Luận văn just culture practice in the aviation industry recommendations for vietnam airlines

KIHIØA QUẦN TRỊ VÀ KINH DOANTT NGUYEN HAI ANE JUST CULTURE PRACTICE IN THE AVIATION INDUSTRY: RECOMMENDATIONS FOR VIETNAM AIRLINES THỰC HIỆN VĂN HOÁ CHÍNH TRỰC TRONG NGẢNH HÀNG| KHÔN

ĐẠI HỌC QUỐC GIÁ HÀ NỘC

KIHIØA QUẦN TRỊ VÀ KINH DOANTT

NGUYEN HAI ANE

JUST CULTURE PRACTICE IN THE AVIATION INDUSTRY:

RECOMMENDATIONS FOR VIETNAM AIRLINES

THỰC HIỆN VĂN HOÁ CHÍNH TRỰC TRONG NGẢNH HÀNG|

KHÔNG: MỘT SỐ GỢI Ý CHO HÃNG HÀNG KHÔNG QUỐC

GIÁ VIETNAM ATRLINES

LUẬN VĂN THẠC SĨ QUẦN TRI KINII DOANII

THẠI HỌC QUỐC GIÁ HÀ NỘI

KHOA QUAN TRI VA KINIT DOANTE

NGUYEN HAI ANH

Just culture practice in the aviatiun industry: recommendations [or|

vietnam airlines

THIUC HIEN VAN HOA CHINH TRUC TRONG NGANH HANG

KHÔNG: MỘT SỐ GOT Y CHO HANG HANG KHONG QUOC

GIA VIETNAM AIRLINES

Chuyên ngành: Quản trị kinh doanh

Mã số: H340101.01

LUAN VAN TIIAC SI QUAN TRI KINII DOANIL

NGƯỜI HƯỚNG DẪN KHOA HỌC: PGS.TS NGUYÊN NGỌC THẲNG

IIA NOI - 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.

6, Structure of the thesis "—

CHAPTER I: THEORETICAL BACKGROUND -. - 552cc cccnntriierrriiie

Safety culture deñinition

A Just Culture definition

Benefits of Just Culture

Distinguish acceptable and unacceptable behaviors

Just Culture đeeision tree

Creating and implementing Just Culture

R II: METHODOLOGY

Research approach

Interview implementation

Method of analysis Research ethics

History of Just Culture in the world aviation industry

Just Culture Practice in the world aviation

3.3.1 Vietnam Aùlincsimwoduetion 35 3.3.2 Just Culture Policy and Documentation in Vietnam Airlines .37 3.3.3 Vietnam Airlines Safety Improvement lndicalors el CHAPTER IV: RESEARCH FINDINGS AND RECOMMENDATIONS FOR VIETNAM

Al Rescarch finding - Cantent situation of applying a Just Cullure in Vietnam

4.1.1, Just Culture relating policies that put by Vietnam Airlines in encouraging

4.1.2 Vietnam Ahlincs has a saftty rcporting system that is elcar confidential and

Tiên-DMNfWE on nnierreieerrie

1.3 Vietnam Airtines” Just Culture implementation roadmap

42 Recommendations for Victnam Airlines: A human factor training progyam

4.2.1, ‘The necessity to establish a human factor training program

42.2 — Guidelines for establishing a human factor training program

423 — Suggestions for human faetors training contents

APPENDIX 1: INTERVIEW SCHEDULE

APPENDIX 2: INTERVIEW TRANSCRIPT

„47

Just Culture safety behavior definition madel Reason’s Decision Tree for determining the culpability of unsaft acts

‘Thematic analysie’s slages

Safety and Quality policy of Vietnam Airlines in 2009 and 2010 Safety and Quality Policy of Vietnam Airlines in 2016

The “Just Culture line?

