How to Build a Just Culture in 3 Steps (Without Losing Control)
- Steve Barbour
- Jun 16
- 4 min read
Updated: Jul 19
I joined the RAF back in 2016, after the findings of Haddon-Cave’s Nimrod review. The changes to culture were already well and truly progressing, and by the time I had completed training, I was in an organisation that was living and breathing Just culture. Whether everything was spot on is a different discussion, but I hadn’t experienced life before.
Creating this Just Culture doesn’t mean giving up discipline or control; it means applying fairness, clarity, and consistency. This post introduces how to build a just culture, using a practical 3-step framework built on Reporting, Response, and Recovery. This is tailored for leaders, coaches, and aviation SMEs who want high performance without fear.
Why Just Culture Matters More Than Ever
In aviation, elite sport, and high-stakes organisations, human performance is everything. But when mistakes happen, and they will, how a leader responds can either build a culture of safety and growth or destroy it with silence, fear, or blame.
Enter Just Culture - a model that balances accountability with learning. It distinguishes between honest errors, risky decisions, and negligent behaviour, ensuring teams don’t just avoid mistakes but grow from them.
But for many leaders, the challenge is clear:
“How do I apply this without losing authority or letting standards slide?”
The answer? A simple, 3-step framework that maintains control and builds trust.
Step 1:
Reporting - Build the Door, Then Leave It Open
The foundation of any Just Culture is open reporting. If team members don’t feel safe to report mistakes, near misses, or procedural shortcuts, you’ll never know what’s going wrong until it becomes critical.
What This Looks Like in Practice:
Aviation: Pilots file air safety occurrence reports (DASORs in the military) without fear of punishment for honest errors.
Sport: Athletes feel safe disclosing training issues or tactical missteps without judgment.
Leadership: Employees highlight gaps or mistakes without worrying about being labelled incompetent.
How to Build a Reporting Culture:
Use simple, non-punitive reporting tools
Eliminate complexity. A basic form or digital submission tool is enough to start.
Recognise reports publicly (when appropriate)
Celebrate transparency, not just success. “Thanks to this report, we fixed a systemic flaw.”
Lead with vulnerability
Share your own mistakes. Leaders who admit errors set the tone for openness.
“You can’t fix what you don’t know. And you won’t know if people are afraid to tell you.”
Step 2:
Response - Separate Behaviour from Outcome
The most critical moment in a Just Culture comes right after a report is made. What happens next determines whether your culture deepens or fractures.
Response is where many organisations go wrong, jumping straight to consequences without context. But not every mistake is equal.
Use the Just Culture Decision Tree:
Was the action intentional?
Was the person properly trained and supported?
Was there reckless disregard or known violation of safety?
This decision-making process separates:
Human Error (accidental)
At-Risk Behaviour (taking shortcuts, often due to pressures or habits)
Reckless Behaviour (conscious disregard of rules or safety)
Tailored Responses for Each:
Error → Coach and learn
At-Risk → Understand motivations and address the environment
Reckless → Apply proportionate accountability
In Aviation:
If a pilot accidentally programs the wrong waypoint but self-reports, it’s a chance to improve training or interface design - not grounds for suspension.
In Sport:
If an athlete ignores recovery advice under pressure to perform, examine the team environment before assigning blame.
In Business:
If an employee overlooks a detail due to an unrealistic deadline, look at workflow before pointing fingers.
“Respond to errors with curiosity, not consequences.”
Step 3:
Recovery - From Mistake to Momentum
Even when errors occur, what happens next is an opportunity to strengthen the team. Recovery isn’t just about fixing the mistake; it’s about building trust and improving future performance.
Three Recovery Principles:
Debrief Without Defensiveness
Use a structured, non-emotional review process. Focus on what happened, not who caused it.
Apply Systems Thinking
Look for root causes beyond the individual: communication breakdowns, policy gaps, interface design, etc.
Create Feedback Loops
Share lessons learned across the team or organisation. Make it clear that reports lead to action.
Practical Recovery Actions:
Host “no-blame” debriefs after incidents or close calls.
Document and share findings with a focus on system improvements.
Recognise contributors to safety and transparency, not just performance metrics.
In Aviation:
Recovery might include a team-wide review of a procedural error, followed by a process update and new checklist.
In Coaching:
Turn a tactical failure into a film review session focused on decision-making patterns, not mistakes.
In Leadership:
When a project misses its mark, gather the team to examine process flow, not just individual output.
“Recovery is where resilience is built—and where culture becomes visible.”
Does Just Culture Mean No Consequences?
No. A true Just Culture isn’t soft, it’s smart. It isn’t about establishment a blameless environment, but one that addresses the root cause of issues.
It means:
Clear expectations
Fair, consistent consequences
A recognition that intention and context matter
As a leader, you retain control - but you use it to foster growth, not fear.
Final Thoughts: Culture Is Built in the Moments You Think No One Will Notice
When someone makes a mistake, all eyes are on you - even when you don’t realise it.
Your tone.
Your response.
Your follow-up.
They all signal to your team:
“Is this a safe place to learn - or a dangerous place to be human?”
By building your culture around Reporting, Response, and Recovery, you reinforce accountability while unlocking performance and trust.
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