ĐẠI HỌC QUỐC GIA HÀ NỘI
KHOA QUẢN TRỊ VÀ KINH DOANH
---------------------
NGUYỄN HẢI ANH
JUST CULTURE PRACTICE IN THE AVIATION INDUSTRY:
RECOMMENDATIONS FOR VIETNAM AIRLINES
THỰC HIỆN VĂN HOÁ CHÍNH TRỰC TRONG NGÀNH HÀNG
KHÔNG: MỘT SỐ GỢI Ý CHO HÃNG HÀNG KHÔNG QUỐC
GIA VIETNAM AIRLINES
LUẬN VĂN THẠC SĨ QUẢN TRỊ KINH DOANH
HÀ NỘI - 2020
ĐẠI HỌC QUỐC GIA HÀ NỘI
KHOA QUẢN TRỊ VÀ KINH DOANH
---------------------
NGUYỄN HẢI ANH
Just culture practice in the aviation industry: recommendations for
vietnam airlines
THỰC HIỆN VĂN HOÁ CHÍNH TRỰC TRONG NGÀNH HÀNG
KHÔNG: MỘT SỐ GỢI Ý CHO HÃNG HÀNG KHÔNG QUỐC
GIA VIETNAM AIRLINES
Chuyên ngành: Quản trị kinh doanh
Mã số: 8340101.01
LUẬN VĂN THẠC SĨ QUẢN TRỊ KINH DOANH
NGƯỜI HƯỚNG DẪN KHOA HỌC: PGS.TS. NGUYỄN NGỌC THẮNG
HÀ NỘI - 2020
DECLARATION
The author confirms that the research outcome in the thesis is the
result of author‟s independent work during study and research period and it is
not yet published in other‟s research and article.
The other‟s research result and documentation (extraction, table,
figure, formula, and other document) used in the thesis are cited properly
and the permission (if required) is given.
The author is responsible in front of the Thesis Assessment
Committee, Hanoi School of Business and Management, and the laws for
above-mentioned declaration.
TABLE OF CONTENTS
LIST OF FIGURES
LIST OF TABLES
TITTLE CHAPTER .............................................................................................................. 1
1. Rationale .................................................................................................................... 1
2. Literature review........................................................................................................ 2
3. Research Aim ............................................................................................................ 4
4. Research Objectives .................................................................................................. 4
5. Research Scope .......................................................................................................... 4
6. Structure of the thesis ................................................................................................ 4
CHAPTER I: THEORETICAL BACKGROUND ................................................................ 6
1.1. Safety culture definition ........................................................................................ 6
1.2. A Just Culture definition ....................................................................................... 7
1.3. Benefits of Just Culture ......................................................................................... 8
1.4. Principles of Just Culture ....................................................................................... 9
1.5. Distinguish acceptable and unacceptable behaviors ............................................ 11
1.6. Just Culture decision tree ..................................................................................... 13
1.7. Creating and implementing Just Culture ............................................................. 15
CHAPTER II: METHODOLOGY ...................................................................................... 18
2.1. Research approach ............................................................................................... 18
2.2. Data collection ..................................................................................................... 20
2.2.1. Secondary data ............................................................................................. 20
2.2.2. Primary data: semi-structured interviews ................................................... 20
2.2.3. Interview preparation ......................................................................................... 21
2.2.4. Sampling ............................................................................................................ 22
2.2.5. Pilot test ............................................................................................................. 22
2.3. Interview implementation .................................................................................... 23
2.4. Method of analysis .............................................................................................. 23
2.5. Research ethics .................................................................................................... 24
CHAPTER III: JUST CULTURE PRACTICE IN THE AVIATION INDUSTRY ........... 25
3.1. History of Just Culture in the world aviation industry ........................................ 25
3.2. Just Culture Practice in the world aviation .......................................................... 26
3.2.1. Legal Aspects .............................................................................................. 26
3.2.2. Reporting Policy and Procedures ................................................................ 27
3.2.3. Methods of Reporting .................................................................................. 29
3.2.4. Determine roles and responsibilities............................................................ 33
3.2.5. Developing and Maintaining Just Culture ................................................... 33
3.3. Just Culture implementation in Vietnam Airlines ............................................... 35
3.3.1. Vietnam Airlines introduction ..................................................................... 35
3.3.2. Just Culture Policy and Documentation in Vietnam Airlines ..................... 37
3.3.3. Vietnam Airlines Safety Improvement Indicators ....................................... 41
CHAPTER IV: RESEARCH FINDINGS AND RECOMMENDATIONS FOR VIETNAM
AIRLINES ........................................................................................................................... 46
4.1. Research finding - Current situation of applying a Just Culture in Vietnam
Airlines ............................................................................................................................ 46
4.1.1. Just Culture relating policies that put by Vietnam Airlines in encouraging
everyone to raise safety related issues ......................................................................... 46
4.1.2. Vietnam Airlines has a safety reporting system that is clear confidential and
non-punitive ................................................................................................................. 47
4.1.3. Vietnam Airlines‟ Just Culture implementation roadmap ................................. 48
4.2. Recommendations for Vietnam Airlines: A human factor training program ...... 52
4.2.1. The necessity to establish a human factor training program ....................... 52
4.2.2. Guidelines for establishing a human factor training program ..................... 53
4.2.3. Suggestions for human factors training contents ......................................... 54
4.2.4. Recommendations ....................................................................................... 62
CONCLUSION ................................................................................................................... 64
1. Summary .................................................................................................................. 64
2. Limitations and Direction for further researches ..................................................... 64
REFERENCE ...................................................................................................................... 66
APPENDIX 1: INTERVIEW SCHEDULE ........................................................................ 72
APPENDIX 2: INTERVIEW TRANSCRIPT ..................................................................... 73
LIST OF FIGURES
Name of figure Page
Figure 1 Safety culture components 9
Figure 2 Just Culture safety behavior definition model 14
Figure 3 Reason‟s Decision Tree for determining the culpability of unsafe 16
25
Thematic analysis‟s stages
acts
Figure 4
Figure 5 Safety and Quality policy of Vietnam Airlines in 2009 and 2010 38
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Figure 6 Safety and Quality Policy of Vietnam Airlines in 2016 39
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Figure 7 The „Just Culture line‟
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Figure 8 Just Culture of Vietnam Airlines
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Figure 9 Vietnam Airlines incident rate 2010-2018
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Figure 10 IATA Operations Safety Audit Results of Vietnam Airlines
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Figure 11 IATA Operations Safety Audit Certificate of Vietnam Airlines
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Figure 12 Vietnam Airlines Safety Reporting Statistics
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Figure 13 Mandatory Occurrence Report to CAAV
Figure 14 Vietnam Airlines‟ Just Culture implementation roadmap
LIST OF TABLES
Name of table Page
Table 1 Main features of inductive and deductive approach (Adopted from 20
Sauders et al. 2011)
Table 2 The main features, advantages and disadvantages of qualitative and 21
quantitative research method (Adopted from Sauders et al. 2011)
33
Table 3 Different types of interview (adopted from Sauders et al.2011) 23
35
Table 4 Steps to build a Just Culture Reporting System
38
Table 5 Main ideas to develop and maintain a Just Culture
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Table 6 The development process of Vietnam Airlines in 2006-2019
Table 7 Acceptable & Unacceptable Behaviours
TITTLE CHAPTER
1. Rationale
Through hundreds year of formation and development, the aviation industry has been
considered as one of the most complex, dynamic and safety critical environment. As a fact
that the aviation history witnesses cases where millions of dollars and people's lives can be
costed due to a single unsafe act of individuals (Filn et al., 2000). It could easily be proven
by researches and experience that no matter how well-trained or motivated an individual is,
due to the physiological, cognitive and sensory limits on the human condition, this
individual will end up making errors in analysis or misjudgement of a situation, which
finally causes unsafe acts (Reuter 2016). And all this might lead to situations where safety
is impaired or perceived to be impaired. Leaders in the aviation industry need to accept this
and need to be aware that in order to continuously improve their imperfect system and
need to learn from these “unsafe” events and deviations from the norm to analyze them,
and improve on what to do and how to do. As an investigation of the Global Aviation
Information Network (GAIN) in 2018, by adhering to Just Culture principles, airlines
industry members are trying to change that deeply engrained behavior of hiding mistakes
and rather, encourage people to actively, honestly report these events without needing to
fear undue retribution. With the introduction of the Occurrence Reporting Regulation
376/2014, the European aviation industry finally received a legally binding definition of
„Just Culture‟ (GAIN, 2018). While obviously, a binding regulation is what really counts,
there were several initiatives not only to define what Just Culture is, but also to outline
how it should work. The efforts of EUROCONTROL Just Culture Task Force or the Just
Culture Declaration - signed by most European Aviation stakeholders on 1st October 2015
- are just two of such initiatives (GAIN, 2018).
However, regardless of all intentions, most organizations still struggle with the
concept of Just Culture, how to introduce it in their operation system and more
importantly, how to make fully use of it. The reasons for this are manifold. But one of the
most typical reasons is that, Just Culture requires more than just a regulatory compliance
and copy-pasting the definition in the manuals. Just Culture requires a far-reaching
paradigm shift, which is a long and challenging journey for airlines to enhance Just Culture
implementation. In Vietnam, Aviation brands gradually realize the importance of a Just
Culture in generating a more effective safety and operational management. On May 12th
2018, the CEO of Vietnam Airlines - the most typical Vietnamese airlines brand, Mr.
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Duong Tri Thanh had a session discussing problems relating Just Culture practice; and he
also underlined the obligations and responsibilities of aviation stakeholders towards
implementing Just Culture in all aspects of the working environment. Thus, this thesis will
not only try to clarify current situation of Just Culture practice in the aviation industry, but
also give some recommendations for Vietnam Airlines in particular.
2. Literature review
Before the 21st century, very few people had heard about Just culture. Currently,
almost every organization in the aviation industry has implemented the Just Culture in all
their activities. Recent findings have suggested that; the Just Culture has become the
foundation for safety in the aviation industry (Frazier, 2012).
The research “Achieving a safe culture: theory and practice” of Reason (1998)
introduced the concept of Just Culture as one of five components of Safety Culture along
with Informed culture, Reporting Culture, Flexible Culture and Learning Culture. This
paper considered why it is that an unsafe culture is more likely to be involved in the
causation of organizational rather than individual accidents. And this investigation also
concerned with the practical question of whether a safety culture can be engineered. It is
argued that a safe culture is an Informed Culture and this, in turn, depends upon creating an
effective Reporting Culture that is underpinned by a Just Culture in which the line between
acceptable and unacceptable behavior is clearly drawn and understood.
Walulik (2011) with the paper “Just Culture Principles and the Investigation of
Air Accidents and Incidents” is one of the most typical air accident investigations. The
article discusses the issue of the proper balance between ensuring aviation safety and
executing responsibility. The article concentrates on Just culture Principles aimed at
balancing safety and responsibility in aviation. This includes a discussion of
EUROCONTROL heritage in this respect and of the implementation of Just principles in
Annex 13 to the Chicago Convention, Regulation 966/2010/EU and Polish aviation law.
The analysis also focuses on relations between safety investigations and Just Culture
before concluding some with recommendations for the lawmaker.
The investigation of McCall, J.R. and Pruchnicki, S., (2017) about “Just culture: A
case study of accountability relationship boundaries influence on safety in high-
consequence industries” indicate a barrier to advancing meaningful safety agendas, which
is the desire of many managers to “hold someone accountable” for errors. The
misconception that clear lines of accountability can and do exist, and that employees who
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cross the line between acceptable and unacceptable behavior should be punished, fails to
recognize the different types of accountability relationships negotiated by employees every
day. Such judgments run counter to the concept and practice of a Just Culture. This
opaqueness is seen in numerous accidents which reveal the conflicting effects employees
in high-consequence industries face as they move between and across these accountability
boundaries. This germane example is the crash of Swissair Flight 111, near Halifax, Nova
Scotia, in 1998. Here we offer dialogue to aid in understanding the influence accountability
relationships have on safety, and how employee behavioral expectations shift in
accordance. The authors proposed that this examination would help redefine accountability
boundaries that support a Just Culture within dynamic high-consequence industries.
Global Aviation Information Network in a report in 2018 also proposed “A
Roadmap to a Just Culture: Enhancing the Safety Environment”, which provide some
preliminary guidance on how to create a just reporting culture and some insights on how to
plan the implementation of such a system. This report also indicated principles of a Just
Culture and benefits of an organization applying a Just Culture. Especially, eight steps to
implement Just Culture in operation and management were introduced, which are legal
aspects, (2) Reporting Policy and Procedures; (3) Method of reporting; (4). Determine
Roles and Responsibilities, Tasks and Timescale; (5) Develop Reporting Form; (6)
Develop Template for Feedback to Potential Users; (7) Develop a Plan for Educating the
Users and Implementing the System; (8) Developing and Maintaining the Right Culture.
The eight-step implementation is developed and applied by a lot of airlines brand
nowadays.
In terms of ground services, a product of Air Transport Safety Institution (2011) in
cooperation with the Civil Aviation Authority of the Netherlands named “Just culture and
human factors training in ground service providers”, investigated what elements are
required to establish and maintain a Just Culture, and what elements are required to
establish a human factors training program. The results of the research on Just Culture
have been tested by means of a practical application of a Just Culture self-audit at six
ground service providers in the Netherlands. This may raise ideas of creating and
implementing a Just Culture self-audit for other players in the aviation market in order to
to manage human errors and promote safe behavior. Besides, this report also gave specific
recommendations to service providers to improve their Just Culture, a Just Culture audit
template to be used by ground service providers and auditing organizations.
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3. Research Aim
The aim of this study is to critically evaluate Just Culture practice in the aviation
industry and give some recommendations for Vietnam Airlines.
4. Research Objectives
The objectives of this report include the following:
• Provide a review of literature of Safety Culture and Just Culture
• Raising awareness in the aviation community of the benefits of creating a Just
Culture
• Provide a road map of Just Culture implementation in aviation organizations
• Provide initial guidelines from case studies to develop and maintain a Just
Culture; and share learned lessons that might be helpful to others who also
benefit from applying Just Culture
• Give some recommendations for Vietnam Airlines to improve Just Culture
implementation.
5. Research Scope
The scope of the thesis focuses on the aviation industry and particularly Vietnam
Airlines from 2000 till now.
6. Structure of the thesis
This study includes five chapters
1) Title Chapter: this chapter provides the background of Just Culture practice in
the airlines industry in the world and the case of Vietnam airlines as well as
clarify the reason of choosing this topic. Then, the research aims, objectives,
research questions, research methodology and research structure are respectively
given.
