Why does Just Culture look at the system first?

People work within goals, tools, procedures, time pressures and technical limitations. If multiple people can make the same mistake, addressing the last person alone is not a complete solution. The same conditions can then cause the problem again.

Therefore, a Just Culture also examines system design, access rights, training, workload, supervision, conflicting goals and previous signals. This does not exclude individual responsibility. It does prevent a visible human action from concealing deeper causes from view.