Just culture practice in the aviation industry recommendations for vietnam airlines

The thesis satisfies the urgency, deals with topical issues and has theoretical and practical significance. The thesis has discussed the basic theoretical issues of Just Culture in the aviation industry. The thesis also analyzed the status of Just Culture in the aviation industry and at Vietnam Airlines. Since then, the thesis has proposed four groups of solutions and recommendations to improve the Just Culture of Vietnams aviation industry and particularly, in 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

Figure 2 Just Culture safety behavior definition model 14 Figure 3 Reason‟s Decision Tree for determining the culpability of unsafe

acts

16

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 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 14 Vietnam Airlines‟ Just Culture implementation roadmap 49

LIST OF TABLES

Table 1 Main features of inductive and deductive approach (Adopted from

Sauders et al 2011)

20

Table 2 The main features, advantages and disadvantages of qualitative and

quantitative research method (Adopted from Sauders et al 2011)

21

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

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

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 consequence industries” indicate a barrier to advancing meaningful safety agendas, which

high-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

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 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

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

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)

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 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)

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

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

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

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

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 induced reasons (insufficient training or positioned)? If not, negligent behavior should be considered

system-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

Figure 3: Reason‟s Decision Tree for determining the culpability of unsafe acts (1997)

1.7 Creating and implementing Just Culture

The creation of a Just Culture within an organization also requires a positive outcome for noticing errors and mistakes that are recorded Cooper (2000) notes that managerial roles in the creation of a Just Culture are fundamentally important Thus, those in managerial positions must be goal-oriented and very clear with the actions and steps requisite towards creating a Just Culture within a given organization Essentially, the creation of a Just Culture, does require the establishment of new and adequate behavioral norms This is with regard to individuals acting within a certain environment; authority figures within such an environment must set realistic and subsequently attainable goals (Cooper, 2000)

The Global Aviation Information Network (GAIN) developed guidelines for attaining, implementing and maintaining a Just Culture [GAIN, 2004] These guidelines are based on a number of sources, including Reason (1997), Johnson (2003); lessons from the Danish experience and Vecchio-Sadus and Griffiths (2004) The GAIN guidelines were worked upon by the Eurocontrol Safety Regulatory Commission for Eurocontrol Just Culture guidelines (SRC, 2006) Based on these guidelines, a Just Culture includes the following elements that can be assessed for their presence and maturity:

Step 1: Develop reporting policy and procedures

The first step that mentioned by the researcher in creating a Just Culture is reporting organizational policy and procedures This step is very important because it considers safety issues concerning the underlying reporting structure and company commitment Management commitment is the primary requirement for establishing and maintaining a Just Culture Similarly, management commitment is the basis for developing a reporting policy and related procedures When management commitment is not obtained to establish

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

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

substantiate

When developing a reporting policy and procedures, it is important to consider whether reports may be issued anonymously and whether the person receiving and assessing the reports have an independent function within the organization This avoids interference between reported human errors and career prospects for each major accident, which involves fatalities, there are as many as several hundred unreported incidents Researchers have suggested that, if these incidents are properly investigated, they might identify underlying problems on time and prevent future incidents from taking place again

Lack of reported events does not necessarily indicate a safe operation (Dekker, 2012) Likewise, increased reporting on events does not indicate a decrease in the level of safety Even reporting illuminates the potential safety concerns an organization has Increased reporting should be seen as a healthy, safety indicator (Eurocontrol, 2006)

Step 2: Determine roles, responsibilities and tasks

A number of different people needs to be involved in the development, implementation and maintenance of the safety reporting system A person has to be appointed who is responsible for the development, implementation, promotion and management of the safety reporting system This person ensures confidentiality of reporting and reports directly to the board of directors to highlight (potential) safety issues and trends At management level, a person has to be assigned the responsibility to decide if disciplinary actions have to be taken after errors, incidents or accidents

To support the safety reporting system, personnel have to be appointed to perform the activities of collecting, assessing, analyzing and monitoring of safety reports and trends, and circulating safety information in the organization

Step 3: Reduce legal barriers

The first step to be taken for consideration is the legal aspect of Just Culture An organization has to have in place a disciplinary framework that supports reporting of incidents This will significantly reduce any legal impediments to reporting The first significant step in changing the legal aspects may entail substantiating the current legal situation and establishing whether it needs to be changed