2) Chapter 1: Theoretical background: in this chapter, the conceptual framework
and theoretical foundation of Just Culture and Just Culture practice process are
presented carefully. This section also delivers a brief discussion of benefits of
Just Culture in an airlines industry. The implementation of Just Culture in an
airlines industry is also discussed in this chapter.
3) Chapter 2: Methodology describes the methodology research which is used in
the study. A qualitative approach with semi-structured interviews is adopted
4) Chapter 3: Just Culture Practice in an aviation industry descriptive analysis,
factor analysis, reliability analysis and group comparison tests are undertaken in
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this chapter. Besides, the result of qualitative data is presented in a diagram
format.
5) Chapter 4: Recommendations for the Vietnamese Aviation Brand the most
outstanding findings are analyzed and discussed in comparison with the
literature in the previous chapter. Some reasons for this research results are also
proposed and proved.
6) Conclusion: this chapter begins with a summary of what this paper was done in
general. Then, some implications and limitations are presented in this chapter,
following by directions for future research.
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CHAPTER I: THEORETICAL BACKGROUND
1.1. Safety culture definition
An ideal safety culture is the “engine” that drives the system towards the goal of
sustaining the maximum resistance towards its operational hazards, regardless of the
leadership's personality or current commercial concerns. In aviation organizations, there
are air traffic controllers, pilots, flight crew, maintenance personnel and others who can
provide key information about aviation safety problems and potential solutions. According
to Reason (1997), the components of a safety culture include: just, reporting, learning,
informed and flexible cultures.
First of all, achieving this Reporting Culture requires an organization climate in
which people are willing to report their errors and incidents. In particular, an effective
Reporting Culture depends on the way an organization handles blame and punishment. A
Reporting Culture supports an informed culture in which the managers and operators have
good knowledge of all factors that determine the level of safety. Other relevant parts in the
safety culture framework of Reason are a Flexible Culture, the ability to reconfigure in the
face of high-tempo operations or certain kinds of danger, and a Learning Culture, the
willingness and competence to draw right conclusions from its safety information system
and the will to implement major reforms when needed. Besides, once Just Culture has been
established, the organization can begin to have a reporting culture, something that provides
the system with an accessible memory, which is essential in underpinning to a Learning
Culture. All these contributing parts interact and the overall safety culture is more than the
sum of its parts (Reason, 1997).
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Figure 1: Safety culture components (Reason 1997)
1.2. A Just Culture definition
Reason (1997) describes a Just Culture as an atmosphere of trust in which people are
encouraged, even rewarded, for providing essential safety-related information, but in
which they are also clear about where the line must be drawn between acceptable and
unacceptable behavior. A “Just Culture” therefore, comprises of pertinent unique features
such as trust, the lack of unjustified blame, steady and timely response to criminal and
negligible activities. This is in addition to the prevailing the reward system, especially on
the aspect of reporting near misses, regarding incidents or accidents (Soeters & Boer,
2010). In other words, a Just Culture is built on integrity, consistency and commitment to
achieve the desired results of absolute safety to passengers. As Denison (1996) states, both
safety standards and organizational cultures can be used interchangeably to portray the
same thing.
Another definition for Just Culture derived from Sidney Dekker in his paper in 2008
is a culture in which employees must be accountable for their actions and, in return, are
provided assurance that they will be treated in a fair manner following an incident or
accident. The discipline needs to be tied to the behavior of individuals and the potential
risks their behavior presents more than the actual outcomes of their actions.
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This is also reflected by the definition provided by the European Commission, in
which: „Just culture‟ means a culture in which front line operators or others are not
punished for actions, omissions or decisions taken by them that are commensurate with
their experience and training, but where gross negligence, willful violations and destructive
acts are not tolerated (EC No 691/2010). An effective reporting culture depends on how
the organization handles blame and punishment. A “no-blame” culture is neither feasible
nor desirable. Most people desire some level of accountability when a mishap occurs. In a
Just Culture environment the culpability line is more clearly drawn. A “Just Culture” refers
to a way of safety thinking that promotes a questioning attitude, is resistant to
complacency, is committed to excellence, and fosters both personal accountability and
corporate self-regulation in safety matters.
A “Just” safety culture, then, is both attitudinal as well as structural, relating to both
individuals and organizations. Personal attitudes and corporate style can enable or facilitate
the unsafe acts and conditions that are the precursors to accidents and incidents. It requires
not only actively identifying safety issues, but responding with appropriate action. In fact,
Just Culture operates by design to encourage compliance with the appropriate regulations
and procedures, foster safe operating practices, and promote the development of internal
evaluation programs.
1.3. Benefits of Just Culture
The GAIN report (2004) suggests that creating a Just Culture promotes an
environment where everyone involved in the situation learns from potentially unsafe acts
or mistakes. This is as opposed to an environment where potentially unsafe acts or
mistakes become compounded by individuals, assigning blame and covering up their
mistakes (GAIN Working Group, 2004). To be noted is that Safety Culture and Just
Culture, are not synonymous. According to Cox & Cheyne (2000), a culture of safety is
something that can be achieved through the creation of a Just Culture. Thus, although the
two concepts are intricately linked, they are not synonymous, as they do indicate to varying
ideals. When a Just Culture is created within a given organization, the resulting blame-free
environment improves the overall safety standards present. This is due to the increase in
the willingness of employees to actively participate in the reporting of unwarranted and
hence dangerous (reckless) behaviors (Cox & Cheyne, 2000).
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The benefits that can be gained from the creation of a Just Culture in an organization
include measurable effects such as increased event reports and corrective actions taken, as
well as intangible organizational and managerial benefits.
Increased reporting
A Just Culture can lead to not only increased event reporting, particularly of
previously unreported events, but also the identification of trends that will provide
opportunities to address latent safety problems. It has been estimated that for each major
accident involving fatalities, there are as many as several hundred unreported incidents
that, properly investigated, might have identified an underlying problem in time to prevent
the accident. (GAIN Operator‟s Flight Safety Handbook, 1999). A lack of reported events
is not indicative of a safe operation, and likewise, an increase in reported events is not
indicative of a decrease in safety. Event reporting illuminates potential safety concerns,
and any increase in such reporting should be seen as a healthy safety indicator. Peter
Majgard Nørbjerg of Naviair, Denmark‟s air traffic service provider, reported that after a
June 2001 change to Denmark‟s law making confidential and non-punitive reporting
possible for aviation professionals, the number of reports in Danish air traffic control rose
from approximately 15 per year to more than 900 in the first year alone.
More Effective Safety and Operational Management
Just Culture will enhance the organization‟s effectiveness by defining job
performance expectations, establishing clear guidelines for the consequences of deviance
from procedures, and promoting the continuous review of policies and procedures.
Just Culture is expected to allow an organization to be better able to determine
whether violations are occurring infrequently or if deviation from established procedures
has become normalized among its front-line employees and supervisors.
Outdated or ineffective management structures can be manifested in many ways, as
by operational inefficiencies, lost opportunities, or safety lapses. While Just Culture is
primarily implemented by a safety motive, it is recognized “that the same factors which are
creating accidents are creating production losses as well as quality and cost problems.”
(Capt. Bertrand DeCourville, Air France, 1999)
1.4. Principles of Just Culture
This section discusses some of the main issues surrounding Just Culture, including
the benefits of having a learning culture versus a blaming culture; learning from unsafe
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acts; where the border between “acceptable” and “unacceptable” behavior should be; and
ways to decide on culpability.
Evaluating the benefits of punishment versus learning. A Just Culture supports
learning from unsafe acts. The first goal of any manager is to improve safety and
production. Any event related to safety, especially human or organizational errors, must be
first considered as a valuable opportunity to improve operations through experience
feedback and lessons learnt.
Failures and „incidents‟ are considered by organizations with good safety cultures as
lessons which can be used to avoid more serious events. There is thus a strong drive to
ensure that all events which have the potential to be instructive are reported and
investigated to discover the root causes, and that timely feedback is given on the findings
and remedial actions, both to the work groups involved and to others in the organization or
industry who might experience the same problem. This „horizontal‟ communication is
particularly important.
Organizations need to understand and acknowledge that people at the sharp end are
not usually the instigators of accidents and incidents and that they are more likely to inherit
bad situations that have been developing over a long period (Reason, 1997). In order that
organizations learn from incidents, it is necessary to recognize that human error will never
be eliminated; only moderated. In order to combat human errors we need to change the
conditions under which humans work. The effectiveness of countermeasures depends on
the willingness of individuals to report their errors, which requires an atmosphere of trust
in which people are encouraged for providing essential safety-related information (Reason,
1997).
Marx (2001) has identified four types of behavior that might result in unsafe acts.
The issue that has been raised by Marx (2001) and others is that not all of these behaviors
necessarily warrant disciplinary sanction.
1. Human error – is when there is general agreement that the individual should have
done other than what they did. In the course of that conduct where they inadvertently
caused (or could have caused) an undesirable outcome, the individual is labeled as having
committed an error.
2. Negligent conduct – Negligence is conduct that falls below the standard required
as normal in the community. Negligence, in its legal sense, arises both in the civil and
criminal liability contexts. It applies to a person who fails to use the reasonable level of
skill expected of a person engaged in that particular activity, whether by omitting to do
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something that a prudent and reasonable person would do in the circumstances or by doing
something that no prudent or reasonable person would have done in the circumstances. To
raise a question of negligence, there needs to be a duty of care on the person, and harm
must be caused by the negligent action. In other words, where there is a duty to exercise
care, reasonable care must be taken to avoid acts or omissions which can reasonably be
foreseen to be likely to cause harm to persons or property. If, as a result of a failure to act
in this reasonably skillful way, harm/injury/damage is caused to a person or property, the
person whose action caused the harm is liable to pay damages to the person who is, or
whose property is, harmed.
3. Reckless conduct – (gross negligence) is more culpable than negligence. The
definition of reckless conduct varies between countries; however, the underlying message
is that to be reckless, the risk has to be one that would have been obvious to a reasonable
person. In both civil and criminal liability contexts it involves a person taking a conscious
unjustified risk, knowing that there is a risk that harm would probably result from the
conduct, and foreseeing the harm, he or she nevertheless took the risk. It differs from
negligence (where negligence is the failure to recognize a risk that should have been
recognized), while recklessness is a conscious disregard of an obvious risk.
4. Intentional “willful” violations – when a person knew or foresaw the result of the
action; but went ahead and did it anyway.
1.5. Distinguish acceptable and unacceptable behaviors
As a basis for achieving a Just Culture, there should be ways to distinguish between
acceptable and unacceptable behavior. However, it is difficult to discriminate between the
truly “unacceptable behavior” (bad behavior) and “acceptable behavior”. There is always
existence of a “grey area” between two extremes where issue has to be decided on a case
by case basis. Thus, it is necessary to agree with a set of principles for drawing this line.
First of all, the author will define the “negligence”, which includes a harmful consequence
that a “reasonable” and “prudent” person would have foreseen. And the definition of
“Recklessness” is the person who takes a deliberate and unjustifiable risk. According to
Reason (1997), the line between “unacceptable” and “acceptable” behavior should be
drawn after clarifying substance abuse for recreational and “malevolent damage”. A
successful Just Culture must draw the line between acceptable and unacceptable behavior,
then encourages compliance with appropriate regulations and procedures, foster safe
operating practices and promote the development of internal evaluation programs.
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This is especially due to the fact that the “Blame Culture” still plays a crucial role,
regarding incident/ accident investigations, as well as the prosecution cases. A large
number of aviation organizations have embarked upon this process, and the general
indications are that only around 10% of actions contributing to bad events are judged as
culpable. In principle, this means that the large majority of unsafe acts can be reports
without fear of sanction.
Figure 2: Just Culture safety behavior definition model (author derived based on Reason
1997)
In this model, a positive behavior is considered as such when it generates positive
benefits to the organization. All good activities, assignments and behaviors should be
recognised and rewarded.While below expectation behavior includes all other types of
unintentional behaviors, which usually generates unsafe instances in the organisation. This
could range widely from errors caused by the system, honest individual mistakes or
behaviors that can be categorized as both.
In this thesis, the author also introduces Vietnam Airlines‟s Just Culture following
this behavior definition model. Each Department Divisions in Vietnam Airlines to be
required continuously update the safety behavior examples of themselves in each
categories follow Just Culture Definition Tree and dissemeniate them internally for all
employees to understand what exactly positive behaviour, acceptable or unacceptable
behaviour.
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1.6. Just Culture decision tree
The Decision tree is created by Professor James Reason with the aim of determining
the culpability of unsafe acts. In order to decide whether a particular behavior is culpable
enough to require disciplinary action, a policy is required to decide fairly on a case-by-case
basis. Reason‟s Culpability Decision Tree follows, representing a structured approach for
determining culpability. The assumption is that the actions under scrutiny have a
contributed to an accident or to a serious incident. There are likely to be a number of
different unsafe acts that contributed to the accident or incident, and Reason believes that
the decision tree should be applied separated to each of them. The concern is with
individual unsafe acts committed by either single person or by different people at various
points of the event sequence
The 5 stages include:
Step 1: Intended act: The first question in the decision tree related to intention. If both
actions and consequences are intended, it is possibly criminal behavior and should be dealt
with outside of the company
Step 2: Under the influence of alcohol or drugs: Known to impair performance at the
time that the error was committed. A distinction is made between substance abuse with or
without “reasonable purpose”, which is still not blameless, but not as serious as taking
drugs for recreational purposes
Step 3: Deliberate violation of rules: did the system promote the violation or discourage
the violation or had the behavior become automatic or part of the local working practices
Step 4: Substitution test: could a different person (equally motivated, competent and
qualified) have made the same error under similar circumstances (determined by peers). If
“yes”, the person who made the error is likely to be blameless. If “no”, were there system-
induced reasons (insufficient training or positioned)? If not, negligent behavior should be
considered
Step 5: Repetitive errors: The final question asks whether the person has committed
unsafe acts before. This does not presume culpability, but may imply that additional
training or counseling is required
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Figure 3: Reason‟s Decision Tree for determining the culpability of unsafe acts (1997)
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1.7. Creating and implementing Just Culture
The creation of a Just Culture within an organization also requires a positive outcome
for noticing errors and mistakes that are recorded. Cooper (2000) notes that managerial
roles in the creation of a Just Culture are fundamentally important. Thus, those in
managerial positions must be goal-oriented and very clear with the actions and steps
requisite towards creating a Just Culture within a given organization. Essentially, the
creation of a Just Culture, does require the establishment of new and adequate behavioral
norms. This is with regard to individuals acting within a certain environment; authority
figures within such an environment must set realistic and subsequently attainable goals
(Cooper, 2000).
