Decision Tree for Unsafe Acts CulpabilityTo strongly support and foster the organisation’s Just Safety Culture the implementation of the below Decision Tree for Unsafe Acts Culpability is introduced. It is adapted from James Reason’s Decision Tree for Determining the Culpability of Unsafe Acts.SwissPSA uses the decision tree when analysing an adverse event or error. This will help to identify how human factors and organisational system deficiencies have contributed to the event and thus helping the SwissPSA management discern between unintentional errors and conscious choices to disregard policy, procedures or protocols – and how to respond consistently in a Fair and Just manner.The presumption of innocence applies and, in this sense, if uncertain err on the side of caution. Meaning the answer should then be in favour of the individual being under scrutiny.The Substitution Test requires some further explanation:If the answers to the Questions are „YES“, the problem is not necessarily the individual, but more likely the environment that would lead most individuals to that action. If the answer is „NO“, it is more likely that the individual being evaluated is more culpable and bears more accountability.Furthermore, whatever the result of this analysis it is crucial to identify contributing system factors., SwissPSA uses the decision tree when analysing an adverse event or error. This will help to identify how human factors and organisational system deficiencies have contributed to the event and thus helping the SwissPSA management discern between unintentional errors and conscious choices to disregard policy, procedures or protocols – and how , Figure 1: Decision Tree for Determining Culpability of Unsafe Acts (Adapted from James Reason, 1997). Reason’s algorithm uses a series of questions to explore why the event occurred and to determine culpability..