Just Cultwe of Vietnam Airlines Vietnam Airlines incident rate 2010-2018 IATA Operations Safety Andit Results of Viemam Airlines IATA Operations Safcty Audit Certificate of Victnam Airlines Vietnam Airlines Safety Reporting Statistics

Mandatory Occurrence Report to CAAV Vietnam Airlines" Just Culture implementation roadmap

Page

14

16

The main features, advantages and disadvantages of qualitative and quantitative research method (Adopted from Sauders et al 2011) Different types of interview (adopted from Sauders el al.2011) Steps to build a Just Cultwe Reporting System

Main ideas to develop and maintain a Just Culture The development process of Vielnam Airfines in 2006-2019 Acceptable & Unacceptable Behaviours

Page

20

2l

TITTLE CHAPTER

1 Rationale

‘Through hundreds year of formation and develapmenl, the aviation industry has been considered as ane 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 duc lo a single unsafe act of individuals (Filn el al., 2000) 11 could casily 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 acls (Reuler 2016), And all this might lead to situations where safety

is impaired of 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 leam from these “unsafe” events and deviations fiom 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 Cullure principles, aistines 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 Furopeam 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 outlins

how if should work The efforls of EUROCONTROT Just Cullure Task Force or the Just

Culture Declaration - signed by most European Aviation stakeholders on Ist October 2015

- are just two of such initiatives (GAIN, 2018)

However, regardless of all intentions, most organizations still stiuggle with the concept of Just Culture, how fo 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 Tcwsơns ïs (hal, Jus! Culture requires more than just a regulatory complianes and copy-pasting the definition in the mammals Just Culture requires a far-reaching paradigm shift, which is a long and challenging joumey for airlines to enhance Just Culture implementation Tn Vielnam, Aviation brands grarhally reative the importance of a Tust Cullure in generating a more cfivetive safcly and operational imanagement, On May 12th

2018, the CEO of Vietnam Airlines - the most typical Vietnamese airlines brand, Mr

Duong ‘Int ‘Thanh had a session discussing problems relating Just Cultwe practice, and he also underlined the obligations and responsibilitics of aviation stakcholders 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 atso give some recommendations for Viemam Airlines in particular

1 Literature review

Before the 21st century, very few people had heard about Just culture Currantly, 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 (Frazicr, 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 Leaming Culturc 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 concernsd 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 tum, depends upon creating an

effective Reporting Culture that is underpinned by a Just Culture in which the line between

acceptable and tmacczpiatile beltavior is clearly drawn and underslond

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 enswing aviation safety and

this respocl and of the implsmontation of Just principles in

Annex 13 lo the Cincago Convention, Regulation 966/2010/EU and Polish aviation law

The analysis also focuses on relations between safely investigations and Just Culturs

bofora concluding some with recommendations for the lawmaker

The investigation of McCall, IR and Pruchnicki, S., (2017) about “Just culture: A case study of accountability relationship boundaries influence on safety in blgh- consequence industries” indicate a barrier to advancing meaningfill 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 tace as they move between and across these accountability boundaries This germane example is the crash of Swissaix 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 thal this examination would hetp redefine accountability boundaries thal support a Just Culture within dynamic high-consequence industties

Global Aviation Information Network in a report in 2018 also proposed “A Roadmup (» a Just Culture: Enhancing the Safety Environment”, which provide somo

preliminary guidance on how to create a just reporting culture and some insights on how to plan the implementation of such a system This repert also mdicated principles of a Just

Culture and benefits of an organization applying a Just Culture Kspecially, eight steps to

implement Just Culturs 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 Cultue The eight-step implementation is developed and applied by a lot of airlines brand nowadays

In terms of ground services, a product of Aix Transport Safty Institution (2011) in cooperation with the Civil Aviation Authority of the Nethotlands named “Jusl culture and human factors training in ground service providers”, investigated what clements arc roquired to ostablish and maintain a Just Culture, and what clemenis are required to establish a hmman factors training program The results of the research on Just Culture have been lested by means of a practical application of a Inst Culiure selaudit al six ground service providers in the Netherlands, ‘This may raise ideas of creatng and implementing a Just Culture self-audit for other players in the aviation market in arder 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 Tust Culture audit template to be used by ground service providers and auditing organizations

3

Rescarch Aim

‘The aim of this study is (o critically evaluate Just Cultwe practice in the aviation industry and give some recommendations for Vietnam Airlines

4 Rescarch Objectives

“The objectives of this report include the following:

Provide a review of literature of Safsty Cultura and Just Culure Raising awareness in the aviation community of the benefits off creating a Just Culture

Provide a road map of Just Culture implementation in aviation organizations Provide initial guidelines from case studies to develop and muintain 4 Just Culture; and share leamed lessons that might be helpful to others who also benefit trom applying Just Culture