In order to reduce the legal barriers to reporting and assessment of safety occurrences and trends, the two most important issues are: indemnity against disciplinary proceedings and a legal framework that supports reporting and investigation of incidents Without these aspects firmly established in the organization, ramp personnel may not report errors and incidents because of fear of legal proceedings

Step 4: Establish methods of reporting and assessment

Another important step is selecting the reporting method to be used Some of the issues the organization may consider with regard to the method by which reports are collected are the rapid, usefulness and intelligible feedback of the reporting community The organization should also consider the ease at which reports are generated This is because; voluntary reporting is often perceived an extra task (Bayuk, 2007) Therefore, the organization will require a clear and unambiguous direction for reporting and accessing to reports Reporting of safety issues should be a clearly described and easy process, safety

reports should be professionally assessed and managed, and feedback should be rapid,

useful, accessible and intelligible to all personnel

Step 5: Develop reporting form

Although safety issues could be reported verbally, it is beneficial to also develop a reporting form that encourages accurate and complete reporting (e.g questions that are understandable) and is easy to fill in; otherwise reporters may provide erroneous or misleading responses The objective of the safety reporting system has to be carefully considered when deciding on what information is required to reach this objective

Step 6: Develop template for feedback to potential users

It is important that reporters and other ramp personnel know as soon as possible that

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

or memos

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

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

Step 8: Develop and maintain a Just Culture

A number of additional issues concerning the „cultural‟ aspects of reporting are necessary in order to maintain motivation to report, such as trust between the reporters and their supervisors, and between the supervisors and their managers This is a precondition for the safety reporting system to function The main objectives are to develop an open culture in which people feel able to trust the system and to develop new ways to motivate people to use the system

Continuous management commitment has to be ensured To maintain and improve management commitment to safety, management has to be continuously involved in the reporting process to show visibly that they believe in and are willing to promote the Just Culture Simultaneously, commitment to safety of ramp personnel has to be ensured by actively involving them in the assessment of safety issues and development of corrective actions

Although above steps are based upon the GAIN roadmap to a Just Culture (GAIN, 2004), it is clear that they have interactions with a variety of safety culture aspects In particular, a large number of these steps are related to what Reason calls „engineering a reporting culture‟ (Reason, 1997) This thesis also tries to check the implementation of Just Culture in aviation industry through these seven-steps

CHAPTER II: METHODOLOGY

This chapter will describe the methodology undertaken in this study In the first section, research approach will be given, followed by the discussion of secondary and primary research Data collection and data analysis are outlined in the following section Research limitations and ethnic considerations are discussed in the fourth section followed

by summary of the methodology chapter

2.1 Research approach

With regard to research approach, deductive approach and inductive approach are two major approaches In this study, deductive approach is known as “top-down” approach digging into existing theories, then generating specific hypotheses from these theories, and finally testing these hypotheses by a number of observations (Bryman & Bell, 2015) In the opposite direction, inductive approach as “bottom-up” reasoning starts with observation to discover the evenness and patterns, then create hypotheses and concludes by the development of explanations or theories (Bernard, 2017)

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”

Inductive approach Deductive approach

Theory follows data Data follows theory

Less structured methodology Structured methodology

A small sample of subjects A large number of samples

Little attention to generalisation Generalisation

Develop in-depth understandings of

human‟s emotion and perceptions

Enable cause-effect link between variables

Whereas, inductive approach is usually characterized by qualitative (Saunders, 2011) Inductive approach along with qualitative method are good combination to hold the perception of constructivist for building theories or knowledge (Morgan & Smircich, 1980; Denzin & Lincoln, 2011) Alasuutari et al (2008) described that qualitative method provides in-depth understandings about opinions, reason or motivations, which could support in developing hypotheses for quantitative study Bowen (2009) indicates some typical forms of qualitative method including group discussion, interviews or open-ended questions

Table 2: The main features, advantages and disadvantages of qualitative and quantitative research method (Adopted from Sauders et al 2011)

