Fair Investigations: Playing the [do not] blame game…

When I conduct safety orientation for new hires or when I provide safety onboarding to newly starting leaders, I emphasize a concept I call Fair Investigations. The goal of an investigation should be to find out how the organization failed the individual involved - not how the individual failed. This means identifying what the systemic or organizational contributing factors were. 

This mindset is critical in fostering a Just Culture - one that is open, fair, and supportive rather than punitive. By focusing on systemic and organizational factors rather than blaming individuals, we encourage employees to participate actively and openly in safety reporting, investigations, and safety risk assessments, which strengthens the safety program and culture and we turn our organization into a learning culture.

Let’s explore this through a real-life example from my career.

A Case Study: The LAX Incident

One particular incident I recall took place at Los Angeles International Airport (LAX), while I was working in aviation. Our ramp crew had recently been instructed to begin a new operation that required them to tow a Boeing 777 to a remote parking location near a hangar. The final maneuver was very tricky for such a large aircraft, and it involved reversing the tail-first toward a blast fence, a massive structure designed to divert jet thrust upward. The tail had to be placed very close to the fence to keep it clear of passing aircraft, into and out of the hangar. This required precision to avoid a tail strike.

The Incident

On that particular midnight shift, the crew attempted the maneuver; however, they got too close, and the aircraft's tail struck the blast fence. The damage was significant—the aircraft was grounded for days. Worse, the airline had no spare aircraft in the U.S., causing massive disruptions to their schedule and the cancellation of an international flight. Hundreds of passengers were affected, and the incident had ripple effects for days.

The Immediate Reaction

As expected, local leadership was furious and wanted to prove to the customer airline they were doing something about this disruptive incident. They wanted heads to roll, believing this was an issue of employee negligence, without even looking into it further. The instinct was to fire the entire crew to demonstrate accountability to the client. However, this would not have solved the problem

Key Findings: Systemic and Organizational Failures

Given time and some patience, the safety investigation determined that rather than employee negligence, there were several critical systemic and organizational failures at play here, including:

1. No Painted Ground Markings

   • The crew was relying on pavement cracks as reference points and not properly measured and painted guidelines.

2. No Formal Procedure

   • There was no written guidance for how to execute this unique maneuver safely.

3. No Training

   • Subsequently there was not a specific sign off of trained individuals, based on written procedures, which would have created a qualified operator list for this difficult move.

4. Inadequate Staffing

   • Instead of the usual three to four-person crew, only two employees were assigned to the task that night.

5. Poor Lighting

   • The remote parking area was dimly lit, far darker than standard operating areas, making depth perception difficult, especially for this extremely large aircraft.

6. Lack of Leadership Oversight

   • Local leadership was unfamiliar with the specific details of the maneuver and had rarely conducted an on-site observation.

The Danger of the Blame Game

Had the company simply fired the crew, the causal factors would have remained unidentified and unaddressed. The next crew assigned to the task would have faced the same challenges, eventually leading to another incident.

Instead, by taking a Just Culture approach, we focused on organizational accountability, asking: How did we set these individuals up to fail? And we found a lot of ways the individuals were failed by the organization!

Corrective Actions Implemented

Instead of punishing employees, we fixed the system:

• Added Ground Markings – Clear visual guidance for safe maneuvering.

• Developed a Formal Procedure – A written, standardized process for the maneuver.

• Increased Staffing Levels – Scheduling enough crew members for safe execution.

• Enhanced Training & Certification – Only trained personnel could perform the task.

• Implemented Leadership Oversight – Regular inspections and presence on-site.

The Role of Human Error & At-Risk Behavior

Although human behavior did not play a direct role in this example, it often plays a role in workplace incidents. So let’s talk about how to handle behavior issues within a Just Culture mindset. 

First the organizational policy and leadership should explicitly acknowledge that humans do make errors and mistakes. In fact, I like to say that the organization should not only understand that but expect errors and mistakes to happen. None of us are immune to human error or mistakes! 

Once you identify or rule out the systemic and organizational factors, if there is suspected human behavior also contributing, you must determine if there is culpability of those involved. A common way to think about this is on a scale, generally from human error (no or low culpability) through reckless behavior (full culpability). Here is a simple review of the scale:

1. Human Error (Low or no culpability) - Unintentional, expected and acceptable. 

   • Response - Console those involved, determine contributing factors leading to the error (which could be personal to the individual or organization induced), provide awareness of identified contributing factors, implement system improvements

2. At-Risk Behavior (Moderate culpability) - Deviation from procedures due to improper or incorrect perception or judgement of level of risk of task; develops through desensitization of risk causing procedural draft. 

   • Response - Retraining, oversight, feedback mechanisms, implementing behavioral reinforcement strategies, reporting and feedback.

3. Reckless Behavior (Full culpability) - Willful and conscious disregard for safety.

   • Response - Strong accountability is necessary through disciplinary measures.