The Global Aviation Information Network (GAIN) developed guidelines for
attaining, implementing and maintaining a Just Culture [GAIN, 2004]. These guidelines
are based on a number of sources, including Reason (1997), Johnson (2003); lessons from
the Danish experience and Vecchio-Sadus and Griffiths (2004). The GAIN guidelines were
worked upon by the Eurocontrol Safety Regulatory Commission for Eurocontrol Just
Culture guidelines (SRC, 2006). Based on these guidelines, a Just Culture includes the
following elements that can be assessed for their presence and maturity:
Step 1: Develop reporting policy and procedures
The first step that mentioned by the researcher in creating a Just Culture is reporting
organizational policy and procedures. This step is very important because it considers
safety issues concerning the underlying reporting structure and company commitment.
Management commitment is the primary requirement for establishing and maintaining a
Just Culture. Similarly, management commitment is the basis for developing a reporting
policy and related procedures. When management commitment is not obtained to establish
a safety reporting system in which ramp personnel report errors and incidents without fear
of disciplinary actions, no resources will be made available and corrective actions will not
substantiate.
When developing a reporting policy and procedures, it is important to consider
whether reports may be issued anonymously and whether the person receiving and
assessing the reports have an independent function within the organization. This avoids
interference between reported human errors and career prospects. for each major accident,
which involves fatalities, there are as many as several hundred unreported incidents.
Researchers have suggested that, if these incidents are properly investigated, they might
identify underlying problems on time and prevent future incidents from taking place again.
15
Lack of reported events does not necessarily indicate a safe operation (Dekker, 2012).
Likewise, increased reporting on events does not indicate a decrease in the level of safety.
Even reporting illuminates the potential safety concerns an organization has. Increased
reporting should be seen as a healthy, safety indicator (Eurocontrol, 2006).
Step 2: Determine roles, responsibilities and tasks
A number of different people needs to be involved in the development,
implementation and maintenance of the safety reporting system. A person has to be
appointed who is responsible for the development, implementation, promotion and
management of the safety reporting system. This person ensures confidentiality of
reporting and reports directly to the board of directors to highlight (potential) safety issues
and trends. At management level, a person has to be assigned the responsibility to decide if
disciplinary actions have to be taken after errors, incidents or accidents.
To support the safety reporting system, personnel have to be appointed to perform
the activities of collecting, assessing, analyzing and monitoring of safety reports and
trends, and circulating safety information in the organization.
Step 3: Reduce legal barriers
The first step to be taken for consideration is the legal aspect of Just Culture. An
organization has to have in place a disciplinary framework that supports reporting of
incidents. This will significantly reduce any legal impediments to reporting. The first
significant step in changing the legal aspects may entail substantiating the current legal
situation and establishing whether it needs to be changed.
In order to reduce the legal barriers to reporting and assessment of safety occurrences
and trends, the two most important issues are: indemnity against disciplinary proceedings
and a legal framework that supports reporting and investigation of incidents. Without these
aspects firmly established in the organization, ramp personnel may not report errors and
incidents because of fear of legal proceedings.
Step 4: Establish methods of reporting and assessment
Another important step is selecting the reporting method to be used. Some of the
issues the organization may consider with regard to the method by which reports are
collected are the rapid, usefulness and intelligible feedback of the reporting community.
The organization should also consider the ease at which reports are generated. This is
because; voluntary reporting is often perceived an extra task (Bayuk, 2007). Therefore, the
organization will require a clear and unambiguous direction for reporting and accessing to
reports. Reporting of safety issues should be a clearly described and easy process, safety
16
reports should be professionally assessed and managed, and feedback should be rapid,
useful, accessible and intelligible to all personnel.
Step 5: Develop reporting form
Although safety issues could be reported verbally, it is beneficial to also develop a
reporting form that encourages accurate and complete reporting (e.g. questions that are
understandable) and is easy to fill in; otherwise reporters may provide erroneous or
misleading responses. The objective of the safety reporting system has to be carefully
considered when deciding on what information is required to reach this objective.
Step 6: Develop template for feedback to potential users
It is important that reporters and other ramp personnel know as soon as possible that
an occurrence has been investigated and that the root cause is solved. Feedback may be
given on individual reports, but also in a combined form by means of regular safety letters
or memos.
Step 7: Develop plan for educating users and implementing the system
Potential reporters have to be informed about the safety reporting system and know
how to submit their information. This may include induction courses and periodic
awareness sessions to remind ramp personnel of the importance of reporting and to ensure
that all ramp personnel are familiar with the reporting procedures.
Step 8: Develop and maintain a Just Culture
A number of additional issues concerning the „cultural‟ aspects of reporting are
necessary in order to maintain motivation to report, such as trust between the reporters and
their supervisors, and between the supervisors and their managers. This is a precondition
for the safety reporting system to function. The main objectives are to develop an open
culture in which people feel able to trust the system and to develop new ways to motivate
people to use the system.
Continuous management commitment has to be ensured. To maintain and improve
management commitment to safety, management has to be continuously involved in the
reporting process to show visibly that they believe in and are willing to promote the Just
Culture. Simultaneously, commitment to safety of ramp personnel has to be ensured by
actively involving them in the assessment of safety issues and development of corrective
actions.
Although above steps are based upon the GAIN roadmap to a Just Culture (GAIN,
2004), it is clear that they have interactions with a variety of safety culture aspects. In
particular, a large number of these steps are related to what Reason calls „engineering a
reporting culture‟ (Reason, 1997). This thesis also tries to check the implementation of Just
Culture in aviation industry through these seven-steps.
17
CHAPTER II: METHODOLOGY
This chapter will describe the methodology undertaken in this study. In the first
section, research approach will be given, followed by the discussion of secondary and
primary research. Data collection and data analysis are outlined in the following section.
Research limitations and ethnic considerations are discussed in the fourth section followed
by summary of the methodology chapter
2.1. Research approach
With regard to research approach, deductive approach and inductive approach are
two major approaches. In this study, deductive approach is known as “top-down” approach
digging into existing theories, then generating specific hypotheses from these theories, and
finally testing these hypotheses by a number of observations (Bryman & Bell, 2015). In the
opposite direction, inductive approach as “bottom-up” reasoning starts with observation to
discover the evenness and patterns, then create hypotheses and concludes by the
development of explanations or theories (Bernard, 2017).
Inductive approach Deductive approach
Theory follows data Data follows theory
Less structured methodology Structured methodology
A small sample of subjects A large number of samples
Little attention to generalisation Generalisation
Develop in-depth understandings of Enable cause-effect link between
human‟s emotion and perceptions. variables
Table 1: Main features of inductive and deductive approach (Adopted from Sauders et al.
2011)
As facts that quantitative strategy is established under deductive theory which starts
with the theoretical background, deduces a hypothesis and then based on empirical
findings to test hypothesis again (Bryman & Bell, 2007). The quantitative refers to a
statistical analysis method applied for measuring the problems, opinions, attitudes and
behaviors by quantifiable data; then predict the possibility of population features
(Mugenda, 1999; Neuman, 2002). Meanwhile, quantitative research gives the outcome
based on measurement which is supposed to detect clear distinction between categories as
well as “more precise estimates of the degree of relationship between concepts”.
18
Whereas, inductive approach is usually characterized by qualitative (Saunders,
2011). Inductive approach along with qualitative method are good combination to hold the
perception of constructivist for building theories or knowledge (Morgan & Smircich, 1980;
Denzin & Lincoln, 2011). Alasuutari et al. (2008) described that qualitative method
provides in-depth understandings about opinions, reason or motivations, which could
support in developing hypotheses for quantitative study. Bowen (2009) indicates some
typical forms of qualitative method including group discussion, interviews or open-ended
questions.
Table 2: The main features, advantages and disadvantages of qualitative and quantitative
research method (Adopted from Sauders et al. 2011)
Take into account of this research purpose to define the practice of Just Culture in the
aviation industry and give perspectives for Vietnam Airlines, thus it is reasonable to
19
deliver an in-depth understanding about Just Culture and its implementation, qualitative
research accompanied by inductive approach is well suited to this study.
2.2. Data collection
2.2.1. Secondary data
The literature review chapter has reviewed some secondary literature. According to
Salkind (2010), secondary data is data that was produced and interpreted in existence or
data that was used differently from the original purpose. Secondary literature or secondary
data collection is really important because it is a source of adequate information in a
comprehensive way from the past present investigated by many prestigious scholars
(Windle, 2010). By using secondary data, research problem/gap in literature from previous
researches can be posed, hence, to develop a research topic (Walliman, 2011).
Additionally, researchers who utilise secondary data could easily make comparison
amongst existing data (Veal, 2011). Various sources of data are examined to ensure they
are accurate. There are several sources of secondary data such as written materials from
organisational records, textbook, journals, government publications; non-written materials
such as films, videos and audios; and survey data such as government statistics (Walliman,
2011).
In this research, the research statements are mainly built based on academic sources
relating to research method and aviation market books and peer reviewed academic journal
such as Emerald and Ebscohost. Furthermore, the data of Civil Aviation Authority of
Vietnam (CAA), official reports of reputed organizations such as European Organization
for the Safety of Air Navigation (EUROCONTROL), International Civil Aviation
Organization (ICAO), International Air Transport Association (IATA) and Global Aviation
Network (GAIN) are compelling raw data for researchers as it provides updated data of
Aviation industry. In this study, secondary data is utilised to achieve objective 1 and 2.
Although secondary research is useful in making contribution to the formal base of the
research as well as literature review, it is not enough to answer the research question which
the study is looking for to solve.
2.2.2. Primary data: semi-structured interviews
The critical secondary literature has provided good insights of research problem, but
not completely answer the research aim; thus, it is necessary to do primary research.
According to Marshall and Rossman (2006), primary research is to grasp the profound
meaning of the experiences in the words of the participants. Primary research refers to the
20
participation of a study on a subject in which data is collected originally by the first
observation gathered by the researcher (Dawson, 2007). While secondary data is in
existence, primary data is primarily collected and used by the current researchers in order
to complement secondary data (Veal 2011). Primary data can be collected in various ways
such as interviews, questionnaires and obervations (O‟Leary, 2014).
Research interview is a conversation in purpose between researcher and one or more
people, in which interviewees are willing to answer concise questions, while interviewer
(researcher) has to listen thoroughly in order to discuss further (Sauders et al. 2011). There
are several types of interview, which are normally categorized into: structured interview,
semi-structured interview and unstructured/in-depth interview (Bernard et al. 2010,
Sauders et al. 2011), which are presented in Table 3.
Structured interview Semi-structured interview Unstructured/In-depth
interview
Standardized questionnaire Non-Standardized Non-Standardized
questionnaire questionnaire
Qualitative research Qualitative research Qualitative research
Descriptive research Exploration and explanation Exploration research
research
Table 3: Different types of interview (adopted from Sauders et al.2011)
According to Saratakos (2013), semi-structured interview is developed based on
research topic and research‟s objectives. In addition, Walliman (2011) states that semi-
structured interviews are intended to attain specific answers to the identified questions and
provide further opportunities for further answers. This type of interview normally has a
framework of themes to be explored, meanwhile, gains past experience, feelings, emotions
and perceptions of interviewees in the interview process. Thus, semi-structured interview
allows the researcher to deeply investigate the perceptions of Vietnam Airlines top
managers through their emotions and experiences. In this research, semi-structured
interviews could be the most suitable method for author to understand exactly current
situation of Just Culture implementation in Vietnam Airlines.
2.2.3. Interview preparation
Based on the literature review about Just Culture and data collection, themes were gathered
to prepare interview schedule. The schedule included some ice breaking questions, which
are related to the demographics of interviewees, for examples, the background of
21
participants, age, nationality, as well as their business histories and background. Some key
questions focusing on the motivations of establishing social entrepreneurs in community-
based tourism were asked. Following each key question, the researcher asked some probe
questions in order to further the answers. Questioning was also opened to allow
respondents freely to interpret and narrate at their own pace. Interview schedule has been
designed with six main questions to meet research objectives. The semi-structured
questions linking to two main objectives of the research is given in Appendix.
2.2.4. Sampling
The number of interviews was specified by the “saturation effect”, in which the data
collected was iteratively analysed (Srivastava and Hopwood 2009). According to Thomson
(2010 cited by Marshall et al. 2013), the “saturation effect” is usually accomplished within
10–30 interviews which this study matches. “Purposive” and “snowballing” sampling
techniques are used to attain these participants. Purposive sampling is the process that
participants, who have knowledge about the phenomenon under study, are purposely found
by current researcher (Bryman 2012). In this research, “purposive” sampling techniques is
used to attain these participants. The responders in this study are able to satisfy the
following principle requirements:
They are top managers in Vietnam Airlines
They are department managers or staffs in Safety - Quality Department
They are managers or staffs in Human Resource Department
They are people who takes responsibility in building and maintaining safety culture
in Vietnam Airlines. Thus, they will have deep understanding about current situation of
Just Culture implementation in the organization. Besides, to minimize the bias, the
researcher tried to diversity the answers by looking for interviewees who are working at
different position in a department or in different department in Vietnam Airlines. There are
10 interviewees participating in this interview.
2.2.5. Pilot test
According to Bryman (2012), the implementation of a pilot study is important due to the
fact that it assists the researcher in ensuring the interview schedule suitable and run
smoothly during the process of data collection. Additionally, Saunders et al (2011) and
Turner (2010) also argued that the pilot test plays an important role in the detection of any
flaws or difficulties that exist or might arise in data collection. Therefore, researchers are
22
able to determine and make amendments if needed. Some alterations were made and
several probe questions were added to improve data collection.
2.3. Interview implementation
The interviews were conducted at different dates and different location based on the
suitability of the participants. Due to the focus of this study being Just Culture Practice in
Vietnam Airlines, the researcher would like to conduct face-to-face conversations, besides,
the researcher‟s ability to approach potential participants remains low because of the new
topic. The first interview was conducted on 1 November, while the last one was on 25
November 2019. Informal conversations before commencing interviews helped to ease
overall ambience of the interview and create a receptive environment (Apendix 1).
2.4. Method of analysis
According to Holloway et al (2003), qualitative approach is significantly complicated
and diverse. A common criticism of qualitative research is that data analysis procedures are
rarely well understood by researchers, thus leading to the inability of the reader to
understand the presence of the researcher's findings (Stirling, 2001). In addressing this
concern, thematic analysis method has been used to analyze the data, but data analysis will
remain flexible and adapt to the requirements of the researcher (Richards, 2015).