Give some recommendations for Victnam Aislines to improve Just Culture

implementation

Rescarch Scope

‘The scope of the thesis focuses on the aviation industry and particularly Vietnam

Ailines from 2000 till mow

6 Structure of the thesis

This study includes five chapters

Chapter |: Theoretical background: in this chapter, the conceptual framework

an theoretical foundation of Fust Culture and Just Culture practice process are presented carefully This section also delivers a brisf discussion af benefits of Just Culture in an aislincs industry The implementation of Just Culture in an airlines industry is also discussed in this chapter

Chapler 2: Methadology describes the methodology research which is used in the study A qualitative approach with semi-structured interviews is adopted

Chapter 3; Just Culture Practice in an aviation industry descriptive analysis, factor analysis, reliability analysis and group comparison tests are undertaken in

4

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.

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 personatity or current commercial concems In aviation organizations, there

ac 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 safely culture include: just, reporting, learning, informed and flexible cultures

First of all, achieving this Reporting Culture requires an organization climate in

which people aro willing to roport their crrors anid 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 flamcwork of Reason arc a Flexible Culture, the ability to reconfigure in the face of hightempo operations or certain kinds of danger, and a Leaming Culture, the willingness and competence to draw right conclusions from its safety information system and the will to implement major refooms when nccded, Besides, once Just Culture has been established, the organization can begin to have a reporting culture, something that provides the syslern with au accessible memory, which is essenlial in underpimming io a Learning Culture All those contributitys parts interact and the overall safety culture is more than the

sum of its parts (Reason, 1997)

INFORMED CULTURE FLEXIBLE CULTURE

‘Those who manage and operate the system have Aculture in which an

current knowledge about the human, technical, ‘organization is able to

organizational and environmental factors that reconfigure itself in the

determine the safety of the system as a whole face of high-tempo

operations or certain kinds

of danger — often shifting

from the conventional hierarchical mode toa

.n organizational climate in which

LEARNING CULTURE

An atmosphere of trust in which people are An organization must possess the

encouraged (even rewarded) for providing essential willingness and the competence 10

information, but in which they are also clear about draw the right conclusions from its

where the line must be drawn between acceptable safety-information system along with

and unacceptable behavior the will to implement major reforms

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.

‘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, Ina

Just Culture environment the culpability line is more clearly drawn A “Just Culture” refers

fo a way of safely thinking that promotes a questioning altitude, is resistant to

complacency, is comuniticd lo exccllcnec, and fosters both personal accounlabilily and corporate sel Pregulation in safety malters

A “Just” safety cultura, then, is both attitudinal as well as structural, rolaling ta both individuals and organizations, Personal attitudes and corporate style can enable or facilitate the unsafe acts and conditions that are (he precursors lo accidents and incidenis, Trequires 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

13 Benefits of Just Culture

The GAIN report (2004) suggests that creating a Just Cultwe promotes an

environment where everyone involved in the situation leams from potentially unsafs acts

or mistakes This is as opposed to an environment where potentially unsate acts or mistakes become compounded by individuals, assigning blame and covering up thei mistakes (GAIN Working Group, 2004) To be noted is that Safety Culture and Just

Culture, are nol synonymous According lo Cox & Cheyne (2000), a culture of safuty is something that can be achieved through the creation of a Just Culture Thus, although the

twa concepls are inlrivalely linked, they are nol synonymous, as they do indicale to varying

ideals, When a Just Cullure is croaled within a given organization, the resulting blarnc- free environment improves the overall safsty 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)

‘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 umeporled events, bul also the identification of trends thal 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 mndred unreported incidents that, properly investigated, might have identified an underlying problom in time to prevent the accident (GAIN Uperator’s Hight 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 safely Event reporting illuminates potential safety concems,

from approximately 15 per year to more than 900 in the first year alone

More Effective Safety and Operational Management

Just Culture will cnbancc the organization’s cfftctiveness by defining job performance expectations, establishing clear guidelines for the consequences of deviance from procedures, and promoting the contimous teview of policies and procedures

Just Culture is expected to allow an organization to be batter able to determine whether violations are occurring infrequently or if deviation from established procedures has become normalized among its front-line enuptoyces and suparvisors

