What does an honest investigation within Just Culture look like?

The investigation begins with a timeline and verifiable facts, not with a suspected culprit. Researchers speak to those involved respectfully, test various statements and examine procedures, training, tools, workload, communication, design choices and previous signals. What remains uncertain is also recorded.

Anyone who is personally involved or has a conflict of interest should not decide the outcome alone. Persons involved must be able to explain the relevant facts and have factual inaccuracies corrected. The measure chosen must be appropriate to the conduct and circumstances and comparable cases must be treated similarly. Urgent security measures may be necessary in the meantime, but should not be presented as a disguised punishment.