Beardy, I would have to agree with Vin Rouge that your outcome focussed approach to Just Culture is never going to improve safety in the slightest. It is exactly such an approach that clamours for the scapegoat when something bad happens and fails to deals with the real causes of an occurrence that will actually stop it happening again.
I'd advise a read of a book called "Whack a Mole" by David Marx.