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 cxcating accidents are crcating 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 # leaming cultwe versus a blaming allure; learning from unsafe

acts; where the border between “acceptable” and “unacceptable” behavior should be; and ways lo decide on culpability

Evaluating the benefits of punishment versus leaming, A Just Culture supports leaming ftom unsaf 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 leamt,

Failures and ‘“incidenls’ are considered by organivalions will good safely cultures as lessons which can be used te 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

over the rool cans

Organizations necd to understand and acknowicdge that poople at the sharp end arc not usually the instigators of accidents and incidents and that they are more likely to inharit bad situations that have been developing over a long period (Reason, 1997) In order that organizations Icam fiom incidents, it is necessary to recognize that human c1ror will never

be eliminated; only moderated, In order to combat human errors we need to change the conditions umder which nutans work The effectiveness of countermeasures depends on the willingm s 0F individuals to rcport (hạr crrors, which requires an atmosphere of [rust

in which people are encouraged for providing essential safety-related information (Reason, 1997)

Marx (2001) hus i

The issue that has been raised by Marx (2001) and others is that not all of these behaviors necessarily warrant disciplinary sanction

entified four Lypes of behavior thal might result in unsafe acts

1, Hunan crror is when there is genzral agrccmnent that th 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 individnal is labeled as having

corre lied 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 Halility contexts Tt epplics to a person who fails lo use tha reasonable level of skill expected of a person engaged in that particular activity, whether by omitting to de

10

something that a prudent and reasonable person would do in the circumstances or by doing something that no prudent or reasonable parson would havs done in the circumnstaness 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 cara, reasonable care must be taken to avoid acts or amissions which can reasonably be forescen to be likely to causc harm to persons or property If, as a result of a failure to act

in this reasonably skillful way, hamyinjury/damage is caused to a person ot property, the person whose action caused the harm is liable lo pay damages to the person who is, ot whose property is, harmed

3, Reckless conduet — (gross negligence) is more culpable than negligence ‘The

nition of tockless conduct varias belwosn counlries; however, the underlying m age

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 forcsceing 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 reckl ess 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,

15 Distinguish acceptable and unacceptable behaviors

‘As a basis for achieving a just Culture, there should be ways to distinguish between acceplable and unacceptable bhavior, However, il is difficull to diseriminats between the truly “unacceptable behavior” (bad behavior) and “acceptable behavior” There is always existence of a “grey area” hetween two extremes where issue has to be decided on a case

by case basis, Thus, it is necessary to agree with a sct of principles for drawing this linc Furst of all, the author will define the “negligence”, which includes a harmful consequence that 2 “reasonable” and “prudent” person would have foreseen, And the definition of

“Rocklossi

is the person who takes a deliberate and unjustifiable risk According ta Reason (1997), the line between “unacceptable” and “acceptable” behavior should be drawn after clarifying substance abuse for recreational and “malevolent damage” A

suoccss[Ml Just Culture must draw the line between acceplable and una: havior,

splable thon cneourages 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

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£6, Just Culture decision tree

‘The Decision tree is ercaled by Professor James Reason with the aim of determining the culpability of unsaté 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 Reasons Culpability Decision Tree follows, representing a stmetured 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 differen unsafe acts thal contributed (o the accident or incident, amd Reason believes (hal the decision tree should be applied separated to each of them The concain 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 drags: Known to impair performance at the time that the error was committed A distinction is madz between snbstance abuse with or without “rcasonable purpose”, which is still not blameless, but not as scrious as taking drugs for recreational purposes

Step 3: Deliberate vialation of rules: did the syslem promote the violation or discourage

tho violation or had the behavior become aulomatic or part of the toval working practices Step 4: Substitution test; could a different person (equally motivated, competent and qualified) have made the same error under similar cixcunstances (determined by peers) If

“yes”, the person wha made the orror is likely to be bla Tf “no”, wore there system induced reasons (insutlicient training or positioned)? If not, negligent behavior should be considered

Step 5: Repetitive errors: The Ginal question asks whether the person has committed unsafe acts before, This does not presume culpability, but may imply that additional training ot comnseling is required