Take into account of this research purpose to define the practice of Just Culture in the aviation industry and give perspectives for Vietnam Airlines, thus it is reasonable to

deliver an in-depth understanding about Just Culture and its implementation, qualitative research accompanied by inductive approach is well suited to this study

2.2 Data collection

2.2.1 Secondary data

The literature review chapter has reviewed some secondary literature According to Salkind (2010), secondary data is data that was produced and interpreted in existence or data that was used differently from the original purpose Secondary literature or secondary data collection is really important because it is a source of adequate information in a comprehensive way from the past present investigated by many prestigious scholars (Windle, 2010) By using secondary data, research problem/gap in literature from previous researches can be posed, hence, to develop a research topic (Walliman, 2011) Additionally, researchers who utilise secondary data could easily make comparison amongst existing data (Veal, 2011) Various sources of data are examined to ensure they are accurate There are several sources of secondary data such as written materials from organisational records, textbook, journals, government publications; non-written materials such as films, videos and audios; and survey data such as government statistics (Walliman, 2011)

In this research, the research statements are mainly built based on academic sources relating to research method and aviation market books and peer reviewed academic journal such as Emerald and Ebscohost Furthermore, the data of Civil Aviation Authority of Vietnam (CAA), official reports of reputed organizations such as European Organization for the Safety of Air Navigation (EUROCONTROL), International Civil Aviation Organization (ICAO), International Air Transport Association (IATA) and Global Aviation Network (GAIN) are compelling raw data for researchers as it provides updated data of Aviation industry In this study, secondary data is utilised to achieve objective 1 and 2 Although secondary research is useful in making contribution to the formal base of the research as well as literature review, it is not enough to answer the research question which the study is looking for to solve

2.2.2 Primary data: semi-structured interviews

The critical secondary literature has provided good insights of research problem, but not completely answer the research aim; thus, it is necessary to do primary research According to Marshall and Rossman (2006), primary research is to grasp the profound meaning of the experiences in the words of the participants Primary research refers to the

participation of a study on a subject in which data is collected originally by the first observation gathered by the researcher (Dawson, 2007) While secondary data is in existence, primary data is primarily collected and used by the current researchers in order

to complement secondary data (Veal 2011) Primary data can be collected in various ways such as interviews, questionnaires and obervations (O‟Leary, 2014)

Research interview is a conversation in purpose between researcher and one or more people, in which interviewees are willing to answer concise questions, while interviewer (researcher) has to listen thoroughly in order to discuss further (Sauders et al 2011) There are several types of interview, which are normally categorized into: structured interview, semi-structured interview and unstructured/in-depth interview (Bernard et al 2010, Sauders et al 2011), which are presented in Table 3

Structured interview Semi-structured interview Unstructured/In-depth

interview

Standardized questionnaire Non-Standardized

questionnaire

Non-Standardized questionnaire Qualitative research Qualitative research Qualitative research

Descriptive research Exploration and explanation

research

Exploration 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

participants, age, nationality, as well as their business histories and background Some key questions focusing on the motivations of establishing social entrepreneurs in community-based tourism were asked Following each key question, the researcher asked some probe questions in order to further the answers Questioning was also opened to allow respondents freely to interpret and narrate at their own pace Interview schedule has been designed with six main questions to meet research objectives The semi-structured questions linking to two main objectives of the research is given in Appendix

2.2.4 Sampling

The number of interviews was specified by the “saturation effect”, in which the data collected was iteratively analysed (Srivastava and Hopwood 2009) According to Thomson (2010 cited by Marshall et al 2013), the “saturation effect” is usually accomplished within 10–30 interviews which this study matches “Purposive” and “snowballing” sampling techniques are used to attain these participants Purposive sampling is the process that participants, who have knowledge about the phenomenon under study, are purposely found

by current researcher (Bryman 2012) In this research, “purposive” sampling techniques is used to attain these participants The responders in this study are able to satisfy the following principle requirements:

 They are top managers in Vietnam Airlines

 They are department managers or staffs in Safety - Quality Department

 They are managers or staffs in Human Resource Department

They are people who takes responsibility in building and maintaining safety culture

in Vietnam Airlines Thus, they will have deep understanding about current situation of Just Culture implementation in the organization Besides, to minimize the bias, the researcher tried to diversity the answers by looking for interviewees who are working at different position in a department or in different department in Vietnam Airlines There are

