Thực hiện văn hoá chính trực trong ngành hàng không một số gợi ý cho hãng hàng không quốc gia 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 HỐ CHÍNH TRỰC TRONG NGÀNH HÀNG
KHƠNG: 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 HỐ CHÍNH TRỰC TRONG NGÀNH HÀNG
KHƠNG: MỘT SỐ GỢI Ý CHO HÃNG HÀNG KHÔNG QUỐC
GIA VIETNAM AIRLINES
Chuyên ngành: Quản trị kinh doanh
Mã số: 8340101.01

LUẬN VĂN THẠC SĨ QUẢN TRỊ KINH DOANH

NGƯỜI HƯỚNG DẪN KHOA HỌC: PGS.TS. NGUYỄN NGỌC THẮNG

HÀ NỘI - 2020


DECLARATION

The author confirms that the research outcome in the thesis is the
result of author‟s independent work during study and research period and it is
not yet published in other‟s research and article.
The other‟s research result and documentation (extraction, table,
figure, formula,

and other document) used in the thesis are cited properly

and the permission (if required) is given.
The author is responsible in front of the Thesis Assessment
Committee, Hanoi School of Business and Management, and the laws for
above-mentioned declaration.


TABLE OF CONTENTS
LIST OF FIGURES
LIST OF TABLES
TITTLE CHAPTER .............................................................................................................. 1
1.

Rationale .................................................................................................................... 1

2.

Literature review........................................................................................................ 2

3.

Research Aim ............................................................................................................ 4

4.

Research Objectives .................................................................................................. 4

5.

Research Scope .......................................................................................................... 4

6.

Structure of the thesis ................................................................................................ 4

CHAPTER I: THEORETICAL BACKGROUND ................................................................ 6
1.1.

Safety culture definition ........................................................................................ 6

1.2.

A Just Culture definition ....................................................................................... 7

1.3.

Benefits of Just Culture ......................................................................................... 8

1.4.

Principles of Just Culture....................................................................................... 9

1.5.

Distinguish acceptable and unacceptable behaviors ............................................ 11

1.6.

Just Culture decision tree ..................................................................................... 13

1.7.

Creating and implementing Just Culture ............................................................. 15

CHAPTER II: METHODOLOGY ...................................................................................... 18
2.1.

Research approach ............................................................................................... 18

2.2.

Data collection ..................................................................................................... 20

2.2.1.

Secondary data............................................................................................. 20

2.2.2.

Primary data: semi-structured interviews ................................................... 20

2.2.3. Interview preparation......................................................................................... 21
2.2.4. Sampling ............................................................................................................ 22
2.2.5. Pilot test ............................................................................................................. 22
2.3.

Interview implementation .................................................................................... 23

2.4.

Method of analysis .............................................................................................. 23

2.5.

Research ethics .................................................................................................... 24

CHAPTER III: JUST CULTURE PRACTICE IN THE AVIATION INDUSTRY ........... 25
3.1.

History of Just Culture in the world aviation industry ........................................ 25

3.2.

Just Culture Practice in the world aviation .......................................................... 26

3.2.1.

Legal Aspects .............................................................................................. 26


3.2.2.

Reporting Policy and Procedures ................................................................ 27

3.2.3.

Methods of Reporting .................................................................................. 29

3.2.4.

Determine roles and responsibilities............................................................ 33

3.2.5.

Developing and Maintaining Just Culture ................................................... 33

3.3.

Just Culture implementation in Vietnam Airlines ............................................... 35

3.3.1.

Vietnam Airlines introduction ..................................................................... 35

3.3.2.

Just Culture Policy and Documentation in Vietnam Airlines ..................... 37

3.3.3.

Vietnam Airlines Safety Improvement Indicators ....................................... 41

CHAPTER IV: RESEARCH FINDINGS AND RECOMMENDATIONS FOR VIETNAM
AIRLINES ........................................................................................................................... 46
4.1.

Research finding - Current situation of applying a Just Culture in Vietnam

Airlines ............................................................................................................................ 46
4.1.1. Just Culture relating policies that put by Vietnam Airlines in encouraging
everyone to raise safety related issues ......................................................................... 46
4.1.2. Vietnam Airlines has a safety reporting system that is clear confidential and
non-punitive ................................................................................................................. 47
4.1.3. Vietnam Airlines‟ Just Culture implementation roadmap ................................. 48
4.2.