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abuse with mitigation

Diminishing culpability

17 Creating and implementing Just Culture

‘The ersation ofa Jus! Culture within an organization also requires a positive outoome for noticing errors and mistakes that are recorded Cooper (2000) notes that managerial roles in the creation of a Just Culture are fundamentally important ‘hus, those in managerial positions must he goal-oriented and very clear with the actions and steps requisite towards crcating a Just Culture within a given organization, Esscntially, 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; aulhority figures within such an environment must set realistic and subsequently attainable goals

(Cooper, 2000)

The Global Aviation Information Network (GAIN) doveloped guidtines for attaining, implementing and maintaining a Just Cultwe |GAIN, 2004] These guidelines are based on a nuniber of sources, including Reason (1997), Johnson (2003); lessons from the Danish experience and Vecchio-Sadus and Griffiths (200) 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 as

sssed for their presence and maturity:

Step 1: Develap repo

‘The first step that mentioned by the researcher in creating a Just Culture is reporting

2 policy and procedures

organivational policy and procedures This step is very important because it considers

safely issnes concerning the underlying reporting smeture 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

poliey and related procedises When management commitincnt is nol obtained to establish

a safety reporting system in which ramp personnel report errors and incidents without fear

of disciplinary actions, no resources will bs made available and corrective actions will not

15

Lack of reported events doss not necessarily indicate a safe operation (Dekker, 2012) Likzwise, inercased reporting on evenls dozs not indicate a decrease in the level af safely Even reporting illuminates the potential safety concems an organization has, Increased

reporting should be seen as a healthy, safety indicator (Lurocontrol, 2006)

Step 2: Determine roles, responsibilities and tasks

A number of different people necds 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 Al management level, a person has Lo be

sponsibility 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 tvonds, and circulating safety information in the organization

Step 3: Reduce legal barriers

‘The first step to be takan 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 carent Tegal situation and establishing whether it needs to be changed

In order to reduce the legal barriers to reporting and assessment of saiety occurences and trends, the two most important issues are: inderanity against disciplinary proceedings anda logal framework thal supports reporting md 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 methorls of reporting and assessment

Another important step is selecting the reporting method to be used, Some of the iasnes The organization may consider with regard to the method by which raporis are collected are the rapid, usefulness and intelligibte feedback of the reporting community

‘The organization should also consider the ease at which reports are generated, This is because; voluntary reparting is often perceived an extra task (Baynk, 2007) ‘Cherefore, the

organization will reqpzite a cloar and unambiguous dircction 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, accessiblz 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 emoneous or misleading responses The objective of the safety reporting system has to be carefully

considered when deciding on what information is required Lp teach this objective

Step 6: Develop template for feedback to potential users

Il is tmportant that reporters and ofhier ramp persomel know as soon es possible thal

an occurrence has been investigated and that the root cause is solved Feedback may be given on individual reports, but also in a combined fom by means of regular safety letters

or memos

Step 7: Develop plan for educating uscrs and implementing the system

Potential reporters have to be informed about the safety reporting system and know how to submit their information This may includs induction courses and periodic awareness sessions to remind ramp persommel of the importance of reparting and to ensure that all ramp personnel are familiar with the reporting procedures

Step 8: Develop and malstain a Just Culture

A munber of additional issucs conccrning the ‘cultural’ aspects of reporting arc

y in order lo tuaintain mofivation te 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 tanction The main objectives are to develop an open culture in which people feel able to trust the system and to develop naw ways to motivate people to use the system

Continuous management commitment has to be ensured ‘Io maintain and improve

management commitment to safety, management has to be contimonsly involved in the roperting process to show visibly that icy believe in and are willing ta promate the Just Culture, Simultancousty, commitinent to safcty of ramp personne! has to be ensured by actively involving them in the assessment of safety iss

17

CHAPTER I: 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)

| Theory follows data Data follows theory

Little attention to generalisation Generalisation

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

Qualltatlv

Data in words, images and videos, etc

‘Sinall scale of data

Subjectivity

Characteristics Inductive approach Deductive approach

Flexible research design Fixed research design

‘Non-standardized data collection Standatd data collection

Rich, in-depth detail is possible (participants Ber sample:

can elaborate on wht they mean) Soo ee ee

Perceptions of participants themselves can be ‘The sualysis ly comiderod sclable

aes on (the human factor such as

Appropriate for situations in which detailed "

‘understaniling 1 required Events can be seen, APDSopfló ý situations whees,

in their proper context / more holistically an a alec"

