Understanding and Applying the Principles of Fair and Just Culture in ICAM Incident Investigations

1. Introduction

In today's complex workplaces, especially in high-risk industries like mining, aviation, healthcare, and manufacturing, the traditional reaction to incidents- punish the worker- has increasingly proven inadequate. A more progressive and effective approach recognises that human error is inevitable and often a symptom of deeper systemic issues. This is where Fair and Just Culture comes in. When applied through a robust investigation methodology such as ICAM (Incident Cause Analysis Method), the two together form a powerful duo for driving learning, accountability, and ultimately, safety performance.

2. Defining Fair and Just Culture

Fair and Just Culture refers to an organisational philosophy that fosters openness, learning, and continuous improvement by balancing accountability and systemic responsibility. It recognises that while people may make mistakes, most errors are not the result of recklessness or negligence but occur within imperfect systems.

A Fair and Just Culture distinguishes between:

• Human error (slips, lapses, mistakes)

• At-risk behaviour (taking shortcuts or deviating from procedures without malicious intent)

• Reckless behaviour (conscious disregard of known risks)

The key is not to eliminate accountability, but to apply it fairly, in proportion to the behaviour and context, rather than automatically punishing those involved.

3. The Need for a Fair and Just Culture in Safety-Critical Workplaces

Without a Fair and Just Culture, workers are less likely to report incidents, near misses, or unsafe conditions for fear of retaliation. This creates a safety blind spot- a culture of silence where risk festers unnoticed.

The benefits of adopting this culture include:

• Increased reporting of hazards and near misses

• More honest and thorough investigations

• Better system-level improvements

• Higher employee morale and trust

• Reduced repeat incidents

An organisation that consistently applies these principles creates a psychologically safe environment, encouraging transparency, reflection, and improvement rather than blame.

4. The Role of ICAM in Investigations

The Incident Cause Analysis Method (ICAM) is a structured framework for investigating incidents. Built on the Swiss Cheese Model, ICAM focuses on uncovering latent conditions, active failures, and organisational factors.

ICAM shifts investigations away from the “who did it?” mindset toward “why did it happen?” It examines:

• Task-level failures

• Individual actions

• Teamwork and supervision

• Conditions of work

• Organisational influences

This aligns naturally with the philosophy of a Fair and Just Culture, making ICAM an ideal vehicle for applying it.

5. Interlinking Fair and Just Culture with ICAM

To truly operationalise a Fair and Just Culture, it must be embedded in the investigative process. ICAM enables investigators to delve deeper into systemic issues without being limited by frontline worker error.

Here’s how they align:

In essence, ICAM provides the process; Fair and Just Culture provides the mindset.

6. Core Principles of a Fair and Just Culture

To apply a Fair and Just Culture effectively, the following principles should guide investigations:

People Make Mistakes

Expect human error. Build systems that anticipate and tolerate it.

Blame Fixes Nothing

Blame might feel satisfying, but it does little to prevent recurrence.

Learning is the Goal

Investigations should uncover lessons to improve systems, rather than focusing on punishment.

Accountability Must Be Fair

There is a difference between holding someone accountable and scapegoating.

Context Matters

Understand why people acted the way they did- the pressures, tools, and cues they had.

Systems Influence Behaviour

People operate within the systems they are given. If the system is flawed, even good people can fail.

7. Application of Fair and Just Culture Throughout the ICAM Investigation Phases

Scoping the Investigation

Ensure the Terms of Reference are written to explore contributory factors and not just “find the person responsible.” Include cultural, organisational, and supervisory aspects in the scope.

Assembling the Team

Select a team that is trained in Fair and Just principles, ensuring objectivity and understanding of human factors.

Data Gathering

• Conduct interviews in a psychologically safe manner.

• Use open-ended questioning.

• Separate facts from assumptions.

• Avoid adversarial techniques.

Timeline and Event Analysis

Reconstruct the sequence of events without assigning blame. Clarify what actually happened, including deviations from normal operations.

Cause Identification

Categorise factors into active failures and latent conditions. Focus on what enabled the error- not just who made it.

Recommendations and Actions

Ensure recommendations address systemic improvements, not just retraining or procedural reinforcement unless truly warranted.

Debriefing and Reporting

• Use inclusive language (“we” and “the system” vs “the person”).

• Avoid sensationalising.

• Share findings widely for learning.

8. Case Studies and Examples

Case: Maintenance Error in Aviation

An engineer omitted a crucial step due to a confusing procedure and an ambiguous checklist. Initially, management wanted to suspend the engineer. But the ICAM investigation revealed:

• Inadequate supervision

• Poor checklist design

• Normalisation of deviation

A Fair and Just response led to:

• Redesign of the checklist

• Supervisor training

• No punitive action

The result: improved safety culture and no repeat incidents.

Case: Forklift Collision in a Warehouse

A worker struck a racking unit. The investigation team, influenced by a Fair and Just mindset, uncovered:

• Poor lighting

• Unclear traffic lanes

• Inadequate fatigue management

The operator was not disciplined. Instead, the organisation:

• Upgraded lighting

• Painted clearer traffic lines

• Implemented better break scheduling

9. Common Challenges in Implementation

Despite the clear benefits, applying Fair and Just Culture can be difficult. Common obstacles include:

Management Resistance

Some leaders are accustomed to control through discipline. Changing this mindset requires ongoing education and reinforcement.

Fear of Losing Authority

Investigators or managers may fear they appear weak if no one is held “responsible.”

Inconsistent Application

If some employees are punished and others are not, credibility collapses. Consistency is key.

Lack of Training

Investigators need training in human factors, interview techniques, and systems thinking to apply these principles properly.

10. Strategies to Promote a Fair and Just Culture in ICAM Practice

Establish Clear Behavioural Expectations

Create a “decision tree” or matrix that helps differentiate between error, at-risk, and reckless behaviour.

Embed it in Policy

Include Fair and Just principles in your safety and HR policies.

Train Leaders and Investigators

Conduct workshops on bias, human error, and systemic thinking.

Role Model at the Top

Leaders must consistently demonstrate Fair and Just responses to incidents.

Celebrate Reporting

Create visible rewards and recognition for speaking up.

Use Language Deliberately

Avoid “operator error” in reports. Focus on “contributory factors” and “performance shaping factors.”

11. The Role of Leaders and Investigators

Leaders

• Set the tone and expectations.

• Make the hard call to defend employees who make honest mistakes.

• Resource the investigation process adequately.

Investigators

• Create safe spaces for disclosure.

• Recognise and check their own biases.

• Seek understanding before judgement.

• Frame findings constructively.

12. Measuring the Impact of Fair and Just Culture on Safety Outcomes

Adopting Fair and Just Culture can positively impact:

• Incident Reporting Rates – Typically increase as fear decreases.

• Repeat Incidents – Decrease as systemic fixes are implemented.

• Employee Engagement – Improves with trust in leadership.

• Near-Miss Capture – Increases due to a safer reporting culture.

Use surveys, trend analysis, and cultural assessments to measure these changes over time.

13. Conclusion

Fair and Just Culture is not a soft, fluffy concept- it's a strategic enabler of safety, learning, and performance. When woven into ICAM investigations, it transforms the process from one of blame to one of insight.

The goal is not to absolve all actions but to understand them in context. Only by recognising the complex web of human, technical, and organisational factors can we build workplaces where people can learn, improve, and ultimately, go home safe.

As organisations evolve, those that embrace this approach will not only improve safety but also build resilient systems and trust-filled cultures- the true markers of world-class operations.

Download the PDF version of our Fair and Just Culture Poster shown below, from the Resources section of our website- https://www.safetywise.com/resources