Recommendations for Vietnam Airlines: A human factor training program ...... 52

4.2.1.

The necessity to establish a human factor training program ....................... 52

4.2.2.

Guidelines for establishing a human factor training program ..................... 53

4.2.3.

Suggestions for human factors training contents ......................................... 54

4.2.4.

Recommendations ....................................................................................... 62

CONCLUSION ................................................................................................................... 64
1.

Summary.................................................................................................................. 64

2.

Limitations and Direction for further researches ..................................................... 64

REFERENCE ...................................................................................................................... 66
APPENDIX 1: INTERVIEW SCHEDULE ........................................................................ 72
APPENDIX 2: INTERVIEW TRANSCRIPT ..................................................................... 73


LIST OF FIGURES

Name of figure

Page

Figure 1

Safety culture components

9

Figure 2

Just Culture safety behavior definition model

14

Figure 3

Reason‟s Decision Tree for determining the culpability of unsafe

16

acts
Figure 4

Thematic analysis‟s stages

25

Figure 5

Safety and Quality policy of Vietnam Airlines in 2009 and 2010

38

Figure 6

Safety and Quality Policy of Vietnam Airlines in 2016

39

Figure 7

The „Just Culture line‟

40

Figure 8

Just Culture of Vietnam Airlines

41

Figure 9

Vietnam Airlines incident rate 2010-2018

42

Figure 10

IATA Operations Safety Audit Results of Vietnam Airlines

43

Figure 11

IATA Operations Safety Audit Certificate of Vietnam Airlines

43

Figure 12

Vietnam Airlines Safety Reporting Statistics

44

Figure 13

Mandatory Occurrence Report to CAAV

45

Figure 14

Vietnam Airlines‟ Just Culture implementation roadmap

49


LIST OF TABLES

Name of table
Table 1

Main features of inductive and deductive approach (Adopted from

Page
20

Sauders et al. 2011)
Table 2

The main features, advantages and disadvantages of qualitative and

21

quantitative research method (Adopted from Sauders et al. 2011)
Table 3

Different types of interview (adopted from Sauders et al.2011)

23

Table 4

Steps to build a Just Culture Reporting System

33

Table 5

Main ideas to develop and maintain a Just Culture

35

Table 6

The development process of Vietnam Airlines in 2006-2019

38

Table 7

Acceptable & Unacceptable Behaviours

41


TITTLE CHAPTER
1.

Rationale
Through hundreds year of formation and development, the aviation industry has been

considered as one of the most complex, dynamic and safety critical environment. As a fact
that the aviation history witnesses cases where millions of dollars and people's lives can be
costed due to a single unsafe act of individuals (Filn et al., 2000). It could easily be proven
by researches and experience that no matter how well-trained or motivated an individual is,
due to the physiological, cognitive and sensory limits on the human condition, this
individual will end up making errors in analysis or misjudgement of a situation, which
finally causes unsafe acts (Reuter 2016). And all this might lead to situations where safety
is impaired or perceived to be impaired. Leaders in the aviation industry need to accept this
and need to be aware that in order to continuously improve their imperfect system and

need to learn from these “unsafe” events and deviations from the norm to analyze them,
and improve on what to do and how to do. As an investigation of the Global Aviation
Information Network (GAIN) in 2018, by adhering to Just Culture principles, airlines
industry members are trying to change that deeply engrained behavior of hiding mistakes
and rather, encourage people to actively, honestly report these events without needing to
fear undue retribution. With the introduction of the Occurrence Reporting Regulation
376/2014, the European aviation industry finally received a legally binding definition of
„Just Culture‟ (GAIN, 2018). While obviously, a binding regulation is what really counts,
there were several initiatives not only to define what Just Culture is, but also to outline
how it should work. The efforts of EUROCONTROL Just Culture Task Force or the Just
Culture Declaration - signed by most European Aviation stakeholders on 1st October 2015
- are just two of such initiatives (GAIN, 2018).
However, regardless of all intentions, most organizations still struggle with the
concept of Just Culture, how to introduce it in their operation system and more
importantly, how to make fully use of it. The reasons for this are manifold. But one of the
most typical reasons is that, Just Culture requires more than just a regulatory compliance
and copy-pasting the definition in the manuals. Just Culture requires a far-reaching
paradigm shift, which is a long and challenging journey for airlines to enhance Just Culture
implementation. In Vietnam, Aviation brands gradually realize the importance of a Just
Culture in generating a more effective safety and operational management. On May 12th
2018, the CEO of Vietnam Airlines - the most typical Vietnamese airlines brand, Mr.
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Duong Tri Thanh had a session discussing problems relating Just Culture practice; and he
also underlined the obligations and responsibilities of aviation stakeholders towards
implementing Just Culture in all aspects of the working environment. Thus, this thesis will
not only try to clarify current situation of Just Culture practice in the aviation industry, but
also give some recommendations for Vietnam Airlines in particular.
2.