Not always generalizable due to small Does noi always shed light on the full sample sizes and the subjective nature of the complexity of human experience or

Disadvantage Conclusions need to be carefully hedged Can reveal what / to what extent, but

Accusations of unreliability are common May givea false impression of

(different results may be achieved on a homogeneity ina sample

different day/with different people)

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 rescarch accompanied by inductive approach is well suited to this study

2.2 Data collection

2.2.1 Secondary data

‘The literature roview 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 fiom 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 prescnt investigated by many prestigious scholars (Windle, 2010), By using secondary data, research probleny‘gap in literature from previous researches can be posed hence, to develop a research topic (Walliman, 2011)

‘Additionally, researchers who utilise secondary data could casily make comparison

amongst existing data (Veal, 2011) Various sources of data are examined to ensure they

ave accurale There are several sources of secondary data such as written malerials from organisational records, loxtbook, journals, government publications, nonewrillen materials such as films, videos and andios, and survey data such as government statistics (Walliman,

2011)

Tn this rescarehy, the research statements are maainty built based on aearlermic sources relating to research method and aviation market books and peer reviewed academic joumal such as limerald and Ebscohost Vurthermore, 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 (LATA) and Global Aviation

Network (GAIN) are compelling raw dala for researchers as il provides updated data of Aviation industry In this study, secondary data is utilised to achieve objective | and 2 Although secondary research is usefull in making contribution to the formal base of the research as well as lilcralure review, il is not cnough to answer the resuarch question which the study is Looking for to solve

2.2.2 Primary data: semi-structured interviews

The critical sccondary literature has provided good insights of rescarch problem, but not completely answer the research aim; thus, it is necessary to do primary research According to Marshall and Rossman (2006), pritwary research is to grasp the yrofound

auzaning 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

Standardized questionnaire Non-Standardized ‘Non-Standardized

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 sooial entroprencurs in community based tourism were asked, Following each key question, the researcher asked some probe questions in order to Âưther 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 mect rescarch obicctives The semi-structured questions linking to two main objectives of the research is given in Appendix,

2.2.4, Sampling

‘rhe number of interviews was specified by the “saturation efifect”, in which the data collected was iteratively analysed (Srivastava and Hopwood 2009), According lo Thomson (2010 cited by Marshall et al 2013), the “saturation effet” is usually accomplished within 10-30 interviews which this study matches “Purposive” and “snowballing” sampling techniques arc uscd to attain thesc participants Perposive sampling is the process that participants, who have knowledge about the phenomenon under study, are purposely found

by current researcher (Bryran 2012) In this 7

rch, “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 Aitlines

* They are department managers or staffs in Safety - Quality Departinent

©) They are hanagers or staffs in Human Resoures Department

‘They are people who takes responsibility in building and maintaining satety culture

in Vietnam Airlines Thus, they will have deep understanding about owrent situation of

Tust Culture implementation in the organization Besides, to minimize the bias, the

rescarcher tricd to diversity the answers by looking for interviewees who are working at

different position in a department or in different department m Vietnam Airlines There are

10 interviewses participating in this interview

2.2.5, Pilot test

Accorling to Bryman (2012), the implementation of a pilot study is important duc 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 st al (2011) and

‘Tumer (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 | 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)

Figure 4: Thematic analysis's stages (Adopted from Braun et al 2006)

Besides, this thesis supposes to analyze data collected from papers, articles, books and reports from reputsil 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 policics towards Just Culture implementation in the world

aviation industry and in Vietnam

information sourecs arc summarized, analyzed, compared and evalua

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

arami the lopic

According to Ritchic ct al (2013), cthical considerations are the essence of how rcscarchisrs treat their participants Prior to data collectian, 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 respec, inlarviewees’ privacy and was bound te protect participants? recognition or any private information, Afler transcription, alt information will be destroyed Children (below 16) and vulnerable people were excluded due to ethical and

health concerns

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CHAPTER II: JUST CULTURE PRACTICE IN THE AVIATION INDUSTRY

3.41 History of Just Culture in the world aviation industry

Before the 2Ist century, very few people had heard about Just Culture Currently atmost every organization in the aviation industry has implemented the Just Cultme in all their aetivitics Recent findings have suggested that; the Just Culture has become the foundation for safety in the aviation industry (Krazier, 2012) Organization leaders have to focus al achieving a Just Cullure in the firin 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