Thematic analysis is the involvement of discovery, interpretation, report and cluster
of data. Due to the flexibility of this analysis method in terms of theory and epistemology,
thematic analysis is able to amass detailed, complicated and yet extensive data (Braun et al.
2006).
Familiarising with your data
Searching for themes
Generating initial code
Reviewing themes
Defining and naming themes
Producing report
Figure 4: Thematic analysis’s stages (Adopted from Braun et al 2006)
23
Besides, this thesis supposes to analyze data collected from papers, articles, books
and reports from reputed aviation organizations by some analysis methods such as
Comparative and Contrastive Analysis. Firstly, the comparative and contrastive method is
used to compare the in the current situation Practice of Just Culture in the world aviation
industry and in Vietnam. This method also gives a deep understanding of similarities and
differences in mechanisms and policies towards Just Culture implementation in the world
aviation industry and in Vietnam.
Furthermore, the thesis uses the analytical - synthesis method, which is one of the
most frequently used qualitative research methodologies. The collected data will be
screened and analyzed to fit the content of the thesis. The secondary data from various
information sources are summarized, analyzed, compared and evaluated around the topic
of Just Culture; then, theoretical background will be systematized and generalized. This
method is used almost throughout the three main chapters of the thesis.
2.5. Research ethics
According to Ritchie et al (2013), ethical considerations are the essence of how researchers
treat their participants. Prior to data collection, it is important to gain ethical approval. The
research‟ summary with aims and objectives are given and that the conversions will be
recorded. In addition to this, a comprehensive explanation on confidentiality and
anonymity issues were carefully given before each interview. During interviews, the
researcher showed respect interviewees‟ privacy and was bound to protect participants‟
recognition or any private information. After transcription, all information will be
destroyed. Children (below 16) and vulnerable people were excluded due to ethical and
health concerns.
24
CHAPTER III: JUST CULTURE PRACTICE IN THE AVIATION
INDUSTRY
3.1. History of Just Culture in the world aviation industry
Before the 21st century, very few people had heard about Just Culture. Currently,
almost every organization in the aviation industry has implemented the Just Culture in all
their activities. Recent findings have suggested that; the Just Culture has become the
foundation for safety in the aviation industry (Frazier, 2012). Organization leaders have to
focus at achieving a Just Culture in the firm so that the business can benefit from the
simplicity, power and effectiveness of the culture.
In 1999, the New Zealand Civil Aviation Authority (NZ CAA) became interested in
“Just Culture”, and started the process of learning how it functions, and the process
required to implement it. They are frequently faced with making decisions regarding the
choice of regulatory tool that is appropriate to apply to an aviation participant when there
is a breach of the Civil Aviation Act or Rules, and they saw the “Just Culture” model as
holding the promise of promoting compliance and facilitating learning from mistakes.
However, to fully embrace „Just Culture‟ in New Zealand, there will need to be some
legislation changes and considerably more selling of the concept to the aviation industry
(particularly at the GA end) in order to get the necessary paradigm shift (away from fear of
the regulator when considering whether or not to report occurrences). In the following
years, the New Zealand CAA has organised Just Culture Seminars invited relevant people
in the aviation industry (including large and small airline operators) and CAA personnel to
attend a seminar by a leading expert on Just Culture. The seminars were extremely well
received by all attendees, thus giving the CAA confidence that Just Culture principles were
appropriate to apply in a safety regulatory context.
In 2000, the Chairman of the Danish Air Traffic Controllers Association described
the obstacles for reporting during an interview on national prime-time television. This
influenced the Transportation Subcommittee of the Danish Parliament to ask for the
Danish Air Traffic Control Association to explain their case. After exploring various
international legislations on reporting and investigating incidents and accidents, the Danish
government proposed a law in 2002 that would make non-punitive, confidential reporting
possible.
On 3 April 2014, Occurrence reporting in the UK and the rest of Europe is governed
by European Regulation 376/2014 on the reporting, analysis and follow-up of occurrences
in civil aviation. The Mandantory Occurrence Reporting (MOR) was established to ensure
25
that all hazardous or potentially hazardous incidents and defects are informed to CAA.
Besides, MOR also supports for an assessment to be made and monitor performance
standards that have been set by the CAA. Since MOR system was introduced, there is an
increase in the number of unsafe acts reported. Undoubtely, MOR system has contributed
to enhance awareness of managers and staffs in aviation organzations of safety-issues
reporting.
3.2. Just Culture Practice in the world aviation
This section briefly describes how the world aviation brands create and implement
Just Culture through some of the main steps to achieving a Just Culture. These have come
from a number of sources: including Reason (1997); Johnson (2003); lessons from the
Danish experience; EUROCONTROL ESARR2 Workshops in 2000 and Vecchio-Sadus
and Griffiths (2004).
3.2.1. Legal Aspects
For many organizations, the main challenge of developing a Just Culture will be to
change the legislation, especially if the changes are counter to societal legislation. In order
to reduce the legal impediments to reporting, the two most important issues are: 1)
indemnity against disciplinary proceedings and 2) having a legal framework that supports
reporting of incidents. The first steps in changing the legal aspects could be to substantiate
the current legal situation and define whether it needs to be changed. Then, they need to
discuss possibilities of change with company lawyers or legal advisors. And importantly,
the organization should discuss with operational personnel what changes in the legal policy
they think would improve incident reporting.
One example of the marked changes in an organization as a result of creation of Just
Culture occurred at Danish Air Traffic Control Service Provider (Naviair) made possible
through a change in its national law. An extensive briefing campaign was conducted to
give information to air traffic controllers; in the briefing process the controllers expressed
concerns about confidentiality and non-punitive issues. These issues were addressed by
explaining the intention of the law governing the reporting system, the law that would
grant media and others no access to the reports and would secure freedom from
prosecution. After exploring various international legislations on reporting and
investigating incidents and accidents, the Danish government proposed a law in 2002 that
would make non-punitive, confidential reporting possible.
26
Another example, the UK Civil Aviation Authority (UK CAA) has recently reviewed
the Mandatory Occurrence Reporting System (MOR) to try to improve the level of
reporting within the UK aviation community. Assurance Regarding Prosecution - The UK
CAA gives an assurance that its primary concern is to secure free and uninhibited reporting
and that it will not be its policy to institute proceedings in respect of unpremeditated or
inadvertent breaches of law which come to its attention only because they have been
reported under the Scheme, except in cases involving failure of duty amounting to gross
negligence. With respect to licenses, the CAA will have to take into account all the
relevant information about the circumstances of the occurrence and about the license
holder. The purpose of license action is to ensure safety and not to penalize the license
holder.
In case of Alaska Airlines, no disciplinary action will be taken against any employee
following their participation in an error investigation, including those individuals who may
have breached standard operating procedures. Disciplinary action will be only limited to
the following narrow circumstances, for example, an employee fails to promptly report
incidents. For example, when an employee delays making a report in a reasonable time. A
reasonable time for reporting is within 24 hours. However, reports should be submitted as
soon as possible after the employee is aware of the safety error or close call. On more
example of disciplinary action stated in the law documentation is the employee‟s actions
involve criminal activity or substance abuse.
3.2.2. Reporting Policy and Procedures
The step that mentioned by the researcher in creating a Just Culture is reporting
organizational policy and procedures. This step is very important because it considers
safety issues concerning the underlying reporting structure and company commitment. One
of potential obstacles when creating a Just Culture in an aviation organization is to
persuade senior management of the need for creating a Just Culture and to commit
adequate resources to it.
In case of Naviair, priorities were set up on which reports are dealt with immediately, and
on how much attention is given by the investigators. The investigation of losses of
separation are investigated thoroughly including gathering factual information such as
voice recordings, radar recordings, collection of flight progress strips and interviews with
involved controllers. Investigative reports have to be completed within a maximum of 10
27
weeks. The reports include the following elements: Aircraft proximity and avoiding
manoeuvers; safety nets (their impact on and relevance for the incident); system aspects;
human factors; procedures; conclusion and recommendations. The ultimate purpose of the
report is to recommend changes to prevent similar incidents.
CAA encourages the use of company reporting systems wherever possible. Reports
collected through the company are filtered before they are sent to the CAA (to determine
whether they meet the desired criteria of the CAA). The company is encouraged to inform
the reporter as to whether or not the report has been passed on to the CAA.
- Individuals may submit an occurrence report directly to the CAA, although in the
interest of flight safety they are strongly advised to inform their employers.
- Reports must be dispatched within 96 hours of the event (unless exceptional
circumstances) and informed by the fastest means in the case of particularly hazardous
events.
- Confidential reports – can be submitted when the reporter considers that it is
essential that his/her identity not be revealed. Reporters must accept that effective
investigation may be inhibited; nevertheless, the CAA would rather have a confidential
report than no report at all.
The Alaska Airlines Error Reporting System (ERS) is a non-punitive reporting
program which allows employees to report to management operational errors or close calls
that occur in the workplace. This system is designed to capture events that normally go
unreported. It also provides visibility of problems to management and provides an
opportunity for correction. The report procedure can be process in 2 steps.
1st step: Reporters can file a report on www.alaskasworld.com. An employee can
also submit a report over the phone by contacting the Safety Manager on Duty.
2nd step: A report should be promptly submitted, normally as soon as the employee
is aware of the error or close call. Reports made later may be accepted where extenuating
circumstances exist.
3rd step: The employee‟s supervisor will review the report, determine if it meets all
criteria for acceptance and notify the employee. If the report is not accepted, the
employee‟s supervisor is responsible for contacting the Safety Division immediately for
review. The Safety Division will record and review all reports submitted under this
program.
In general, the Internal Evaluation Program (IEP) will accomplish a monthly review
of corrective actions. All long-term changes to procedures and policies will be added to the
28
IEP audit program and become permanent evaluation items for future audits. A summary
of employee reports received under this system will be presented to the Board of Directors
Safety Committee quarterly. Summary information will also be shared with employees on
a regular basis.
3.2.3. Methods of Reporting
It is important that issues such as the following are considered with regard to the
method by which reports will be collected a rapid, useful, accessible and intelligible
feedback to the reporting community. Most literature present, suggests that a Just Culture
requires open and blame- free communication strategies to maintain the integrity of the
safety culture. However, the logistical issues that arise when considering the blame-free
environment are problematic, and thus are handled differently by a variety of existing
researchers. Wagner (2013), suggests that anonymous and confidential reporting are both
extremely important tools for use in creating a safety culture within an organization. He
further suggests that confidential reporting in particular encourages active learning in
employees and members of the organization (Wagner, 2013). Dekker (2009) on his part,
notes that active learning is a fundamental underlying purpose in the creation of a safety
culture within a given organization (Dekker, 2009).
The GAIN report (2004) suggests that mandatory reporting of events by Danish air
traffic controllers has vastly reduced the number of incidents that have occurred. The
knowledge that reports must be made and filed, has improved the attention paid to details
by the air traffic controllers. The report notes the important difference between blameless
and non-punitive organizational Just Culture. However, reporters are ensured of their
indemnity against unjust (blame-based) prosecution or disciplinary actions against them.
This is for any events that they may, or have reported, especially those based on the
information contained in the reports they may have submitted. However, this does not
always mean that such reports can be submitted without any consequences” (GAIN
Working Group, 2004).
Mandatory reporting, according to the report, has been utilized effectively, in the
aviation industry to great success. In addition, when mandatory reporting is used in
conjunction with confidential reporting, incident levels do have a tendency of decreasing.
The new system for Danish air traffic controllers also allows authorities to train individuals
to both assess and further produce their reports. This is done through by prioritizing
reports; those, which require urgent attention are addressed first. The culture of trust that
29
this system created as a result, was able to permeate the entire air-traffic control chain of
command. It thus allowed existing air traffic controllers to address existing problems
earlier, and with less fear of punishment from figures of authority (GAIN Working Group,
2004).
Glendon and Stanton (2000), suggest that reporting methods should be quantitative
in nature, as well as qualitative, for the maximum efficacy of the reports. They further
suggest that the measurement of existing safety culture, does depend on its definition. The
prevailing definition in turn, reflects the perspective adopted within a given organizational
culture. This measurement is not merely empirical, but it rests upon a value decision. As a
result, ethnographic approaches, while being possibly the most valid form an interpretive
perspective, are often costly and time consuming in nature. Case study data reported here,
showed that two existing and independent measures did reveal existing safety
improvements over time. This was as reflected in the patterns of behavior and working
practices, as found within an existing organizational environment (Glendon & Stanton,
2009).
The convergence of existing data, from the different methodologies utilized, is most
likely to improve both the breath and subsequent accuracy. However, the direction and
resulting influences, of such prevailing “cause and effect” situational contexts, cannot
necessarily be established from their analysis. It may thus be summarized, in the fact that
observed changes, if present in both measures, do reflect the prevailing corresponding
changes. These are as found in the underlying aspects of the prevailing safety culture
(Glendon & Stanton, 2009). They are of the suggestion that such methods of quantitative
analysis, do provide those in authority with more accurate and hence concrete knowledge
of safety measures and analysis, within a given organization.
New Zealand operates a mandatory reporting system, with provision for information
revealing the identity of the source to be removed if confidentiality is requested (the latter
happens only rarely). The reporting requirements apply to all aircraft accidents and to all
serious incidents except those involving various sport and recreational operations. In
addition to the notification requirements for accidents and incidents, the rules require the
aircraft owner or the involved organization notifying a serious incident to conduct an
investigation to identify the facts relating to its involvement and the causal factors of the
incident. A report of the investigation is required within 90 days of the incident and must
include any actions taken to prevent recurrence of a similar incident.
30
Information received under this mandatory reporting system cannot be used for
prosecution action, except in special circumstances such as when false information is
supplied or when „unnecessary danger‟ to any other person is caused. (Ref New Zealand
Civil Aviation Rule CAR Part 12.63.)
31
Decide on voluntary versus mandatory reporting system
Decide on anonymous, confidential, open reporting system
Develop procedures for determining culpability (such as the Just Culture
The first steps to develop a “Just Culture” Reporting System
Decide who shall decide culpability (e.g., team consists of safety; operations;
decision tree) and follow-up action (type of discipline or coaching)
Draft a plan and discuss with a small selection of operational personnel
Decide if and how the reports will be further investigated (the focus of the
management; HR)
Decide which reports will be further investigated (those which are most severe;
investigation; face-to-face interview.)
Decide who will investigate the reports.
or those with the most learning potential).
