Just Culture: Turning Incidents Into Safer Systems

When an incident occurs, it is often not the first time something has gone wrong, but the first time the issue has been brought to light. Surfacing problems early creates opportunities to prevent future mishaps and strengthen systems.

However, speaking up is not easy. Reporting a mistake, especially one you have made or one involving a teammate, can feel uncomfortable. That hesitation is exactly what Just Culture aims to address.

At its core, Just Culture shifts how organizations view incidents. Instead of focusing on blame, it emphasizes learning, trust, and accountability—helping Airmen and leaders alike see safety reporting as a tool for improvement rather than a source of shame.

Maj Taylor Pearce, a Flight Safety Officer with Air Combat Command’s 55th Wing at Offutt Air Force Base, NE, provided his expertise to The Mobility Forum, an Air Mobility Command Safety Office (AMC SE) publication, including discussions with AMC safety personnel and other groups during the 2025 AMC Safety Conference, where he explained how Just Culture works in practice and why it is essential to building trust, accountability, and effective safety reporting across AMC.

Building Trust from the Top Down

Pearce describes Just Culture as “an atmosphere of trust in which people from the top to the bottom of the organization are encouraged or even rewarded for providing safety-related information, but in which they are also clear about where the line must be drawn for acceptable and unacceptable behavior.”

In his role at Offutt AFB, Pearce serves as both a safety investigator and an advisor to wing leadership. Implementing Just Culture has strengthened both responsibilities. It enables more effective safety investigations while giving commanders consistent guidance on how to respond to mishaps.

“Just Culture allows leaders to expect honest mistakes and expect those mistakes to be reported,” Pearce said. “In return, Airmen can trust that they won’t be punished unless there is malice, neglect, or willful misconduct.”

That trust, he emphasized, must start with leadership.

Overcoming Fear of Reprisal

One of the biggest barriers to self-reporting is fear: fear of punishment, damage to one’s reputation, or career consequences. Pearce noted that a healthy reporting culture depends on Airmen believing their leadership truly has their backs.

At Offutt, leaders use the Just Culture matrix to guide post-mishap decisions. The matrix helps commanders identify root causes and select responses that promote learning and long-term risk reduction rather than defaulting to individual punishment. Just as importantly, it gives Airmen clarity about what behaviors are acceptable and where accountability applies.

From Reporting to Real Change

This approach has produced tangible results. Offutt uses the Airman Safety Action Program Safety Reporting (ASAP/SAFEREP) program and an internal Proactive Safety Report system. Since fiscal year 2021, this emphasis on reporting has led to a three-hundred percent increase in ASAP submissions.

While specific cases remain protected, Pearce shared that multiple reports have led directly to checklist changes. Increased reporting has also made it easier to identify trends early—allowing risks to be addressed before they escalate.

Safety as an Invitation, Not a Warning

Deliberate misconduct, reckless behavior, intentional disregard for procedures, or repeated unsafe actions may still require disciplinary action, and Airmen should use best judgment.

For Pearce, one of the most powerful aspects of Just Culture is its ability to empower Airmen at every level.

“‘Be safe’ is no longer a threat with consequences,” he said. “It’s an invitation to be a player at the table.”

Just Culture allows Airmen to be part of the solution. If a process feels unsafe, inefficient, or nonsensical, speaking up is not just allowed—it is encouraged.

Owning Safety at Every Level

Pearce describes three tiers of safety reporting:

• Tier I: Identifying an issue with a system, process, or procedure.
• Tier II: Identifying an issue involving someone else.
• Tier III: Identifying an issue involving yourself.

All three tiers are valid and valuable. As trust within an organization grows, leaders should expect to see more Tier III reports, where Airmen openly share their own mistakes so others can learn from them.

“If you made a mistake,” Pearce said, “chances are, someone else has—or will.”

Looking Ahead

As AMC modernizes and its mission environments evolve, Pearce believes Just Culture will remain essential. Designed for high-risk, high-reliability organizations, it helps prevent mishaps before they happen while enabling Airmen to make more confident, informed safety decisions.

He also addressed a common misconception: Just Culture does not eliminate accountability.

“There are absolutely situations where punishment is warranted,” Pearce said. “What Just Culture does is increase learning, trust, and accountability.”

Ultimately, this philosophy is not about avoiding responsibility. It is about using transparency and trust to build safer systems—for today’s missions and tomorrow’s challenges.