“Fast, Cultur:

and slarled the process of Isarning how iL fanctions, 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 lcaming fiom 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 ond) in order to act 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 inviled relevant peapte

in the aviation industry (including Earge and small airline operators) and CAA personnal ta attend a seminar by a leading expert on Just Culture, The seminars were extremely well received by all attendees, thns giving the CAA confidence that Just Culture principles were

appropriate Lo apply ina safety regulatory context

In 2000, the Chairman of the Danish Air Trafic Controllers Association described the obstacles for reporting during an interview on national prime-time television ‘this influenced thc Transportation Subcomunittce of the Danish Parliament to ask for the Danish Air Traftic 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-punifive, confidential reporting possible

On 3 April 2014, Occurrence reporting in the UK and the rest of Europe is governed

by Furopcan Regulation 376/2014_ on the reporting, analysis and follow-up of ocouenees

in civil aviation The Mandantory Occurence Reporting (MOR) was established to ensure

25

that all hazardous or potentially hazardous incidents and defects are informed to CAA

MOR also supparts for am ment lo be made and monilor 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

fo enhance awareness of managers and staffs in aviation organzations of safety-issues reporting,

3.2 Tust Cultare Practice in the wortd avi an

‘This section briefly describes how ths watld 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 Reaso (1997), Johnson (2003), Icssons from the Danish experience, EUROCONTROL ESARR2 Workshops in 2000 and Vecchio-Sadus and Griffiths (2004)

One example of the marked changes in an organization as a result of creation of Just Culture occured at Danish Air Traflic Control Service Provider (Maviaiz) 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 concemns about confidentiality and non-punitive issues, Thoso issues wore 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 prosceution Afler cxploring various inlernationat legislations on reporting and investigating incidents and accidents, the Danish government proposcd 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 (MOK) 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 concem 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 failue 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 shoul the liecuse holder The purpose of livense action is (0 ensure safety and nol to penalize the license

holder

Tn case of Alaska Aislings, no disciplinary action will be taken against any employee following their participation in an error investigation, including those individuals who may have reached standard operating procedures Disciplinary action will be only limited to the following narrow circumstances, for example, an employse 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 ot close call, On more example of disciplinary action stated in the law documentation is the employee’s actions invelve ctiminal activity or substance abuse

3.2.2, Reporting Policy aud 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 concemting 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 ease of Naviair, priorities were set up on which reports are dealt with immediately, and

on how much allention is given by the investigators, The imvestigation of lo: of

weeks ‘The reports include the following elements: Aircraft proximity and avoiding manoewvers; safety nets (theit impact on and relevance for the incident); system aspects; human faetors; procedures; conclusion and recommendations ‘Ihe 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 throngh 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 lo infornt 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 inlsrest of fight safety thay arc strongly advised Lo inform their cinptoyers

- Reports nuust be dispatched within 96 hours of the event (unless exceptional circumstances) and informed by the fastest means in the case of particularly hazardons events,

- Confidential reports can bz 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 ralher have a confidential

Tepor† than no report at all

‘The Alaska Airlines Error Reporting System (ERS) is a non-punitive reporting

program which allows employees to report lo management aperational 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 opporlunily for correction The report procedure can be process in 2 steps

Ist stp: Reporters can file a Toport on www-alaskasworld.cam An cmptoyee can also submit a report over the phone by contacting the Safety Manager on Duty

2nd step: A repart should be promptly snbmitted, normally az soon as the employee

is aware of the cượt 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 ciiteria for acceptance and notify the employes If the repat is not accepted, the employee's supervisor is responsible for contacting the Safety Division immediately for

review ‘he 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 correchve 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 bs prescnicd ta the Board of Directars

‘the GAIN report (2004) suggests that mandatory reporting of events by Danish air

traffic controllers has vastly T2duced the number of incidents thal have oecwred The knowledge that reports nmust be made and filed, has improved the attention paid to details

by the air traffic controllers ‘The report nofes the important difference between blameless and non-punitive organizational Just, Culture However, reporters are onsured of (heir indemnity against unjust (blame-based) prosecution or disciplinary actions against them

‘This is for any events that they may, or have reported, especially those hased on the information contained in the reports they may have submitted However, this docs not always mean that such reports can be submitted without any consequences” (GAIN