Table 4: Steps to build a Just Culture Reporting System
In case of Danish Airway, the Danish reporting system ensures immunity against
penalties and disclosure but also any breach against the non-disclosure guarantee is made a
punishable offense. Danish Airway has chosen a mandatory, non-puntive and confidential
reporting system. In particular, Air Traffic Controllers must submit reports of events. It is
punishable not to report an incident in aviation. And, reporters are ensured indemnity
against prosecution or disciplinary actions for any event they have reported based on the
information contained in the reports submitted. However, this does not mean that reports
may always be submitted without consequences. Ideally, the reporter‟s identity may not be
revealed outside the agency dealing with occurrence reports. Investigators are obliged to
keep information from the reports undisclosed. One more important thing is this reporting
system allow to immunity against any penal or disciplinary measure. If a report is
submitted within 72 hours of an occurrence; if it does not involve an accident; or does not
involve deliberate sabotage or negligence due to substance abuse. Punitive measures are
stipulated against any breach of the guaranteed confidentiality.
It may not be obvious to all organizations which system would suit them best.
Ideally, a variety of reporting methods (or a flexible method) will be implemented, as not
one reporting method will suit everyone‟s needs. It may be necessary for the organization
to survey the needs of the potential users to better understand which reporting method
would be more readily accepted.
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3.2.4. Determine roles and responsibilities
For such a system to thrive, a number of different people need to be involved in the
implementation and maintenance of the system. A „local champion‟ will be needed to
promote and act as guarantor to ensure the assurances of anonymity will be preserved in
Champion the system
Educate users and implement system
Collect and analyze the reports
Decide which department will be involved in the disciplinary (decision making)
the face of external or managerial pressures. Decide and select someone to:
Feedback the information (develop newsletter)
Develop and maintain the data collection system
process
The UK- CAA has the following responsibilities: i) evaluate each report; ii) decide which
occurrences require investigation by the CAA iii) check that the involved companies are
taking the necessary remedial actions in relation to the reported occurrences, iv) persuade
other aviation authorities and organizations to take any necessary remedial actions, v)
assess and analyze the information reported in order to detect safety problems (not
necessarily apparent to the individual reporters); vi) where appropriate, make the
information from the reports available and issue specific advice or instructions to particular
sections of the industry; vii) where appropriate, take action in relation to legislation,
requirements or guidance. The Air Accidents Investigations Branch (AAIB) investigates
accidents, and these are passed on to the CAA for inclusion in the MOR.
In Alaska Airlines, the Safety Division has oversight of the program. Supervisors and
local management have responsibility for the day-to-day management of reports submitted,
investigations performed and implementation of corrective actions. They will define
whether they have enough sufficient resources to run the system, as well as having enough
of the „right‟ kind-of people, who are energetic, well-liked, well-known and respected in
the company. Then, they try to maintaining the energy required for the system to function.
3.2.5. Developing and Maintaining Just Culture
A number of additional issues concerning the „cultural‟ aspects of reporting are
necessary in order to maintain motivation to report, such as the trust between reporters and
the managers must genuinely exist for the reporting system to work. The main aims are to
develop an open culture in which people feel able to trust the system and to develop new
ways to motivate people to use the system. Below are initial ideas.
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Main ideas Content
System visibility
Potential contributors to be made aware of the procedures and mechanisms that support the incident reporting system
the
Maintaining employees‟ voice The reports are used to voice the employees voice and not used to suit existing management priorities
Publicized participation Publish the contribution rate from different parts of the organization to show that others have trust in the system
Develop „marketing
1. Customer centered – focusing the marketing strategy to suit the audience (e.g. management will have a different focus than the operations personnel); for safety strategies‟ enhancing
culture
2. Link safety values to the core business – and show tangible evidence for their impact, such as how safety can enhance
production, efficiency, communication and even cost benefits; 3. Reward and recognition – positive reinforcement for reporting
incidents.
Change attitudes and Focus on the immediate, certain and positive consequences of
behaviors
reporting incidents and publicize the “pay-offs” of reporting incidents
Management commitment Raise awareness of management‟s commitment to safety, with a “hands on approach”; have management involved in the reporting
process to show that they visibly believe and promote the Just Culture
Employee involvement Ensure employee involvement so they are committed to the need to be actively involved in decision making and the problem solving
process.
Table 5: Main ideas to develop and maintain a Just Culture
Three planning aspects that need to be taken into consideration: 1) the required time
to undertake the steps and sub-steps (include start and end dates); 2) the estimated costs
involved and 3) who will undertake the work.
The NZ CAA has a set of tools that they apply to an aviation participant when there
is a breach of the Civil Aviation Act or Rules. The tools are many and varied and form a
graduated spectrum from a simple warning, through re-training and diversion, to
administrative actions against Aviation Documents and prosecutions through the Court.
The CAA base their decisions on information which arises from a variety of sources such
as: a CAA audit, an investigation of an accident or incident, or a complaint from the
public.
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For the past four years, the CAA has been using Just Culture principles to decide
when:
1. Information from a safety investigation into a mandatory reported occurrence
should cross the “Chinese wall” to be used in a law enforcement investigation.
(In this context they are using Just Culture to draw the line at recklessness as a
surrogate for "caused unnecessary danger", which is the terminology used in the
relevant NZ Civil Aviation Rule, CAR 12.63.)
2. Document suspension/revocation is appropriate.
3. Education or re-examination is appropriate.
The perhaps natural tendency for a regulatory authority to draw the line below
negligence is resisted. By drawing the line below recklessness when making decisions, the
CAA believes it will encourage learning from human errors and, once the approach
becomes universally understood and accepted by the aviation community, the incidence of
non- reporting of safety failures will decrease.
3.3. Just Culture implementation in Vietnam Airlines
3.3.1. Vietnam Airlines introduction
In January 1956, Vietnam Airlines was founded when the Vietnam Civil Aviation
Department was established by the Government, marking the birth of the civil aviation
industry in Vietnam. The first fleet was small with only five IL-14, AN-2 and Aero-45
aircraft ... offering domestic flights in September 1956. In April 1993, Vietnam Airlines
was officially established as the country‟s national flag carrier. On 27 May 1995, Vietnam
Airlines Corporation was born with the gathering of 20 aviation enterprises and the airline
itself as the core business.
In October 2002, Vietnam Airlines introduced the Golden Lotus brand and corporate
identity that symbolized its dramatic progress towards becoming a world-class airline. The
launch represented a complete re-positioning of brand strategy for Vietnam Airlines,
coupled with significant improvements to its infrastructure, operations and fleet. The
delivery of Vietnam Airlines' first “state- of-the-art” B777 in 2003 also marked a true
revolution in the airline‟s fleet modernization.
After 20 years of development at an average annual growth rate in the double-digits,
the national flag carrier has passed a major milestone to become a key competitor in the
Asian aviation market, owning a modern fleet of Airbus and Boeing planes flown by
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highly trained professionals. Beginning with non-regular domestic services, today Vietnam
Airlines operates in 21 cities throughout the country and 28 international destinations in
Asia, Europe, and Australia. Its network extends to 26 countries and territories. Now,
Vietnam Airlines operates one of the most modern fleets with 99 aircrafts in the region (14
A350-900, 11 B787-9, 57 A321-200, 9 A321 Neo, 2 A330 -200, 6 ATR72-500) with the
average age of planes in the fleet at 5.4 years.
In 2006, after being awarded the IATA Operational Safety Audit (IOSA) certificate,
a strict safety standard set by IATA, Vietnam Airlines joined the International Air
Transport Association (IATA) as an official member, establishing its international
standing. In June 2010, Vietnam Airlines joined SkyTeam, the world‟s second largest
global airline alliance. This established the carrier‟s new position on the global aviation
map as the strategic partner of the Skyteam alliance in Southeast Asia region and by
meeting international service standards. In 2015, Vietnam Airlines began operating both
the Boeing 787-9 and the Airbus A350 at the same time, next-generation aircraft only
operated simultaneously by on other airlines in the word. In July 2016, Vietnam Airlines
received a 4-Star Airline Certificate from Skytrax, the world‟s leading airline and airport
rating organization.
Positioning itself as a young, modern carrier whose brand is characterized by
Vietnamese traditional culture and internationally recognized, Vietnam Airlines is
purchasing the world‟s most modern, environment-friendly aircraft, such as the Boeing
787-9 and the Airbus A350-900 and making constant efforts to improve its service quality.
The airline is striving to become one of the most innovative carriers in the Asia-Pacific
region. On 14 February 2019, The US Federal Aviation Administration (FAA) has granted
Vietnam Category 1 status, setting the stage for Vietnam Airlines to establish direct
services to US destinations with assessment both the Boeing 777X and Airbus A350-1000.
Obviously, Vietnam Airlines has been gradually asserting its position in the
international aviation industry. This table will introduce the process of Vietnam growth
and development since 2006 to now.
Time Process
2006 Vietnam Airlines joined the International Air Transport Association (IATA)
2010 Vietnam Airlines joined SkyTeam
Vietnam Airlines began operating both the Boeing 787-9 and the Airbus A350 at
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the same time
2016 Vietnam Airlines received a 4-Star Airline Certificate from
2019 The US Federal Aviation Administration (FAA) has granted Vietnam Category 1
status
Table 6: The development process of Vietnam Airlines in 2006-2019
3.3.2. Just Culture Policy and Documentation in Vietnam Airlines
Vietnam Airlines’ Just Culture Policy
For Vietnam Airlines, the safety culture is the most important portion in the
developing strategy of Safety Management System. At the beginning SMS setting up stage
on 2009, the Just Culture concept with Non-Punitive Reporting Policy has been applied
and documented in the Safety Management System Manual of Vietnam Airlines.
Vietnam Airlines thoroughly understand how safety policy important, as the policy
will reflect the organization‟s philosophy of safety management. Thus, the safety policy
has been invested to build and fulfill many times. Safety Policy 2009, Just Culture did not
to be written down exactly the word but Vietnam Airlines employees must to comply with
President & CEO in supporting the open sharing on al safety issues and encourage all
employees to report signification errors, safety hazards or concerns; not take discipline
action against any employee who disclose an incident or occurrence involving safety but
this not apply to information sources other than Vietnam Airlines employees or that
involve an illegal act or a deliberate, willful disregard of promulgated regulation or
procedure.
Safety Policy 2010, Safety Culture - Just Culture was written exactly the word in
the policy and still remaining until now. The policy changing from everybody “must to
comply with commitment” to “we commit ourselves to develop Safety Culture - Just
Culture”. That is quite big change from reactive to proactive way to build up Safety
Culture - Just Culture in Vietnam Airlines.
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Figure 5: Safety and Quality policy of Vietnam Airlines in 2009 and 2010
Recently, president & CEO for Just Culture is stated very clearly in 2016 safety-quality
policy “Develop Safety Culture - Just Culture, so that no disciplinary action shall be
applied to any employee who actively disclose an incident or safety occurrence. This
policy shall not be applied to information sources other than Vietnam Airlines employees
or that involve an illegal act or a deliberate, willful disregard of promulgated regulation or
procedure”
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Figure 6: Safety and Quality Policy of Vietnam Airlines in 2016
However, when going deeper these policies (year 2009, 2010 and 2016), the author
would see nothing change behind Just Culture word. Because the policies mention only
discipline or not discipline with the incident or safety occurrence, that depend on how they
report and that is human error or violation. Comparing to the definition of Just Culture by
James Reason (1997): “an atmosphere of trust in which people are encouraged, even
rewarded, for providing essential safety-related information - but in which they are also
clear about where the line must be drawn between acceptable and unacceptable
behavior”; or Sidney Dekker (2008): “a culture of trust, learning and accountability.” the
Safety culture - Just culture policies of Vietnam Airlines does not really update or reflect
the definitions above with the atmosphere of trust, encourage people even reward or
accountability.
Vietnam Airlines’ Just Culture Documentation
Vietnam Airlines approach Safety Culture is comprised of five components including
Reporting Culture, Just Culture, Informed Culture, Flexible Culture and Learning Culture
(James Reason 1997). Base on that approaching, the objective of a Just Culture in Vietnam
Airlines is to promote and encourage active, systematic and transparent reporting of safety
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occurrences, as well as full participation in safety investigation by adopted Non-Punitive
Reporting Policy.
The key to the establishment of a Just Culture in Vietnam Airlines lies in the definition and
implementation of appropriate safeguards which will ensure that individuals involved in
the safety investigation processes are not punished for their actions or omissions which
may have had an influence of the facts being investigated, except for cases of willful
misconduct or gross negligence.
From 2009 until now, Vietnam Airlines has defined four types of unsafe behaviours,
border of “unacceptable behaviour” and determining „culpability‟ on an individual case
basis (Base on A Roadmap to A Just Culture: Enhancing the Safety Environment – GAIN
2004).
Table 7: Acceptable & Unacceptable Behaviours
CEO of Vietnam Airlines – Mr. Duong Tri Thanh developed a Just Culture line based on
based on Job Br ggen Patrick Kools safety and justice navigation model 2016
Figure 7: The „Just Culture line‟
The „Just Culture line‟ is indicated as the balance between „blame-free culture‟ and
punitive culture (author derived based on Job Br ggen Patrick Kools safety and justice
40
navigation model 2016) in which, he admited the definition of a blame (punitive) culture
and a blame-free culture as the following
In a blame culture:
- Employee will not report safety-related information for fear of retribution;
- Lessons cannot be learnt and system improvement cannot be made.
In a blame-free culture:
- No accountability, employee lack responsibility for their behavior
Then he added Acceptable & Unacceptable Behavior connecting with Just Culture by
graph to finalise the model of Just Culture for Vietnam Airlines.
Figure 8: Just Culture of Vietnam Airlines
3.3.3. Vietnam Airlines Safety Improvement Indicators
Vietnam Airlines archive the safety amazed improvements in the safety within 9 years with
effective running Safety Management System. In the Figure 13, overall incidents rate
reduce from 30.61 (2010) to 10.84 per 10,000 flights (2018). For each area, the
maintenance incident rate reduce impressively from 23.91 (2010) to 5.15 per 10,000 flight
(2018); the ground operation incident rate reduce from 1.62 (2010) to 0.31 per 10,000
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flights (2018); the flight operation incident rate maintain around 5.08 (2010) to 5.38 (2018)
per 10,000 flights and the lowest number is 3.74 (2016) per 10,000 flights.
Figure 9: Vietnam Airlines incident rate 2010-2018 (incidents report to CAAV)
The Figure 9 is the evidence of the Safety Management System help Vietnam Airlines to
become much safer in operations. In other word, this is the Safety Culture maturity with
the existing time of Safety Management System inside Vietnam Airlines. That adapt with
the period with lot of changing in Vietnam Airlines with new modern aircraft types (A350,
B787, A321NEO) to operate, new technology in aviation (EFB, ADS-B, ROPS ...), new
requirements and regulations changing in Vietnam (FAA CAT1, RNP, RVSM, EDTO, ...),
new routes to operate, etc.
