[pdfernhout]

https://en.wikipedia.org/wiki/Just_culture "Just culture is a concept related to systems thinking which emphasizes that mistakes are generally a product of faulty organizational cultures, rather than solely brought about by the person or persons directly involved. In a just culture, after an incident, the question asked is, “What went wrong?” rather than “Who caused the problem?”. A just culture is the opposite of a blame culture."

Also "Just Culture: Restoring Trust and Accountability in Your Organization" by Sidney Dekker