Working Group, 2004)

Mandatory reporting, aceordiry to the roporl, has hoon ulilized offectively, 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 aulhorities 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

2s

this system created as a result, was able to permeate the entire air-traffic control chain of command Tt thus allowed sxisting air tralfie controllers lo addres

earher, and with less fear of punishment from figures of authority (GAIN Working Group,

spoetive, are often costly and time consuming in naturs Casc 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, trom the ditferent methodologies utilized, is most likely to improve both the breath and subsequent accuracy ITowever, the direction and resulting influcnces, of such prevailing “cause and effect” situational contexts, cannot necessarily be established tom 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 undarlying aspacls of the provailing safety culture (Glendon & Stanton, 2009) They are of the suggestion that such methods of quantitative

analysis, do provide those in anthority with more accurate and hence concrete knowledge

of safely measures and analysis, within a giver 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 rarcly) The reporting requirements apply Lo all aizcrall 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 males require the aircraft owner or the involved organization nolilying 4 serious incident 1¢ conduct am investigation to identify the facts relating to its involvement and the causal tuctors of the incident A report of the investigation is required within 90 days of the inoident and must inclurte any actions taken to prevent Tacurronce of a similar ineidont,

30

Information received under this mandatory reporting system cannot be used for Prosceution action, cxeepl m special circumstances such as when falsc information is

supplied or when ‘unnecessary danger’ to any other person is caused, (Ref New Zealand

Civil Aviation Rule CAR Part 12.63.)

31

The first steps to develop a “Just Culture” Reporting System

+ Decide on voluntary versus mandatory reporting system

+ Decide on anonymous, confidential, open reporting system

* Develop procedures for determining eulpability (such as the Just Culture decision tree) and follow-up action (type of discipline or coaching)

+ Decide who shall decide culpability (e.g, team consists of safety; operations, management; HR)

+ Draft a plan and discuss with a small selection of operational personnel

+ Decide 1f and how the reports will be fimther investigated (the focus of the

invcsligalion; facc-to-fầ

interview.) + Decide which reports will be further investigated (those which are most severe;

+ Decide who will investigate the reports,

Tahle 4: Steps to build a Just Culture Reporting System

Ta case of Danish Airway, the Danish reporting sysicrn ensures irumunity against ponaltics 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 subniil reports of events This 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

Hinformation from the roports undisclosed, One more imporlant thing is tris reporting system allow lo immmily against any penal or disciplinary measure If a Teport is submitted within 72 hours of an occurrence; if it does not involve an accident; or does not invelve deliberate sabotage or negligence due to substance abuse Punitive measures are stipulated against any broach of the guaranteed confidentiality

It may not be obvious to all organizations which system would suit them best Ideally, a variety of teparting methods (or 4 flexible method) will be implemented, as nol one reporting method will suil everyone's necds Ht may be novessary for the organization

to survey the needs of the potential users to better understand which reporting method would be more readily accepted

32

3.2.4, Determine roles and responsibilities

For such a system to thrive, a murmber 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 the face of externat or managerial pressures Decide and select someone to:

* Champion the system

+ Educate users and implement system

+ Collect and analyra the reports,

+ Decide which department will be involved in the disciplinary (decision making) process

Feedback the information (develop ne ter)

« Develop and maintain the data collection system

‘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 neecssary remedial actions in relation to the reported ocewrrences, iv) persuade other aviaton authorities and organizations to take any necessary remedial actions, v) assess and analyze the information reported in order to detect safety problems (not necessarily apparcnt to the individual reporters), vi) where appropriate, make the information ftom the reports available and issue specific advice or instructions to particular

In Alaska Airlines, the Safety Division has oversight of the program Supervisors and toval management have responsibility for the day-la-day management of reports submiltsd, investigations performed and implementation of corrective actions They will define whether they have enough sufficient resources to rm the system, as well as having enough

of the ‘tight’ kind-of people, who are cnergetic, well-liked, well-known and respeeled in the company Then, they try to maintaining the energy required for the system to function

4.2.5, Developing and Maintaining Tust Culture

A number of additional issues concerning the ‘cultural’ aspects of reporting are

necessary in order to maintain motivation to report, stich as the trust between reporters and

33