DAC - David Arku Consultancy

JustRhythm by DAC

Fair decisions. Just outcomes. Learning, not blame.

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See it in action

The incident: A site engineer on a busy construction project signs off a concrete pour using the previous week's mix specification. The updated spec — requiring a higher-grade mix for a load-bearing section — was emailed to the team but buried in a thread of 40 messages. The pour passes initial checks, but a later audit flags the discrepancy. No structural failure occurred, but the rework cost is significant.

What Just Culture reveals: On the surface, this looks like carelessness. But the tool asks: would a competent colleague, given the same information overload and time pressure, have done the same? The answer is likely yes — the engineer didn't know the spec had changed. No intent, no impairment, no knowing deviation.

Classification Human Error

System response: Investigate why critical specification changes are communicated via email threads instead of flagged in the project management system. The next engineer will make the same miss unless the system changes.

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Rationale

Decision Pathway

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System Factors to Investigate

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      JustRhythm by DAC is a structured decision-support tool, not a substitute for legal advice, HR due process, clinical or medical assessment, or formal disciplinary investigation. Local law, internal policy, union obligations, and professional regulatory requirements always take precedence. Review conclusions with qualified HR, legal, and clinical professionals before formal action. Classifications produced by this tool are analytical starting points, not binding determinations. DAC Consult Ltd accepts no liability for decisions made on the basis of this tool's output.

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