10 interviewees participating in this interview

2.2.5 Pilot test

According to Bryman (2012), the implementation of a pilot study is important due to the fact that it assists the researcher in ensuring the interview schedule suitable and run smoothly during the process of data collection Additionally, Saunders et al (2011) and Turner (2010) also argued that the pilot test plays an important role in the detection of any flaws or difficulties that exist or might arise in data collection Therefore, researchers are

able to determine and make amendments if needed Some alterations were made and several probe questions were added to improve data collection

2.3 Interview implementation

The interviews were conducted at different dates and different location based on the suitability of the participants Due to the focus of this study being Just Culture Practice in Vietnam Airlines, the researcher would like to conduct face-to-face conversations, besides, the researcher‟s ability to approach potential participants remains low because of the new topic The first interview was conducted on 1 November, while the last one was on 25 November 2019 Informal conversations before commencing interviews helped to ease overall ambience of the interview and create a receptive environment (Apendix 1)

2.4 Method of analysis

According to Holloway et al (2003), qualitative approach is significantly complicated and diverse A common criticism of qualitative research is that data analysis procedures are rarely well understood by researchers, thus leading to the inability of the reader to understand the presence of the researcher's findings (Stirling, 2001) In addressing this concern, thematic analysis method has been used to analyze the data, but data analysis will remain flexible and adapt to the requirements of the researcher (Richards, 2015)

Thematic analysis is the involvement of discovery, interpretation, report and cluster

of data Due to the flexibility of this analysis method in terms of theory and epistemology, thematic analysis is able to amass detailed, complicated and yet extensive data (Braun et al 2006)

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

Familiarising with your data

Generating initial code

Searching for themes

Reviewing themes

Defining and naming themes

Producing report

Besides, this thesis supposes to analyze data collected from papers, articles, books and reports from reputed aviation organizations by some analysis methods such as Comparative and Contrastive Analysis Firstly, the comparative and contrastive method is used to compare the in the current situation Practice of Just Culture in the world aviation industry and in Vietnam This method also gives a deep understanding of similarities and differences in mechanisms and policies towards Just Culture implementation in the world aviation industry and in Vietnam

Furthermore, the thesis uses the analytical - synthesis method, which is one of the most frequently used qualitative research methodologies The collected data will be screened and analyzed to fit the content of the thesis The secondary data from various information sources are summarized, analyzed, compared and evaluated around the topic

of Just Culture; then, theoretical background will be systematized and generalized This method is used almost throughout the three main chapters of the thesis

2.5 Research ethics

According to Ritchie et al (2013), ethical considerations are the essence of how researchers treat their participants Prior to data collection, it is important to gain ethical approval The research‟ summary with aims and objectives are given and that the conversions will be recorded In addition to this, a comprehensive explanation on confidentiality and anonymity issues were carefully given before each interview During interviews, the researcher showed respect interviewees‟ privacy and was bound to protect participants‟ recognition or any private information After transcription, all information will be destroyed Children (below 16) and vulnerable people were excluded due to ethical and health concerns

CHAPTER III: JUST CULTURE PRACTICE IN THE AVIATION INDUSTRY

3.1 History of Just Culture in the world aviation industry

Before the 21st century, very few people had heard about Just Culture Currently, almost every organization in the aviation industry has implemented the Just Culture in all their activities Recent findings have suggested that; the Just Culture has become the foundation for safety in the aviation industry (Frazier, 2012) Organization leaders have to focus at achieving a Just Culture in the firm so that the business can benefit from the simplicity, power and effectiveness of the culture

In 1999, the New Zealand Civil Aviation Authority (NZ CAA) became interested in

“Just Culture”, and started the process of learning how it functions, and the process required to implement it They are frequently faced with making decisions regarding the choice of regulatory tool that is appropriate to apply to an aviation participant when there

is a breach of the Civil Aviation Act or Rules, and they saw the “Just Culture” model as holding the promise of promoting compliance and facilitating learning from mistakes However, to fully embrace „Just Culture‟ in New Zealand, there will need to be some legislation changes and considerably more selling of the concept to the aviation industry (particularly at the GA end) in order to get the necessary paradigm shift (away from fear of the regulator when considering whether or not to report occurrences) In the following years, the New Zealand CAA has organised Just Culture Seminars invited relevant people

in the aviation industry (including large and small airline operators) and CAA personnel to attend a seminar by a leading expert on Just Culture The seminars were extremely well received by all attendees, thus giving the CAA confidence that Just Culture principles were appropriate to apply in a safety regulatory context

