The core claim: Just Culture is frequently imposed as mechanics (reporting systems, restorative meetings, non-punitive investigations) without the foundational culture, so teams revert to punitive habits. Drawing on the four lenses of change (values, behaviours, practices, systems/structures) and the NUMMI story, it argues psychological safety is the substrate in which a Just Culture thrives — without it, the effort stays superficial. Wider legal, regulatory and media pressures (headline-driven scapegoating, punitive inquests) routinely undermine even genuine internal efforts. - **This page:** https://explore.psychsafety.com/n/just-culture/ - **Read the full article on psychsafety.com:** https://psychsafety.com/just-culture/ - **Interactive map:** https://explore.psychsafety.com/?node=just-culture ## Connected concepts (51) - [Accountability](https://explore.psychsafety.com/n/accountability.md) - [Accountability: The Neglected Social Context of Judgment and Choice](https://explore.psychsafety.com/n/tetlock-1985.md) (paper) - [Catastrophe and Systemic Change: Learning from the Grenfell Tower Fire and Other Disasters](https://explore.psychsafety.com/n/kernick-2021.md) (paper) - [Deliberate Learning to Improve Performance in Dynamic Service Settings: Evidence from Hospital Intensive Care Units](https://explore.psychsafety.com/n/nembhard-tucker-2011.md) (paper) - [Disrupted Routines: Team Learning and New Technology Implementation in Hospitals](https://explore.psychsafety.com/n/edmondson-bohmer-pisano-2001.md) (paper) - [Human Error: Models and Management](https://explore.psychsafety.com/n/reason-2000.md) (paper) - [Independent Review on the Care Given to Mrs Elaine Bromiley](https://explore.psychsafety.com/n/harmer-bromiley-2005.md) (paper) - [Learning from Mistakes Is Easier Said Than Done: Group and Organizational Influences on the Detection and Correction of Human Error](https://explore.psychsafety.com/n/edmondson-1996.md) (paper) - [Learning from the Piper Alpha Accident: A Postmortem Analysis of Technical and Organizational Factors](https://explore.psychsafety.com/n/pate-cornell-1993.md) (paper) - [Psychological Safety, Trust, and Learning in Organizations: A Group-level Lens](https://explore.psychsafety.com/n/edmondson-2003.md) (paper) - [The Criminalization of Human Error in Aviation and Healthcare: A Review](https://explore.psychsafety.com/n/dekker-2011-criminalisation.md) (paper) - [The Evolution of Crew Resource Management Training in Commercial Aviation](https://explore.psychsafety.com/n/helmreich-merritt-wilhelm-1999.md) (paper) - [The Intuitive Psychologist and His Shortcomings: Distortions in the Attribution Process](https://explore.psychsafety.com/n/ross-1977.md) (paper) - [The Possibilities of Accountability](https://explore.psychsafety.com/n/roberts-1991.md) (paper) - [Why Hospitals Don't Learn from Failures: Organizational and Dynamics That Inhibit System Change](https://explore.psychsafety.com/n/tucker-edmondson-2003.md) (paper) - [A Question of Trust](https://explore.psychsafety.com/n/oneill-2002.md) (paper) - [Blametropism](https://explore.psychsafety.com/n/blametropism.md) - [Errors in Organizations: An Integrative Review via Level of Analysis, Temporal Dynamism, and Priority Lenses](https://explore.psychsafety.com/n/lei-naveh-novikov-2016.md) (paper) - [HOP](https://explore.psychsafety.com/n/hop-human-and-organisational-performance-training.md) - [How Effectively Has a Just Culture Been Adopted? 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