Literature review
Before the 21st century, very few people had heard about Just culture. Currently,

almost every organization in the aviation industry has implemented the Just Culture in all
their activities. Recent findings have suggested that; the Just Culture has become the
foundation for safety in the aviation industry (Frazier, 2012).
The research “Achieving a safe culture: theory and practice” of Reason (1998)
introduced the concept of Just Culture as one of five components of Safety Culture along
with Informed culture, Reporting Culture, Flexible Culture and Learning Culture. This
paper considered why it is that an unsafe culture is more likely to be involved in the
causation of organizational rather than individual accidents. And this investigation also
concerned with the practical question of whether a safety culture can be engineered. It is
argued that a safe culture is an Informed Culture and this, in turn, depends upon creating an
effective Reporting Culture that is underpinned by a Just Culture in which the line between
acceptable and unacceptable behavior is clearly drawn and understood.
Walulik (2011) with the paper “Just Culture Principles and the Investigation of
Air Accidents and Incidents” is one of the most typical air accident investigations. The
article discusses the issue of the proper balance between ensuring aviation safety and
executing responsibility. The article concentrates on Just culture Principles aimed at
balancing safety and responsibility in aviation. This includes a discussion of
EUROCONTROL heritage in this respect and of the implementation of Just principles in
Annex 13 to the Chicago Convention, Regulation 966/2010/EU and Polish aviation law.
The analysis also focuses on relations between safety investigations and Just Culture
before concluding some with recommendations for the lawmaker.
The investigation of McCall, J.R. and Pruchnicki, S., (2017) about “Just culture: A
case study of accountability relationship boundaries influence on safety in highconsequence industries” indicate a barrier to advancing meaningful safety agendas, which
is the desire of many managers to “hold someone accountable” for errors. The
misconception that clear lines of accountability can and do exist, and that employees who
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cross the line between acceptable and unacceptable behavior should be punished, fails to
recognize the different types of accountability relationships negotiated by employees every
day. Such judgments run counter to the concept and practice of a Just Culture. This
opaqueness is seen in numerous accidents which reveal the conflicting effects employees
in high-consequence industries face as they move between and across these accountability
boundaries. This germane example is the crash of Swissair Flight 111, near Halifax, Nova
Scotia, in 1998. Here we offer dialogue to aid in understanding the influence accountability
relationships have on safety, and how employee behavioral expectations shift in
accordance. The authors proposed that this examination would help redefine accountability
boundaries that support a Just Culture within dynamic high-consequence industries.
Global Aviation Information Network in a report in 2018 also proposed “A
Roadmap to a Just Culture: Enhancing the Safety Environment”, which provide some
preliminary guidance on how to create a just reporting culture and some insights on how to
plan the implementation of such a system. This report also indicated principles of a Just
Culture and benefits of an organization applying a Just Culture. Especially, eight steps to
implement Just Culture in operation and management were introduced, which are legal
aspects, (2) Reporting Policy and Procedures; (3) Method of reporting; (4). Determine
Roles and Responsibilities, Tasks and Timescale; (5) Develop Reporting Form; (6)
Develop Template for Feedback to Potential Users; (7) Develop a Plan for Educating the
Users and Implementing the System; (8) Developing and Maintaining the Right Culture.
The eight-step implementation is developed and applied by a lot of airlines brand
nowadays.
In terms of ground services, a product of Air Transport Safety Institution (2011) in
cooperation with the Civil Aviation Authority of the Netherlands named “Just culture and
human factors training in ground service providers”, investigated what elements are
required to establish and maintain a Just Culture, and what elements are required to
establish a human factors training program. The results of the research on Just Culture
have been tested by means of a practical application of a Just Culture self-audit at six

