1.3 The Just Culture (Error Management)

1.3 The "Just Culture" (Error Management)

• Blameless Post-Mortems:
  • The Policy: You cannot be fired for an error caused by a process gap.
  • The Process: Mandatory "5 Whys" analysis after every defect to find the systemic cause (e.g., "The training was ambiguous") rather than the human cause ("The operator forgot").
• The "Red Flag" Reward: Incentivizing employees to stop the line or report near-misses. Treating errors as "free consulting" for process improvement.