In 2000, the Chairman of the Danish Air Traffic Controllers Association described the obstacles for reporting during an interview on national prime-time television This influenced the Transportation Subcommittee of the Danish Parliament to ask for the Danish Air Traffic Control Association to explain their case After exploring various international legislations on reporting and investigating incidents and accidents, the Danish government proposed a law in 2002 that would make non-punitive, confidential reporting possible

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

by European Regulation 376/2014 on the reporting, analysis and follow-up of occurrences

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

that all hazardous or potentially hazardous incidents and defects are informed to CAA Besides, MOR also supports for an assessment to be made and monitor performance standards that have been set by the CAA Since MOR system was introduced, there is an increase in the number of unsafe acts reported Undoubtely, MOR system has contributed

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

3.2 Just Culture Practice in the world aviation

This section briefly describes how the world aviation brands create and implement Just Culture through some of the main steps to achieving a Just Culture These have come from a number of sources: including Reason (1997); Johnson (2003); lessons from the Danish experience; EUROCONTROL ESARR2 Workshops in 2000 and Vecchio-Sadus and Griffiths (2004)

One example of the marked changes in an organization as a result of creation of Just Culture occurred at Danish Air Traffic Control Service Provider (Naviair) made possible through a change in its national law An extensive briefing campaign was conducted to give information to air traffic controllers; in the briefing process the controllers expressed concerns about confidentiality and non-punitive issues These issues were addressed by explaining the intention of the law governing the reporting system, the law that would grant media and others no access to the reports and would secure freedom from prosecution After exploring various international legislations on reporting and investigating incidents and accidents, the Danish government proposed a law in 2002 that would make non-punitive, confidential reporting possible

Another example, the UK Civil Aviation Authority (UK CAA) has recently reviewed the Mandatory Occurrence Reporting System (MOR) to try to improve the level of reporting within the UK aviation community Assurance Regarding Prosecution - The UK CAA gives an assurance that its primary concern is to secure free and uninhibited reporting and that it will not be its policy to institute proceedings in respect of unpremeditated or inadvertent breaches of law which come to its attention only because they have been reported under the Scheme, except in cases involving failure of duty amounting to gross negligence With respect to licenses, the CAA will have to take into account all the relevant information about the circumstances of the occurrence and about the license holder The purpose of license action is to ensure safety and not to penalize the license holder

In case of Alaska Airlines, no disciplinary action will be taken against any employee following their participation in an error investigation, including those individuals who may have breached standard operating procedures Disciplinary action will be only limited to

the following narrow circumstances, for example, an employee fails to promptly report

incidents For example, when an employee delays making a report in a reasonable time A reasonable time for reporting is within 24 hours However, reports should be submitted as soon as possible after the employee is aware of the safety error or close call On more example of disciplinary action stated in the law documentation is the employee‟s actions involve criminal activity or substance abuse

3.2.2 Reporting Policy and Procedures

The step that mentioned by the researcher in creating a Just Culture is reporting organizational policy and procedures This step is very important because it considers safety issues concerning the underlying reporting structure and company commitment One

of potential obstacles when creating a Just Culture in an aviation organization is to persuade senior management of the need for creating a Just Culture and to commit adequate resources to it

In case of Naviair, priorities were set up on which reports are dealt with immediately, and

on how much attention is given by the investigators The investigation of losses of separation are investigated thoroughly including gathering factual information such as voice recordings, radar recordings, collection of flight progress strips and interviews with involved controllers Investigative reports have to be completed within a maximum of 10

weeks The reports include the following elements: Aircraft proximity and avoiding manoeuvers; safety nets (their impact on and relevance for the incident); system aspects; human factors; procedures; conclusion and recommendations The ultimate purpose of the report is to recommend changes to prevent similar incidents

