Luận văn Thạc sĩ Quản trị kinh doanh: Just culture practice in the aviation industry - Recommendations for Vietnam airlines

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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.

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Nội dung Text: Luận văn Thạc sĩ Quản trị kinh doanh: Just culture practice in the aviation industry - Recommendations for Vietnam airlines

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 acts Figure 4 Thematic analysis‟s stages 25 Figure 5 Safety and Quality policy of Vietnam Airlines in 2009 and 2010 38 Figure 6 Safety and Quality Policy of Vietnam Airlines in 2016 39 Figure 7 The „Just Culture line‟ 40 Figure 8 Just Culture of Vietnam Airlines 41 Figure 9 Vietnam Airlines incident rate 2010-2018 42 Figure 10 IATA Operations Safety Audit Results of Vietnam Airlines 43 Figure 11 IATA Operations Safety Audit Certificate of Vietnam Airlines 43 Figure 12 Vietnam Airlines Safety Reporting Statistics 44 Figure 13 Mandatory Occurrence Report to CAAV 45 Figure 14 Vietnam Airlines‟ Just Culture implementation roadmap 49
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) Table 3 Different types of interview (adopted from Sauders et al.2011) 23 Table 4 Steps to build a Just Culture Reporting System 33 Table 5 Main ideas to develop and maintain a Just Culture 35 Table 6 The development process of Vietnam Airlines in 2006-2019 38 Table 7 Acceptable & Unacceptable Behaviours 41
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. 1
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 2
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. 3
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 4
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. 5
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). 6
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. 7
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). 8
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 9
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 10
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. 11
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. 12
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 13