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Figure 10: IATA Operations Safety Audit Results of Vietnam Airlines
Figure 11: IATA Operations Safety Audit Certificate of Vietnam Airlines
Figure 10 and Figure 11 show the IATA Operation Safety Audit (IOSA) results of Vietnam
Airlines from IATA Audit Organizations. Although Vietnam Airlines archived IOSA
certificate from 2005, the turning point year 2009 is when Vietnam Airlines had Safety
Management System with the number of findings and observations decreased dramatically
in the next audit year 2011.
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Figure 12: Vietnam Airlines Safety Reporting Statistics
Figure 12 show the number of safety reports that safety management system received in 10
years periods. The maximum number is 3043 safety reports with 1118 reports insert in
database on year 2014. However, the trend is goes down quickly afterward, and the reason
corresponding to safety culture survey 2019, sometimes reporting goes „underground‟ with
reports to be hidden or buried intentionally in organization, and raising safety concerns
follow up with poor feedback, the problem with report tracking and low quality of internal
investigation program.
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Figure 13: Mandatory Occurrence Report to CAAV
Figure 13 shows the number of mandatory occurrence reports for incidents to CAAV: the
reports are always on time as required by CAAV, quick response to any request from
CAAV to make clear with reports, fulfil the report seriously with exact information, the
quality of report is high with the attached evidence and supporting documents.
In summary, Just Culture has been implemented in Vietnam Airlines and it has proved its
important role in improve safety culture in this organization. However, there is a lack of
the reward policy in Vietnam Airlines Just Culture as, all the documentation concentrate in
unsafe behaviors only. Although Vietnam Airlines apply the James Reason decision tree
for determining the culpability of unsafe acts but still meet the difficulty when making
clear between acceptable behaviours and unacceptable behaviours. Besides that, at the
current context there‟s difficulty when identify that is individual error/mistake or due to
system error/mistake to apply the disciplinary policy.
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CHAPTER IV: RESEARCH FINDINGS AND RECOMMENDATIONS FOR
VIETNAM AIRLINES
The first section of this chapter presents the outcome of the interview analysis, which
makes clear the current situation of Just Culture implementation in Vietnam Airlines.
Based on the data collected from interviewee, who are top managers and staffs working in
the Safety-Quality Department, a human factor training program is proposed with the aim
of enhancing the human awareness of Just Culture‟s role in an aviation organization.
4.1. Research finding - Current situation of applying a Just Culture in Vietnam
Airlines
4.1.1. Just Culture relating policies that put by Vietnam Airlines in encouraging
everyone to raise safety related issues
Top managers of Vietnam Airlines admitted that common errors that can be attributed to
unprofessional conduct include incompetence, negligence and sometimes malpractice.
These types of misconducts often result in injury to both the pilot and passengers. In some
cases, misconduct creates an unreasonable risk that a passenger or the pilot may be
harmed. Therefore, it is significant that reporting or making policies that encourage
everyone in the aviation industry to raise safety and report about safety issues should be
prioritized, subsequently the interviewee believes that Vietnam Airlines has hit that target
and the writer based on that information has a strong believe that he got an answer for the
question “How affective those Just-Culture-relating policies that put by Vietnam Airlines
in encouraging everyone to raise safety-related issues?”
Departments such as the air traffic control, pilots or vehicle drivers are legally bound to
report any occurrence or incident. Several task forces have been created within the aviation
industry. Most of these tasks forces have found out that punishing air traffic controllers and
pilots with fines or suspending their licenses might have led to a reduction in the reporting
of incidents and sharing of safety information. Different tasks forces have recognized the
need for an active culture that encourages honest reporting and one that has not yet been
reconciled with the legislative powers or the judicial system.
For this reason, the researcher has faith in the data presented in answer for the question of
“Did this recognize by everyone that small proportion of unsafe acts were indeed
intentional and reckless and warrant punishment, but that the large majority of such acts
are not intentional and should not attract punishment?” Most of Vietnam Airlines staffs
have a positive level of agreement and the majority of the interviewee are agreed with that.
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The CEO of Vietnam Airlines, Mr. Duong Tri Thanh has presented his idea of
building a Just Culture in his organization, in which the Just Culture line is indicated as the
balance between “blame-free culture” and punitive culture. As a Just Culture supports
learning from all safety events in order to improve the level of safety awareness through
improved recognition of safety situation and helps develop conscious articilation and
sharing of safety information. The shift from the traditional “Blame Culture” to a more
constructive “Just Culture” can be expected to have tangible benefits that will contribute
positively to the overall safety culture of an organization. Thus, all staffs in Vietnam
Airlines are encouraged to report all safety-related issues without caring of punishment.
In the survey in 2015 about Just Culture implimentation in Vietnam Airlines, 84.06
% responders did agree and strongly agree with “people are free to speak up about any
safety concern”. This show the huge improvement of environment to encourage everybody
can talk about safety and the positive effects from Just culture implementation in Vietnam
Airlines. Besides, 79.71 % responders did agree and strongly agree that they saw Vietnam
Airlines deal fairly with safety breaches. That is great number to prove the Just culture
program were implemented effectively and the employees feel fair and trustworthy in
Vietnam Airlines.
4.1.2. Vietnam Airlines has a safety reporting system that is clear confidential and
non-punitive
All interviewees confirmed that Vietnam Airlines has had a safety reporting system only
because it is required by law. This perception has been supported at the Risk Management
workshops where it was identified that safety reporting is primarily limited to occurrence
reporting required by CAAV mandatory reporting regulations. While other forms of pro‐
active safety system reporting (hazard reporting and confidential human factors reporting)
are documented in the airline‟s SMS Manual, these have not been effectively implemented
in the workplace.
The current Vietnam Airlines safety reporting process is cumbersome and that Operations
personnel may be more willing to report if the process was simplified by the
implementation of an electronic, web‐ based, lodgment system. Vietnam Airlines is a large
airline by industry standards, and typically other airlines only having a mandatory
occurrence reporting system in place. Thus, the airline can only react to events after they
have happened.
However, according to the Deputy Director of Safety-Quality Department of Vietnam
Airlines, there is quite low current number of reports across the organisation. He indicated
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that for each major accident, which involves fatalities, there are as many as several
hundred unreported incidents. Researchers have suggested that, if these incidents are
properly investigated, they might identify underlying problems on time and prevent future
incidents from taking place again. Lack of reported events does not necessarily indicate a
safe operation (Dekker, 2012). Likewise, increased reporting on events does not indicate a
decrease in the level of safety. Even reporting illuminates the potential safety concerns an
organization has. Increased reporting should be seen as a healthy, safety indicator
(Eurocontrol, 2006). In a strong safety culture, we would expect to see a high rate of
hazard reporting in addition to mandatory occurrence reporting that is required by law
under CAAV regulations. Otherwise, a system that is unclear could create distrurt in the
system, and the procedures to decide culpability must be clear and understood by all. Clear
definition of the roles and responsibilities of the people is required to implement and
maintain a Just Culture reporting system.
In additional to reporting, the researcher believes that another fundamental procedure to
lead to a Just Culture is to have a good data analysis and data management in place; to
obtain that also we should have a non-punitive and confidential environment that can free
and encourage everyone to report about safety issues. The interviewees have very clearly
responded to the question of “Did Vietnam Airlines has a safety reporting system that is
clear confidential and non-punitive?” and most of them positively agreed with the
reporting and data handling procedure in Vietnam Airlines.
In particular, the Safety-Quality Department (SQD) processes the reports. They evaluate
the occurrences, follow-up on open reports; disseminate occurrence information through a
range of publications; record reports in a database (names and addresses of individuals are
never recorded in the database); monitor incoming reports and store data to identify
hazards/potential hazards; and carry out searches and analyzes in response to requests
within the Vietnam Airlines and industry. Confidential reports are directed to and reviewed
by the Head of SQD, who initiates a dis-identified record. The Head of SQD contacts the
reporter to acknowledge receipt and to discuss further; after discussions the report is
destroyed; and the record is be processed as an occurrence, but annotated as confidential
(only accessible by restricted users).
4.1.3. Vietnam Airlines’ Just Culture implementation roadmap
The researcher in this section also derived some steps an organization can take to create a
Just Culture. Vietnam Airlines‟ Just Culture implementation roadmap can be simplified as
the following model:
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Figure 14: Vietnam Airlines‟ Just Culture implementation roadmap (author derived based
on interviewee‟s comment)
As such, with all aviation stakeholders have shown awareness of Just Culture and its
positive effects, Vietnam Airlines has moved forward with creating a framework on
development and implementation of Just Culture to be used organization-wide in Vietnam
Airlines, as assigned per the department‟s functionality.
Behavior definitions and implementation guide of Just Culture issued by the President &
CEO is attached to the Decision No. 205/QD-TCTHK-ATCL dated February 25, 2019
with scope of application in all activities of Vietnam Airlines; and subjects of application
are all Employees, Departments/Divisions of Vietnam Airlines.
In detail, Safety - Quality Department take the responsibility to:
- Updates the policies of the Definition into Safety Management System Manual;
- Periodically review and update the Definition set in accordance with the current
Safety Management activities of Vietnam Airlines;
- Monthly report to Safety Review Board about the results of behavior evaluation at
Departments/Divisions;
- Implementing the monitoring and supervision the deploying for application of the
Definitions at
All Departments/Divisions:
- Develop, update and implement internal regulations on behavior and behavior
evaluation to all Employees;
- Monthly report on implementation results to Safety Review Board Secretary
(Safety-Quality Department);
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- Request to revise the Definition.
And in implementation phase, the most important thing is all Departments/Divisions will
continue to update the safety positive behaviours and below expectation behaviours
examples in their own internal regulations on behavior and behavior evaluation. That
means all employees at all levels in Vietnam Airlines could learn, could be informed, and
safety habits could be changed with more positive safety behaviours in Just Culture
environment.
With the target Safety Culture archive level 4 Proactive in 2020 and Level 5 Generative in
2025; Vietnam Airlines will have a lot of difficulties and challenges. However, by
consistently applying Behaviour definitions and implementation guide of Just Culture that
will help Vietnam Airlines to success to deliver much safer flights to all passengers in the
future.
An interviewee said that “In the aviation industry, some of the first steps in developing a
Just Culture might include deciding on whether to have a voluntary or a mandatory
reporting system. The organization should put in place a team who will be tasked with the
responsibility of implementing a Just Culture. This team should comprise of the following
members: the safety and operations manager, human researcher manager, risk manager,
employees and the organization's stakeholders”. And the author further suggests that
Vietnam Airlines needs to involve anyone that wants to get involved voluntarily in creating
Just Culture or in safety issues as whole, then selected team should conduct further
investigations with the operational team. This will assist in making informed decisions on
how reports can be investigated further. It is very important for the team to decide on
which reports that will be further investigated. This will allow Vietnam Airlines to
organize the reports in an orderly manner.
According to the CEO of Vietnam Airlines, Mr. Duong Tri Thanh, potential obstacles to
achieve a Just Culture at Vietnam Airlines can be discovered:
1) Changes to the legal framework that support reporting of incidents: The
first step to be taken for consideration is the legal aspect of Just Culture. An
organization has to have in place a disciplinary framework that supports
reporting of incidents. This will significantly reduce any legal impediments to
reporting. The first significant step in changing the legal aspects may entail
substantiating the current legal situation and establishing whether it needs to be
changed. For Vietnam Airlines, one of the main challenges of developing a Just
50
Culture will be to change the legislation, especially because the changes are
counter to societal expectations.
2) Internal resistance: as one of the most senior and largest aviation organization
on Vietnam, Vietnam Airlines will experience difficulties persuading senior
management of the need for creating a Just Culture and to commit adequate
resources. The CEO of Vietnam Airlines also shared his acknowledgement of
potential resistance within Vietnam Airlines, furrther commenting that these
individuals also tend to be the “smart‟ one”
3) Choosing the right reporting system: Due to the low current number of reports
across the organization, Vietnam Airlines may need to survey the needs of
potential users to better understand which reporting method would be best
accepted. A system that is unclear could create distrust in the system, and the
procedures to decided culpability must be clear and understood by all.
4) Determining “champions”: this requires conscious and real commitment from
Vietnam Airlines‟s Management and staff, as having sufficient resources and
having the right people – who are well liked, well known and respected in the
company – may prove to be difficult.
5) Designing the perfect reporting form: Each organization has their own way to
collect information. Reporting forms may be standardized among other airlines
may not the best fit for Vietnam Airlines. It is important that reporting forms are
kept simple, but will enough detail that useful analyzis can be applied.
6) Educating the users with regard to the changes and motives of the new
system: every employee must be trained sufficiently on the reporting scheme
and how to submit a report. This maybe difficult in a large organization with
many subsidiaries like Vietnam Airlines, where information about the system
may not be discriminated to a wide enough audience and a deep enough level
within the organization
7) Methods for developing and maintaining a Just Culture: Since trust between
employees and managers must genuinely exist for reporting system to work, Just
Culture must be open and people must feel able to trust the system. It takes time
and persistence to try and change safety attitudes, and maintaining motivation
throughout the organization can be a challeges. CEO of Vietnam Airlines has
already projected this to be a 10 year endeavour, not a short term issue.
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A Just Culture is necessary for an organization to effectively monitor the safety of its
system both by understanding the effects of normal human error on the system and by
demonstrating its resolve to enforce individual operator responsibility. This responsibility
includes adherence to safety regulations as well as reporting inadvertent errors that can
alert an organization to latent safety dangers. Operating with a Just Culture will create
conditions conducive to reporting and collaborative decision-making regarding policy and
procedural changes. To adjust these potential obstacles and follow the roadmap of Just
Culture implementation, the researcher thinks that a human factor training classes at
aviation organisations is a very clear answer for the question whether the aviation
management has tried to educate their staff despite of their stages about the idea of Just
Culture and how this affect the safety.
4.2. Recommendations for Vietnam Airlines: A human factor training program
4.2.1. The necessity to establish a human factor training program
Currently, organizations within the aviation industry have realized the importance of
educating employees about human factors and Just Culture. It helps professionals in the
process of understanding and accepting the ubiquity of human error and the fact that the
industry is continuously surrounded by risks. Studies also suggested that lack of an
understanding on human errors and risks lowers organizational overall growth. Hence, Just
Culture prepares professionals in understanding and appropriately responding to outcomes
and events that may be unexpected. Education and training in Just Culture should become
mandatory in all disciplines in aviation education. The knowledge and application of Just
Culture principle may soon become one of the most important building blocks for the
aviation industry.