Holding People Accountable the Right Way

Human Error

Many leaders struggle with the idea of consoling employees involved in incidents. Some believe that accountability means punishment. However, punishing honest human error does not prevent future incidents—it only discourages reporting. Realize that individuals generally don’t come to work to make mistakes or to have incidents, so there is a very good chance they are already down on themselves and possibly even embarrassed that they let down their teammates. So if there is genuine human error, the goal is to help them to not make the error again, and not doubling down on their feelings of inadequacy. Building their confidence back is critical at this point. 

Further, in a well thought out Just Culture program, you don’t have to just continue to let an individual make the same errors or at-risk behavior, over and over. There are ways to set up your program to take into account repeated human error and at-risk behavior, which after a certain point, if the individual isn’t able to correct their performance, you can rightfully move them out of the current role.  Of course, this needs to be deliberate and only after proper attempts are made to help them correct their propensity to make errors repeatedly. 

A Just Culture does not mean avoiding accountability; it ensures fair accountability.

At-risk behavior

At-risk behavior may be frustrating to experience and difficult to get your head around. Initially the reaction is to want to punish a person exhibiting at-risk behavior because it may feel like it is reckless, afterall, it is right there in the title, they are doing something that is ‘at-risk’. But even in these cases, there could be, and probably are, some very human reasons for the at-risk behavior and perhaps even organizational reasons. So even then, we need to exhibit restraint and attempt to understand the individual situation and then try to correct it.

For example, perhaps the individual has been doing the task for a while and after initially being very cautious when the task was unfamiliar, like any of us doing a job overtime, slowly became more comfortable with the work. This comfort leads to a natural tendency to not perceive risk as high or intensely as they had when they started. They’ve become somewhat desensitized to it in a very real sense. So, instead of following every single step of the procedure, they start to find shortcuts - faster ways of doing the work. This is not a bad person, this is not someone that is being reckless or someone that is intentionally doing something to hurt the organization and in fact they might even think they are doing something beneficial, by speeding up their performance. 

This behavior doesn’t fall in the category of reckless behavior, since they UNKNOWINGLY perceive the risk at a lower level causing their personal risk appetite to shift naturally over time and therefore taking more risk. And how do you determine this?  The investigator literally needs to get into the mind of the individual and use something like “the reasonable person” test - could you foresee a reasonable person having done the same thing in the same situation. 

Once determined it is at-risk behavior, now what? Do we fire this person for doing something with increased risk or violating a procedure?  - No - However you can hold them accountable with the intent of changing their behavior and making them realize they are operating in an at-risk state. So they can be retrained, they can have an increased level of oversight for a certain period and they can even have written documentation of their transgressions. So it is not a free pass… there is accountability. And ultimately, if they repeatedly do the same risky behavior over and over, and if they cannot be corrected over time, it is still within a  just culture mindset to consider moving them out of the role/task and even consider more permanent changes, including termination.

Reckless Behavior

Finally if the behavior is determined to be reckless or willful, the consequences are much clearer. If there is intent on the part of the individual was to cause harm, these individuals must be punished. There is no room for this type of behavior whether in a just culture system or not. And this includes operating under the influence of illegal or recreational drugs or alcohol or clear sabotage. 

Accountability exists within a Just Culture

So we see that there can be accountability at all levels of the behavior spectrum. For at-risk and repeated at-risk behavior, there is an increasingly stronger set of actions to hold the individuals accountable. For reckless behavior there is zero tolerance and a strong reaction toward accountability. And even for human error, though you start with consoling, with repeated human error and the demonstrated lack of ability to correct the errors, accountability can take the shape of moving the individual into a different role or task.

Oversight of the Just Culture Program

Influencing a positive safety culture is hard work, after all you can have all of the pieces of strong just culture in place, but if the organization doesn’t walk the walk every time, in every corner of the organization, your Just Culture will degrade. So, if you are a safety leader at a large company that has thousands of employees and operations spread out over an area, region or a country, and you are not always there to influence the process directly, like I was in my example. So how do you manage the just culture? Well certainly with strong policy, process, and leadership training for starters. But this doesn't solve every potential problem. 

Something to consider, that I have found helpful, is what I call Just Culture Review Boards. On a regular basis, perhaps monthly or perhaps quarterly, depending on how large your operation is and how many incidents you have, you set up a board that regularly reviews all or a subset of the post-incident investigations and disciplinary or corrective actions taken on those involved by local leadership. These boards should include representatives from safety, human resources, legal as well as operational leadership. The board reviews the investigation details and determines if the just culture process was properly applied. This helps keep local leadership honest and it allows for a type of learning culture and continuous improvement to ensure consistency and fairness.

Conclusion

By creating a culture where employees feel psychologically safe to participate in the safety program, we strengthen the Safety Culture from the ground up. Employees must know:

• They won’t be punished for reporting concerns and incidents.

• There is an expectation they will make honest mistakes (human error) and not be punished.

• They are encouraged to participate honestly in investigations, even if they made mistakes that led to the incident.

• At-risk behavior will be corrected, and not immediately punished.

• Reckless behavior is unacceptable and will lead to serious consequences.

This approach builds trust, transparency, and ultimately a safer work environment.