ground service providers in the Netherlands. This may raise ideas of creating and
implementing a Just Culture self-audit for other players in the aviation market in order to
to manage human errors and promote safe behavior. Besides, this report also gave specific
recommendations to service providers to improve their Just Culture, a Just Culture audit
template to be used by ground service providers and auditing organizations.
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3.

Research Aim
The aim of this study is to critically evaluate Just Culture practice in the aviation

industry and give some recommendations for Vietnam Airlines.
4.

Research Objectives
The objectives of this report include the following:
•

Provide a review of literature of Safety Culture and Just Culture

•

Raising awareness in the aviation community of the benefits of creating a Just
Culture

•

Provide a road map of Just Culture implementation in aviation organizations

•

Provide initial guidelines from case studies to develop and maintain a Just
Culture; and share learned lessons that might be helpful to others who also
benefit from applying Just Culture

•

Give some recommendations for Vietnam Airlines to improve Just Culture
implementation.

5.

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

Airlines from 2000 till now.
6.

Structure of the thesis
This study includes five chapters
1) Title Chapter: this chapter provides the background of Just Culture practice in
the airlines industry in the world and the case of Vietnam airlines as well as
clarify the reason of choosing this topic. Then, the research aims, objectives,
research questions, research methodology and research structure are respectively
given.
2) Chapter 1: Theoretical background: in this chapter, the conceptual framework
and theoretical foundation of Just Culture and Just Culture practice process are
presented carefully. This section also delivers a brief discussion of benefits of

Just Culture in an airlines industry. The implementation of Just Culture in an
airlines industry is also discussed in this chapter.
3) Chapter 2: Methodology describes the methodology research which is used in
the study. A qualitative approach with semi-structured interviews is adopted
4) Chapter 3: Just Culture Practice in an aviation industry descriptive analysis,
factor analysis, reliability analysis and group comparison tests are undertaken in
4


this chapter. Besides, the result of qualitative data is presented in a diagram
format.
5) Chapter 4: Recommendations for the Vietnamese Aviation Brand the most
outstanding findings are analyzed and discussed in comparison with the
literature in the previous chapter. Some reasons for this research results are also
proposed and proved.
6) Conclusion: this chapter begins with a summary of what this paper was done in
general. Then, some implications and limitations are presented in this chapter,
following by directions for future research.

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CHAPTER I: THEORETICAL BACKGROUND
1.1. Safety culture definition
An ideal safety culture is the “engine” that drives the system towards the goal of
sustaining the maximum resistance towards its operational hazards, regardless of the
leadership's personality or current commercial concerns. In aviation organizations, there
are air traffic controllers, pilots, flight crew, maintenance personnel and others who can
provide key information about aviation safety problems and potential solutions. According
to Reason (1997), the components of a safety culture include: just, reporting, learning,

informed and flexible cultures.
First of all, achieving this Reporting Culture requires an organization climate in
which people are willing to report their errors and incidents. In particular, an effective
Reporting Culture depends on the way an organization handles blame and punishment. A
Reporting Culture supports an informed culture in which the managers and operators have
good knowledge of all factors that determine the level of safety. Other relevant parts in the
safety culture framework of Reason are a Flexible Culture, the ability to reconfigure in the
face of high-tempo operations or certain kinds of danger, and a Learning Culture, the
willingness and competence to draw right conclusions from its safety information system
and the will to implement major reforms when needed. Besides, once Just Culture has been
established, the organization can begin to have a reporting culture, something that provides
the system with an accessible memory, which is essential in underpinning to a Learning
Culture. All these contributing parts interact and the overall safety culture is more than the
sum of its parts (Reason, 1997).

