Regulators and management alike define the environment within which individuals conduct their tasks. Leaders define the policies and procedures that individuals must follow and respect. They allocate the critical resources which individuals need in order to achieve the organizations control and production goals. When adverse , they must thoroughly investigate these failures and take all needed remedial action to avoid repetition. As such, managers play a fundamental role in defining and sustaining the culture of their organizations.

Many attempts to organizational change fail because employees and managers perceive changes as a way to determine blame or punishment. This is because conventional management oversight is largely reactive – simply reacting to events only when problems arise. To be more effective, organizations must evolve from a reactive (blame, shame, and punishment) culture, to a more constructive proactive “just culture” that considers all contributing factors in the operating environment to identify elements of individual behaviors, as well as systematic/latent conditions outside the scope of individual control.