CAA encourages the use of company reporting systems wherever possible Reports collected through the company are filtered before they are sent to the CAA (to determine whether they meet the desired criteria of the CAA) The company is encouraged to inform the reporter as to whether or not the report has been passed on to the CAA

- Individuals may submit an occurrence report directly to the CAA, although in the interest of flight safety they are strongly advised to inform their employers

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

- Confidential reports – can be submitted when the reporter considers that it is essential that his/her identity not be revealed Reporters must accept that effective investigation may be inhibited; nevertheless, the CAA would rather have a confidential report than no report at all

The Alaska Airlines Error Reporting System (ERS) is a non-punitive reporting program which allows employees to report to management operational errors or close calls that occur in the workplace This system is designed to capture events that normally go unreported It also provides visibility of problems to management and provides an opportunity for correction The report procedure can be process in 2 steps

1st step: Reporters can file a report on www.alaskasworld.com An employee can also submit a report over the phone by contacting the Safety Manager on Duty

2nd step: A report should be promptly submitted, normally as soon as the employee

is aware of the error or close call Reports made later may be accepted where extenuating circumstances exist

3rd step: The employee‟s supervisor will review the report, determine if it meets all criteria for acceptance and notify the employee If the report is not accepted, the employee‟s supervisor is responsible for contacting the Safety Division immediately for review The Safety Division will record and review all reports submitted under this program

In general, the Internal Evaluation Program (IEP) will accomplish a monthly review

of corrective actions All long-term changes to procedures and policies will be added to the

IEP audit program and become permanent evaluation items for future audits A summary

of employee reports received under this system will be presented to the Board of Directors Safety Committee quarterly Summary information will also be shared with employees on

a regular basis

3.2.3 Methods of Reporting

It is important that issues such as the following are considered with regard to the method by which reports will be collected a rapid, useful, accessible and intelligible feedback to the reporting community Most literature present, suggests that a Just Culture requires open and blame- free communication strategies to maintain the integrity of the safety culture However, the logistical issues that arise when considering the blame-free environment are problematic, and thus are handled differently by a variety of existing researchers Wagner (2013), suggests that anonymous and confidential reporting are both extremely important tools for use in creating a safety culture within an organization He further suggests that confidential reporting in particular encourages active learning in employees and members of the organization (Wagner, 2013) Dekker (2009) on his part, notes that active learning is a fundamental underlying purpose in the creation of a safety culture within a given organization (Dekker, 2009)

The GAIN report (2004) suggests that mandatory reporting of events by Danish air traffic controllers has vastly reduced the number of incidents that have occurred The knowledge that reports must be made and filed, has improved the attention paid to details

by the air traffic controllers The report notes the important difference between blameless and non-punitive organizational Just Culture However, reporters are ensured of their indemnity against unjust (blame-based) prosecution or disciplinary actions against them This is for any events that they may, or have reported, especially those based on the information contained in the reports they may have submitted However, this does not always mean that such reports can be submitted without any consequences” (GAIN Working Group, 2004)

Mandatory reporting, according to the report, has been utilized effectively, in the aviation industry to great success In addition, when mandatory reporting is used in conjunction with confidential reporting, incident levels do have a tendency of decreasing The new system for Danish air traffic controllers also allows authorities to train individuals

to both assess and further produce their reports This is done through by prioritizing reports; those, which require urgent attention are addressed first The culture of trust that

this system created as a result, was able to permeate the entire air-traffic control chain of command It thus allowed existing air traffic controllers to address existing problems earlier, and with less fear of punishment from figures of authority (GAIN Working Group, 2004)

Glendon and Stanton (2000), suggest that reporting methods should be quantitative

in nature, as well as qualitative, for the maximum efficacy of the reports They further suggest that the measurement of existing safety culture, does depend on its definition The prevailing definition in turn, reflects the perspective adopted within a given organizational culture This measurement is not merely empirical, but it rests upon a value decision As a result, ethnographic approaches, while being possibly the most valid form an interpretive perspective, are often costly and time consuming in nature Case study data reported here, showed that two existing and independent measures did reveal existing safety improvements over time This was as reflected in the patterns of behavior and working practices, as found within an existing organizational environment (Glendon & Stanton, 2009)