Air operators may significantly benefit from effective human factors training
provided to all personnel and management by increasing the awareness of the effects and
potential risks of human factors; developing measures to decrease or eliminate the effects
and potential risks of human factors; promoting a just and reporting culture; improving
human performance and also procedures.
Human factor training brings safety issues close to the individual and then improve
the attitudes and behavior of airlines staff and managers towards safety. Consequently, it
influences the perceptions of those people in the safety culture within their team and
organization. By attending human factors training, top management shows commitment to
safety to their employees.
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Not only improving safety culture, human factors training may also increase the
airlines‟ competitiveness when customers are informed that human factors training is
incorporated in the training structure to increase the level of safety and efficiency of the
services provided.
Through daily activities, airlines staff gain knowledge and awareness of human
factors. This knowledge will significantly benefit from the successfully built Just Culture,
in which potential safety issues and their causes are reported openly. With this knowledge,
solutions are made to focus on suppressing potential errors as much as possible. Whereas,
human factors training raises the importance of feedback to improve system safety, which
promotes a just and reporting culture.
As human factors training aims to detect and recover human errors to increase safety,
each air operator should fit the human factors training to their size, needs, local
circumstances and resources available, putting into existing safety programs or starting
new programs.
This section provides recommendations in initial steps to set up a human factor
training program, together with its proposed contents and described by applying existing
human factors knowledge to the operation and maintenance process. The next section
describes general guidelines for establishing a human factor training program. The later
one provides several suggestions for the human factors training contents.
Recommendations regarding to human factors training and its contents are provided in the
last section.
4.2.2. Guidelines for establishing a human factor training program
Stages to implement human factors training for aviation maintenance organizations
could be found in Civil Aviation Publication (CAP) 716, which is often used as the root to
develop the following steps for implementation of human factors training in air service
providers:
1) Redefine safety policies, procedures, roles and responsibilities;
2) Educate and train personnel responsible for the establishment and provision of
human factors training;
3) Establish a human factor training program, including:
a. Training objectives;
b. Definition of target groups;
c. Training schedules (initial/recurrent);
d. Competency check;
53
e. Means of evaluation;
f. Supporting structure (e.g. safety reporting system);
g. Training needs analysis;
4) Decide if training is provided by the air operator themselves, or by an external
training organization;
5) Develop training material;
6) Provide initial and recurrent training or maintain awareness of human factors;
7) Evaluate training contents and instructors;
8) Update and improve the human factors training by:
a. Using the evaluation forms;
b. Incorporating reported safety occurrences;
c. Keeping instructors up-to-dated with human factors information.
The success of human factors training depends on its relevance to the day-by-day
activities of those who received the training. Therefore, human factors training has to be
tailored to various target groups in the organization. Interaction between the instructors and
training participants is also quite important to spread out the human factor knowledge, in
which the discussions on operational examples during the training are quite useful.
The root idea of Just Culture is the recognition that origin of errors may be attributed
to organizational factors or management decisions. Therefore, tailored human factors
training should also be provided to management to create awareness of human factors that
staff experience in their daily activities, and how management decisions may adversely
affect the working situation on the aircraft or maintenance field. Also, human factors
awareness training may be complemented with training about how to cope with specific
human factors.
In order to tailor human factors training to various target groups within the
organization, it is very important to carefully conduct a training needs analysis at various
levels of the organization. The need analysis could be gathered by taking several steps as
follow: Identify organization objectives (1); Identify potential problems in performance
(2); Identify specific concerns about current performance (3); Identify training needs (4);
Analyze training needs (5); Set training objectives (6); Complete training program (7).
Due to organizational differences, air operators should decide on the training
contents and the expected level of competency for the various target groups, which are in
various levels of education, employment (permanent/temporary), interest and motivation.
4.2.3. Suggestions for human factors training contents
54
In the training needs analysis, it is necessary to pay attention to the frequency of
occurrence of specific human factors in the operation and maintenance process. It varies
quite different from one operator to other operators. Some human factors may occur
frequently, requiring appropriate attention in training, whereas other human factors are
seldom or even never encountered. However, the seldom or never encountered human
factors still could not be ignored, it still need to be repeatedly revised and concern through
time.
Personal factors and communication are the most frequently reported human factors
involved in incidents and accidents related to the operation and maintenance process. The
collective term of personal factors could be specified in decreasing order of reported
frequency: Time pressure; Stress; Fatigue; Peer pressure; Motivation; Complacency;
Distractions/interruptions; Personal event; Physical condition; Memory lapse.
ICAO Doc 9806 also pointed out that these human factors, as well as communication
and several other human factors considered relevant to the operation. ICAO Doc 9806
groups the common factors affecting human performance and work efficiency as: Human
factors deriving from the individual; Human factors affecting individuals‟ interactions with
others; Human factors relating to the workplace. In making the distinction among various
human factors, measures to mitigate the effects of human factors in the operational
environment can be focused.
1. Human factors deriving from the individual
Irrespective of the nature of the activities to be conducted, human performance
differs by individual and may be affected by the following list of human factors: Physical
characteristics; Physical fitness; Automated behavior; Complacency; Alertness; Stress;
Body rhythm disturbance; Sleep; Fatigue; Motivation; Personal events; Personality and
attitudes. All airlines staff have to deal with these human factors to some extent during
their daily activities.
Physical characteristics:
Physical characteristics like body size, length, reach, strength, eyesight, and hearing
are important factors to consider in the working process as they may help or hinder airlines
staff when working in the confined spaces of the aircraft (cockpit, aisle, belly or cargo
holds) or dangerous situations.
Physical fitness
Airlines staff with adequate physical characteristics to perform their activities will
still benefit when they arrive physically fit at work. Improved fitness reduces tension and
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anxiety and it is considered that it increases the resistance to fatigue, which is an important
human factor to consider in the operation and maintenance process, especially during shift
work.
Automated behavior
When certain tasks are repeated frequently, performance of these tasks may easily
become an automated routine for which less or no attention is required. Most of the tasks
performed by airlines staff are repetitive tasks and therefore prone to become automated
behavior. However, airlines staff have to deal with different aircraft types, configurations,
procedures and equipment. This increases the risk that automated behavior is incorrectly
applied, with potential hazardous conditions as a result. Since time pressure and stress are
the most frequently reported human factors by airlines staff, attention for automated
behavior must not be neglected.
Complacency
Automated behavior may also relate to complacency. When airlines staff are over-
confident that they are perfectly able to perform a certain task, their alertness may decrease
and the actual performance of the task may become an automated process. Especially in
the masculine culture of ramp workers, characteristics like overconfidence and arrogance
could lead to complacency.
Alertness
Although automated behavior may speed up the working process, it also creates a
risk when deviations from the routine processes are introduced. Deviations or new risks
may not be detected since tasks are performed automatically. It therefore decreases the
alertness to deviations from the routine or to new risks. Boredom has a similar effect on the
alertness of personnel, for example when airlines staff have to wait for equipment or the
next aircraft to arrive. Closely related to alertness is the ability to detect and perceive input
from the five senses. This ability decreases with a rising level of stress, noise, time
pressure, boredom and fatigue, most of which are ever present in the process of operation
and maintenance. A reduction in alertness may lead to memory lapses, which may result in
omissions of certain procedures or process steps. There are examples in which airlines staff
forget to disconnect the external power connection before driving away, forget to retract
protection rails while attaching loading equipment, forget to close doors and panels after
servicing, etc.
Stress
56
Stress may have positive or negative effects on human performance. Positive effects
are beneficial for the operations, since it speeds up the working process, but negative
effects may create risks to airlines staff and to the aircraft and its occupants. Negative
effects are caused by various stressors which are experienced during the operation and
maintenance process; the most important being time pressure. Other stressors are for
example staff shortage, weather conditions, noise and temperature. Training and
experience may help to effectively deal with these stressors. Each individual staff may also
be negatively affected by personal stressors. Potential personal stressors are, among others,
fatigue, workload or conflicts. The supervisor or team leader, as well as fellow team
members, should be attentive to the existence of such stressors in individual staff.
Body rhythm disturbance
In the operation and maintenance process, shift work introduces disturbances of the
body rhythm of all airlines staff. Additionally, the rotation of shifts over time may differ,
depending on the concept that has been adopted: an advanced (afternoon-morning-night) or
delayed (morning-afternoon-night) rotation. Either way, the body rhythm is continuously
forced to adapt itself to the new working schedule with variations in human performance as
result.
Sleep
In shift work, the sleep pattern is the most important factor that has to be changed,
which results in a decrease in quality and quantity of sleep. Disturbances in sleep patterns
may reduce the alertness during the working period which, again, may temporarily be
increased by the use of stimulating substances. However, these substances have a negative
effect on the ability to receive adequate (both in quantity and quality) sleep in between
shifts. When the loss of sleep quality and quantity is not compensated by adequate sleep,
permanent and severe disturbance of the sleep pattern may result. Moreover, it may cause
chronic fatigue and behavioral changes, like persistent anxiety or depression.
Fatigue
Fatigue can be divided into acute, chronic and mental fatigue. Acute fatigue
manifests after performing a series of heavy or demanding tasks, like loading of loose
baggage. Acute fatigue results in chronic fatigue when consistently insufficient rest is
taken between the demanding tasks. Mental fatigue results from emotional stress. When
these kinds of fatigue are not recognized and no corrective measures are taken, they may
result in a decrease in human performance and work efficiency. Similar as stress, fatigue is
aggravated by time pressure, insufficient staff and weather conditions.
57
Motivation
In order to get the best performance of airlines staff, they have to be motivated to
perform the job in a safe and efficient manner. The primary means to increase the
motivation of airlines staff is management continuously propagating their commitment to
safety.
An improved motivation may also be obtained by rewarding airlines staff for good
performance. Rewards may take the form of promotions, awards, mentioning the best
performing team, etc. On the other hand, motivation may decrease due to e.g. consistent
boredom, disciplinary actions or the perception that airlines staff are treated unfair or
unequal in the organization.
Personal events
Personal events have a small or greater influence on the performance of airlines staff.
For example, the death of a family member, martial difficulties or worries about one‟s
health may have a severe impact on physical fitness, alertness, stress perception, sleep,
fatigue and motivation.
Personality and attitudes
Airlines staff are comprised of individuals from different cultural and ethnic
backgrounds, with different personalities and attitudes. Instead of other human factors,
these individual traits are more or less stable and may be accounted for by fellow ramp
workers. However, personal traits may also be resistant to change when needed to improve
for example work performance or behavior.
Next to the fact that all airlines staff have to deal with personal traits of themselves
and fellow ramp workers, permanent staff is working together with temporary staff, who
may have different attitudes with regard to the work and the organization. Effort is needed
from supervisors to make them perform as a team in which these differences do not create
a risk to themselves or to the flight operations. In order to adequately cope with different
personalities and attitudes, interpersonal factors have to be considered.
2. Human factors affecting individuals‟ interactions with others
Due to the various activities to be executed during a specific task in a restricted space
and short time limit, the interpersonal cooperation is essential for a safe and efficient
operation. The “operation and maintenance” is a process in which individuals of different
cultures, specialism and backgrounds have to work as a team and various interactions are
to be made (flight crew members and persons on fueling, catering, ramp coordinator…).
Therefore, adequate attention for interpersonal factors is beneficial to increase work
58
efficiency, to operate as a team, and thereby to increase the level of safety in operation.
Few air operators, however, employ teams that consist out of a fixed composition of staff.
Interpersonal factors could be addressed by several aspects: Team performance (job
design, reward systems, selection and staffing, training); Information processing;
Communication; Peer pressure; Leadership; Coordination; Human Resource Management.
Team performance
If correctly applied, the team concept increases team performance, resulting in a safe
and efficient service. When performance is only monitored at the individual level, this may
lead to well-performing airlines staff adopting an indifferent attitude when ill-performing
airlines staff in their team continuously keep down the actual team performance.
Competition may be an additional motivator to increase team performance and team
pride. Communicating for example the number of on-time-departures, damages or injuries
may increase the team effort to increase their performance and safety awareness. However,
this motivator has to be carefully applied, since a team effort to reach the highest number
of on-time-departures may lead to cutting corners, which threaten to the safety of operation
and maintenance.
Information processing
A formal way of information processing is by means of documentation in which, for
example, procedures are described or safety information is shared. Within Air operator,
documentation has to be tailored to the personnel working in the organization. For
example, training documentation and safety information have to be easily accessible, easy
to read and easy to understand. It may be necessary to involve airlines staff in the
development, compilation and distribution of safety information throughout the
organization.
When teams and team members share the knowledge about the task that has to be
performed, they have a common goal and a common understanding of what is required to
perform the task. Therefore, less information and communication is necessary, since all
team members know what is expected from them. A common understanding that team
work is required to reach the common goal makes the team both effective and efficient.
Knowing how to operate as a team ensures that activities are performed by team members
with the required expertise and backup is provided when necessary. Finally, shared
attitudes and believes lead to effective decisions and increase motivation.
Communication
59
Adequate communication involves the person who intends to pass on a message, the
means of communication (speech, hand signals) and the person(s) who need(s) to receive
and understand the message. The quality of communications may be affected by:Unclear
or ambiguous contents; Background noises or distortions; Misinterpretations; Different
expectations; Impaired hearing/speaking ability; Non-native tongue. These factors are
mitigated by using standard means of communication, like standardized hand signals or
standard phraseology, and by verifying if messages are correctly understood.
Peer pressure
Working in teams introduces the risk that peer pressure is experienced during the
operation and maintenance process. Especially in the masculine culture of airlines staff, it
may be difficult for ramp workers to speak up when unsafe activities are detected or
procedures are not followed. Team pride may also lead to actions that otherwise would be
considered as unsafe.
Next to peer pressure during the operation and maintenance process, peer pressure
may also be experienced before and after the normal shift. Airlines staff may not report ill
because they feel pressure to go to work since they feel that the team is counting on his or
her presence. Similar pressure may be felt when the work is continued after the normal
shift has ended, although team members are extremely fatigued.
To counteract the negative effects of peer pressure, it is extremely important to
establish a mature safety culture within the organization, which disseminates to the teams
and finally becomes an intrinsic team value.
Leadership
A leader is a person whose ideas and actions influence the attitudes and behavior of
others. Since operation and maintenance is performed in teams, the role of the supervisor is
extremely important to manage the team in order to perform the activities in the most safe,
effective and efficient way. Especially when working with teams which are composed of
different cultural and ethnic backgrounds and education, the supervisor faces various
challenges which have to be managed.