6


Figure 1: Safety culture components (Reason 1997)
1.2. A Just Culture definition
Reason (1997) describes a Just Culture as an atmosphere of trust in which people are
encouraged, even rewarded, for providing essential safety-related information, but in
which they are also clear about where the line must be drawn between acceptable and
unacceptable behavior. A “Just Culture” therefore, comprises of pertinent unique features
such as trust, the lack of unjustified blame, steady and timely response to criminal and
negligible activities. This is in addition to the prevailing the reward system, especially on
the aspect of reporting near misses, regarding incidents or accidents (Soeters & Boer,
2010). In other words, a Just Culture is built on integrity, consistency and commitment to
achieve the desired results of absolute safety to passengers. As Denison (1996) states, both
safety standards and organizational cultures can be used interchangeably to portray the

same thing.
Another definition for Just Culture derived from Sidney Dekker in his paper in 2008
is a culture in which employees must be accountable for their actions and, in return, are
provided assurance that they will be treated in a fair manner following an incident or
accident. The discipline needs to be tied to the behavior of individuals and the potential
risks their behavior presents more than the actual outcomes of their actions.

7


This is also reflected by the definition provided by the European Commission, in
which: „Just culture‟ means a culture in which front line operators or others are not
punished for actions, omissions or decisions taken by them that are commensurate with
their experience and training, but where gross negligence, willful violations and destructive
acts are not tolerated (EC No 691/2010). An effective reporting culture depends on how
the organization handles blame and punishment. A “no-blame” culture is neither feasible
nor desirable. Most people desire some level of accountability when a mishap occurs. In a
Just Culture environment the culpability line is more clearly drawn. A “Just Culture” refers
to a way of safety thinking that promotes a questioning attitude, is resistant to
complacency, is committed to excellence, and fosters both personal accountability and
corporate self-regulation in safety matters.
A “Just” safety culture, then, is both attitudinal as well as structural, relating to both
individuals and organizations. Personal attitudes and corporate style can enable or facilitate
the unsafe acts and conditions that are the precursors to accidents and incidents. It requires
not only actively identifying safety issues, but responding with appropriate action. In fact,
Just Culture operates by design to encourage compliance with the appropriate regulations
and procedures, foster safe operating practices, and promote the development of internal
evaluation programs.
1.3. Benefits of Just Culture
The GAIN report (2004) suggests that creating a Just Culture promotes an

environment where everyone involved in the situation learns from potentially unsafe acts
or mistakes. This is as opposed to an environment where potentially unsafe acts or
mistakes become compounded by individuals, assigning blame and covering up their
mistakes (GAIN Working Group, 2004). To be noted is that Safety Culture and Just
Culture, are not synonymous. According to Cox & Cheyne (2000), a culture of safety is
something that can be achieved through the creation of a Just Culture. Thus, although the
two concepts are intricately linked, they are not synonymous, as they do indicate to varying
ideals. When a Just Culture is created within a given organization, the resulting blame-free
environment improves the overall safety standards present. This is due to the increase in
the willingness of employees to actively participate in the reporting of unwarranted and
hence dangerous (reckless) behaviors (Cox & Cheyne, 2000).

8


The benefits that can be gained from the creation of a Just Culture in an organization
include measurable effects such as increased event reports and corrective actions taken, as
well as intangible organizational and managerial benefits.
Increased reporting
A Just Culture can lead to not only increased event reporting, particularly of
previously unreported events, but also the identification of trends that will provide
opportunities to address latent safety problems. It has been estimated that for each major
accident involving fatalities, there are as many as several hundred unreported incidents
that, properly investigated, might have identified an underlying problem in time to prevent
the accident. (GAIN Operator‟s Flight Safety Handbook, 1999). A lack of reported events
is not indicative of a safe operation, and likewise, an increase in reported events is not
indicative of a decrease in safety. Event reporting illuminates potential safety concerns,
and any increase in such reporting should be seen as a healthy safety indicator. Peter
Majgard Nørbjerg of Naviair, Denmark‟s air traffic service provider, reported that after a
June 2001 change to Denmark‟s law making confidential and non-punitive reporting