The convergence of existing data, from the different methodologies utilized, is most likely to improve both the breath and subsequent accuracy However, the direction and resulting influences, of such prevailing “cause and effect” situational contexts, cannot necessarily be established from their analysis It may thus be summarized, in the fact that observed changes, if present in both measures, do reflect the prevailing corresponding changes These are as found in the underlying aspects of the prevailing safety culture (Glendon & Stanton, 2009) They are of the suggestion that such methods of quantitative analysis, do provide those in authority with more accurate and hence concrete knowledge

of safety measures and analysis, within a given organization

New Zealand operates a mandatory reporting system, with provision for information revealing the identity of the source to be removed if confidentiality is requested (the latter happens only rarely) The reporting requirements apply to all aircraft accidents and to all serious incidents except those involving various sport and recreational operations In addition to the notification requirements for accidents and incidents, the rules require the aircraft owner or the involved organization notifying a serious incident to conduct an investigation to identify the facts relating to its involvement and the causal factors of the incident A report of the investigation is required within 90 days of the incident and must include any actions taken to prevent recurrence of a similar incident

Information received under this mandatory reporting system cannot be used for prosecution action, except in special circumstances such as when false information is supplied or when „unnecessary danger‟ to any other person is caused (Ref New Zealand Civil Aviation Rule CAR Part 12.63.)

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 culpability (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 if and how the reports will be further investigated (the focus of the investigation; face-to-face interview.)

 Decide which reports will be further investigated (those which are most severe;

or those with the most learning potential)

 Decide who will investigate the reports

Table 4: Steps to build a Just Culture Reporting System

In case of Danish Airway, the Danish reporting system ensures immunity against penalties and disclosure but also any breach against the non-disclosure guarantee is made a

punishable offense Danish Airway has chosen a mandatory, non-puntive and confidential reporting system In particular, Air Traffic Controllers must submit reports of events It is

punishable not to report an incident in aviation And, reporters are ensured indemnity against prosecution or disciplinary actions for any event they have reported based on the information contained in the reports submitted However, this does not mean that reports may always be submitted without consequences Ideally, the reporter‟s identity may not be revealed outside the agency dealing with occurrence reports Investigators are obliged to keep information from the reports undisclosed One more important thing is this reporting system allow to immunity against any penal or disciplinary measure If a report is submitted within 72 hours of an occurrence; if it does not involve an accident; or does not involve deliberate sabotage or negligence due to substance abuse Punitive measures are stipulated against any breach of the guaranteed confidentiality

It may not be obvious to all organizations which system would suit them best Ideally, a variety of reporting methods (or a flexible method) will be implemented, as not one reporting method will suit everyone‟s needs It may be necessary for the organization

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

3.2.4 Determine roles and responsibilities

For such a system to thrive, a number of different people need to be involved in the implementation and maintenance of the system A „local champion‟ will be needed to promote and act as guarantor to ensure the assurances of anonymity will be preserved in the face of external or managerial pressures Decide and select someone to:

 Champion the system

 Educate users and implement system

 Collect and analyze the reports

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

 Feedback the information (develop newsletter)

 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 necessary remedial actions in relation to the reported occurrences, iv) persuade other aviation authorities and organizations to take any necessary remedial actions, v) assess and analyze the information reported in order to detect safety problems (not necessarily apparent to the individual reporters); vi) where appropriate, make the information from the reports available and issue specific advice or instructions to particular sections of the industry; vii) where appropriate, take action in relation to legislation, requirements or guidance The Air Accidents Investigations Branch (AAIB) investigates accidents, and these are passed on to the CAA for inclusion in the MOR

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

of the „right‟ kind-of people, who are energetic, well-liked, well-known and respected in the company Then, they try to maintaining the energy required for the system to function

3.2.5 Developing and Maintaining Just Culture

A number of additional issues concerning the „cultural‟ aspects of reporting are necessary in order to maintain motivation to report, such as the trust between reporters and the managers must genuinely exist for the reporting system to work The main aims are to develop an open culture in which people feel able to trust the system and to develop new ways to motivate people to use the system Below are initial ideas