The leadership role (authority) of the supervisor may be assigned by the management
of the organization, but in order to be most effective, this kind of leadership by authority
must be complemented by the kind of leadership that has been earned from the team. When
the appropriate leadership role is acquired, a supervisor becomes a valuable asset who is
able to shape and improve the safety culture within the team. Leaders/supervisors have to
be alert on factors that may increase the risk of human errors (e.g. weather, fatigue, stress,
60
equipment). These factors may also affect the attitude and motivation of airlines staff
regarding their activities.
Coordination
Whereas crew coordination has a long history in flight crew training, several aspects
can also be applied to airlines staff in order to detect and correct individual errors and to
use all available resources in the most efficient way.
During stressful periods, coordination amongst team members may decrease, which
may result in communication breakdowns, errors, a lower probability of correcting errors,
and conflicts between team members. In maintaining coordination, the role of the
supervisor is extremely important. The supervisor needs to have open eyes and ears to
sense a breakdown of coordination, and act adequately to re-establish coordination within
the team, for example to spread the workload. Next to coordination within, and between
teams, some airports have appointed a supervisor to coordinate all organizations involved
in the operation and maintenance process during the actual turnaround. This requires
additional skills and a different authority, since several teams with different objectives
perform their activities within the confined space of the ramp in the (usually) short
timeframe available.
3. Human factors relating to the workplace
The workplace and working conditions of airlines staff may also introduce several
human factors that create risks to the flight and even their own safety. Workplace factors
could be addressed by: Workstation design; Workload and Workplace distractions and
interruptions.
Workstation design
As stated before, airlines staff have to deal with different equipment, different types
of the same equipment, different airline procedures, different aircraft configurations, and
different systems in aircraft of the same configuration. Therefore, airlines staff should
adequately be trained to be alert on the differences that may be encountered. Procedures
and equipment should be standardized as much as possible to decrease the risk of errors in
operating the equipment or aircraft systems. Ideally, procedures, systems and equipment
should be designed taking into account human factors principles.
Workload
Due to the focus on the scheduled departure time of aircraft, there is always time
pressure involved in aircraft operation and maintenance. The required activities have to be
performed within a limited timeframe and any disruption in the process increases the
61
workload that is experienced. Airlines staff have to take care that their capacity is not
exceeded. Should this occur, unsafe conditions are potentially ignored or shortcuts are
taken.
Scheduling of airlines staff should be sufficiently flexible to decrease the workload
during peak hours and to compensate for times when no operation and maintenance
activities can be performed. Otherwise, risks of boredom, fatigue and loss of motivation
are introduced. It is noticed that this describes an ideal situation in which sufficient
resources are available. As a practical measure to manage workload, manpower schedules
may be developed proactively, taking into account historical data of actual aircraft arrival
times. This way, standard delays are incorporated in the schedules, making them more
efficient.
Workplace distractions and interruptions
Workplace distractions and interruptions may cause a loss of awareness of what is
happening or may cause a shift or loss of alertness. This, in turn, may cause airlines staff to
forget to perform certain procedures or process steps. Even worse, distractions during
operation and maintenance may result in severe damages or injuries.
4.2.4. Recommendations
Based on the suggestions for human factors training contents as provided, with
regards to the size, needs, local circumstances of Vietnamese aviation industry and
resources available Vietnam Airlines should consider the following recommendations
regarding to human factors training:
Establish a human factor training program tailored to the various target groups
(flight crew, cabin crew, engineers, ramp workers…);
Incorporate human factors training in already established safety initiatives and
training programs;
Establish obligatory rule to carry out regular medical checks for physical fitness
for employees in all positions (particularly eyesight and hearing);
Standardize the procedures, equipment and communication toward safety goal;
Build up good relationship in workplace so that employees can share their
personal events which might affect work performance.
Introduce human factors aspects in scheduling of both flight crew and cabin crew;
Establish a rewarding system for good and safe team performance;
Establish an official way to regularly communicate work-related issues;
62
Provide sufficient time/overlap for shift handovers;
Include team aspects (e.g. group decision making, interpersonal skills) in human
factors training;
Establish a mature safety culture which disseminates to the teams;
Provide leadership courses to supervisors;
Establish a code of conduct to respectfully approach colleagues of different
cultural or ethnic backgrounds;
Use historical data (actual aircraft departure/arrival time) in scheduling of pilots
and pursers.
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CONCLUSION
1. Summary
In summary, this research project has discussed some of the ways in which the top-
down nature of safety management systems may be used to create a Just Culture within
organizations in the aviation industry. Research data gathered in this paper has considered
several aspects of a safety culture in aviation management. The research has also suggested
some of the strategies for a Just Culture that can be designed and implemented. In the
aviation industry, safety is regarded as the reduction of overall risk levels. Organizations in
the aviation industry aim at having the lowest levels of risk.
In this research paper, Just Culture is a new development in management theory
especially in corporate workplaces. In the past, workplaces operated under the mutual
understanding that employees will not inform or report to authorities, as well as,
management about situations and conditions that required improvement. This research
paper has showed that, in some cases, these conditions and situations may be irritating to
workers. However, in other cases, these conditions at the workplace may be actively
dangerous to employees and the public. Reporting of errors will ensure that they are
addressed accordingly and prevented from taking place in the future.
The researcher has used a semi-structured interview approval by Vietnam Airlines top
managers and tried to analyze those data to go deep inside the Just Culture and its
characteristics; and use the answers of Vietnam Airlines particpipants as fundamental
materials for discussions and findings.
2. Limitations and Direction for further researches
This study has been investigated under tight control; however, it still has some
limitations need to adjusted in the further research. Firstly, there is a lack of previous
researches on this subject in Vietnam. The reason is that Just Culture is rapidly emerging in
aviation organizations; hence, it is quite new topic for researchers. While the studies about
the Just Culture in other Western countries are not really well adopted in the Vietnam
aviation context. Secondly, this study has some limits in which the findings can be apply.
Given that, purposive sample technique was utilised for collecting survey sampling in this
study some bias may be present in the research results. As the author and most of his
acquaintances are come from Hanoi – the North of Vietnam, 90% of interview participants
are from Hanoi or the immediate surrounding districts. Recognising the culture differences
64
internationally or even within this country, the finding maybe only appropriate for only the
North of Vietnam rather than the South of Vietnam or other parts of the world.
Based on the research finding and above limitations, some recommendations for
further research are raised. Firstly, the limit about the sample could be solved by applying
mixed technique. As qualitative data collection methods such as interview or group focus
requires a small number of participants, the author is possible of choosing equal participant
groups between region. Qualitative data collection also effectively help author to
understand participant insight more precisely and comprehensively. While quantitative
techique with questionaire study could help author to collect a large sample in a scale of
the whole organization. Thus, future research could be undertaken with quantitative
methods or mixed method to measure the success of a Just Culture program under the view
of all organization staffs. Secondly, as this research confirms the role of Just Cuture in
enhancing safety culture in an aviation industry, future research is proposed to focus on
how Vietnam Airlines educates their staff about Just Culture and how effective is human
factor training program in building a strong Just Culture in such a big aviation
organization.
65
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APPENDIX 1: INTERVIEW SCHEDULE
1. Thank the interviewee for participating.
2. Introduce the author and the project. Answer any questions they may have prior to
interview.
3. Ask for permission to record. Emphasize the anonymous nature of research. Remind
they can stop and withdraw at any time.
4. General questions
- Tell me about when you started your job at Vietnam Airlines and how it has grown
to date.
- To which extent you would know about Just Culture?
- To which extent you classify Vietnam Airlines as a good Just-Culture business?
If you class your business as a good Just-Culture business, to which extent your -
business can maintain and strengthen Just Culture?
5. In-depth questions
Policies encourage people to o raise safety-related issues
1) How affective those Just-Culture-relating policies that put by Vietnam Airlines in
encouraging everyone to raise safety-related issues?
2) Have these been recognized by everyone that small proportion of unsafe acts were
indeed intentional and reckless and warrant punishment, but that the large majority
of such acts are not intentional and should not attract punishment?
A confidential and non-punitive safety reporting system
3) Did Vietnam Airlines have a safety reporting system that is clear confidential and
non-punitive?
4) Which departments take responsibility to handle these reports? Indicate clearly the
process to handle these reports?
A Just-culture implementation roadmap
5) Did Vietnam Airlines have a clear roadmap to implement and maintain Just Culture
in the long term? If have, please introduce Vietnam Airlines roadmap to implement
Just-Culture
6) Defined potential obstacles to achieve a Just Culture at Vietnam Airlines
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APPENDIX 2: INTERVIEW TRANSCRIPT
1. Thank them for participation.
2. Introduce yourself and the project. Answer any questions they may have prior to
interview.
3. Ask for permission to record. Emphasize the anonymous nature of research. Remind
they can stop and withdraw at any time.
4. General questions:
- Tell me about when you started your job at Vietnam Airlines and how it has grown
to date.
I worked as a member of human resource department at Vietnam Airlines 10 years ago and
now I am among the top management of Safety - Quality Department.
- To which extent you would know about Just Culture?
A “Just Culture” refers to a way of safety thinking that promotes a questioning attitude, is
resistant to complacency, is committed to excellence, and fosters both personal
accountability and corporate self-regulation in safety matters.
In my opinion, Just Culture is very important to build a strong aviation business in a long
term because as a Just Culture supports learning from all safety events in order to improve
the level of safety awareness through improved recognition of safety situation and helps
develop conscious articilation and sharing of safety
- To which extent you classify Vietnam Airlines as a good Just-Culture business?
The CEO of Vietnam Airlines, Mr. Duong Tri Thanh has presented his idea of building a
Just Culture in his organization, in which the Just Culture line is indicated as the balance
between “blame-free culture” and punitive culture. Behaviour definitions and
implementation guide of Just Culture issued by the President & CEO is attached to the
Decision No. 205/QD-TCTHK-ATCL dated February 25, 2019 with scope of application
in all activities of Vietnam Airlines; and subjects of application are all Employees,
Departments/Divisions of Vietnam Airlines.
We have also built a road map to implement and maintain Just Culture, which require the
participation of all departments in the company. So I think we are on the way to become a
good Just-Culture business.
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5. In-depth questions
Policies encourage people to raise safety-related issues
1) How affective those Just-Culture-relating policies that put by Vietnam Airlines in
encouraging everyone to raise safety-related issues?”
It is significant that reporting or making policies that encourage everyone in the aviation
industry to raise safety and report about safety issues should be prioritized. Thus, I believe
that Just-Culture-relating policies that put by Vietnam Airlines in encouraging everyone to
raise safety-related issues
2) Did this recognize by everyone that small proportion of unsafe acts were indeed
intentional and reckless and warrant punishment, but that the large majority of such
acts are not intentional and should not attract punishment?
Departments such as the air traffic control, pilots or vehicle drivers are legally bound to
report any occurrence or incident. Several task forces have been created within the aviation
industry. Most of these tasks forces have found out that punishing air traffic controllers and
pilots with fines or suspending their licenses might have led to a reduction in the reporting
of incidents and sharing of safety information. Different tasks forces have recognized the
need for an active culture that encourages honest reporting and one that has not yet been
reconciled with the legislative powers or the judicial system. Thus, the CEO of Vietnam
Airlines, Mr. Duong Tri Thanh has presented his idea of building a Just Culture in his
organization, in which the Just Culture line is indicated as the balance between “blame-free
culture” and punitive culture. The shift from the traditional “Blame Culture” to a more
constructive “Just Culture” can be expected to have tangible benefits that will contribute
positively to the overall safety culture of an organization
A confidential and non-punitive safety reporting system
3) Did Vietnam Airlines have a safety reporting system that is clear confidential and non-
punitive?
Vietnam Airlines has had a safety reporting system only because it is required by law. The
current Vietnam Airlines safety reporting process is cumbersome and that Operations
personnel may be more willing to report if the process was simplified by the
implementation of an electronic, web‐ based, lodgment system.
4) Which departments take responsibility to handle these reports? Indicate clearly the
process to handle these reports?
74
Safety-Quality Department of Vietnam Airlines take responsibility to handle these reports.
They evaluate the occurrences, follow-up on open reports; disseminate occurrence
information through a range of publications; record reports in a database (names and
addresses of individuals are never recorded in the database); monitor incoming reports and
store data to identify hazards/potential hazards; and carry out searches and analyzes in
response to requests within the Vietnam Airlines and industry. Confidential reports are
directed to and reviewed by the Head of SQD, who initiates a dis-identified record. The
Head of SQD contacts the reporter to acknowledge receipt and to discuss further; after
discussions the report is destroyed; and the record is be processed as an occurrence, but
annotated as confidential (only accessible by restricted users).
A Just-culture implementation roadmap
5) Did Vietnam Airlines have a clear roadmap to implement and maintain Just Culture in
the long term? If have, please introduce Vietnam Airlines roadmap to implement Just-
Culture
Vietnam Airlines‟ Just Culture implementation roadmap can be simplified as the five-
phase circle process.
- Phase 1: Effects of Just Culture implemented
- Phase 2: Analytics of results & review of Just Culture definitions and evaluation
procerdure
- Phase 3: Clearly defined Just Culture definitions and expectations
- Phase 4: Clearly defined Just Culture Implementation procedure
- Phase 5: Implemenation phase
6) Potential obstacles to achieve a Just Culture at Vietnam Airlines can be discovered:
- Changes to the legal framework that support reporting of incidents: For
Vietnam Airlines, one of the main challenges of developing a Just Culture will be
to change the legislation, especially because the changes are counter to societal
expectations.
- Internal resistance: as one of the most senior and largest aviation organization
on Vietnam, Vietnam Airlines will experience difficulties persuading senior
management of the need for creating a Just Culture and to commit adequate
resources.
- Choosing the right reporting system: Due to the low current number of reports
across the organization, Vietnam Airlines may need to survey the needs of
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potential users to better understand which reporting method would be best
accepted.
- Determining “champions”: this requires conscious and real commitment from
Vietnam Airlines‟s Management and staff, as having sufficient resources and
having the right people who are well liked, well known and respected in the
company may prove to be difficult.
- Designing the perfect reporting form: Reporting forms may be standardized
among other airlines may not the best fit for Vietnam Airlines.
- Educating the users with regard to the changes and motives of the new
system: This maybe difficult in a large organization with many subsidiaries like
Vietnam Airlines, where information about the system may not be discriminated
to a wide enough audience and a deep enough level within the organization
- Methods for developing and maintaining a Just Culture: It takes time and
persistence to try and change safety attitudes, and maintaining motivation
throughout the organization can be a challeges. CEO of Vietnam Airlines has
already projected this to be a 10 year endeavour, not a short term issue.
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