possible for aviation professionals, the number of reports in Danish air traffic control rose
from approximately 15 per year to more than 900 in the first year alone.
More Effective Safety and Operational Management
Just Culture will enhance the organization‟s effectiveness by defining job
performance expectations, establishing clear guidelines for the consequences of deviance
from procedures, and promoting the continuous review of policies and procedures.
Just Culture is expected to allow an organization to be better able to determine
whether violations are occurring infrequently or if deviation from established procedures
has become normalized among its front-line employees and supervisors.
Outdated or ineffective management structures can be manifested in many ways, as
by operational inefficiencies, lost opportunities, or safety lapses. While Just Culture is
primarily implemented by a safety motive, it is recognized “that the same factors which are
creating accidents are creating production losses as well as quality and cost problems.”
(Capt. Bertrand DeCourville, Air France, 1999)
1.4. Principles of Just Culture
This section discusses some of the main issues surrounding Just Culture, including
the benefits of having a learning culture versus a blaming culture; learning from unsafe

9


acts; where the border between “acceptable” and “unacceptable” behavior should be; and
ways to decide on culpability.
Evaluating the benefits of punishment versus learning. A Just Culture supports
learning from unsafe acts. The first goal of any manager is to improve safety and
production. Any event related to safety, especially human or organizational errors, must be
first considered as a valuable opportunity to improve operations through experience
feedback and lessons learnt.
Failures and „incidents‟ are considered by organizations with good safety cultures as
lessons which can be used to avoid more serious events. There is thus a strong drive to

ensure that all events which have the potential to be instructive are reported and
investigated to discover the root causes, and that timely feedback is given on the findings
and remedial actions, both to the work groups involved and to others in the organization or
industry who might experience the same problem. This „horizontal‟ communication is
particularly important.
Organizations need to understand and acknowledge that people at the sharp end are
not usually the instigators of accidents and incidents and that they are more likely to inherit
bad situations that have been developing over a long period (Reason, 1997). In order that
organizations learn from incidents, it is necessary to recognize that human error will never
be eliminated; only moderated. In order to combat human errors we need to change the
conditions under which humans work. The effectiveness of countermeasures depends on
the willingness of individuals to report their errors, which requires an atmosphere of trust
in which people are encouraged for providing essential safety-related information (Reason,
1997).
Marx (2001) has identified four types of behavior that might result in unsafe acts.
The issue that has been raised by Marx (2001) and others is that not all of these behaviors
necessarily warrant disciplinary sanction.
1. Human error – is when there is general agreement that the individual should have
done other than what they did. In the course of that conduct where they inadvertently
caused (or could have caused) an undesirable outcome, the individual is labeled as having
committed an error.
2. Negligent conduct – Negligence is conduct that falls below the standard required
as normal in the community. Negligence, in its legal sense, arises both in the civil and
criminal liability contexts. It applies to a person who fails to use the reasonable level of
skill expected of a person engaged in that particular activity, whether by omitting to do
10


something that a prudent and reasonable person would do in the circumstances or by doing
something that no prudent or reasonable person would have done in the circumstances. To

raise a question of negligence, there needs to be a duty of care on the person, and harm
must be caused by the negligent action. In other words, where there is a duty to exercise
care, reasonable care must be taken to avoid acts or omissions which can reasonably be
foreseen to be likely to cause harm to persons or property. If, as a result of a failure to act
in this reasonably skillful way, harm/injury/damage is caused to a person or property, the
person whose action caused the harm is liable to pay damages to the person who is, or
whose property is, harmed.
3. Reckless conduct – (gross negligence) is more culpable than negligence. The
definition of reckless conduct varies between countries; however, the underlying message
is that to be reckless, the risk has to be one that would have been obvious to a reasonable
person. In both civil and criminal liability contexts it involves a person taking a conscious
unjustified risk, knowing that there is a risk that harm would probably result from the
conduct, and foreseeing the harm, he or she nevertheless took the risk. It differs from
negligence (where negligence is the failure to recognize a risk that should have been
recognized), while recklessness is a conscious disregard of an obvious risk.
4. Intentional “willful” violations – when a person knew or foresaw the result of the
action; but went ahead and did it anyway.
1.5. Distinguish acceptable and unacceptable behaviors
As a basis for achieving a Just Culture, there should be ways to distinguish between
acceptable and unacceptable behavior. However, it is difficult to discriminate between the
truly “unacceptable behavior” (bad behavior) and “acceptable behavior”. There is always
existence of a “grey area” between two extremes where issue has to be decided on a case
by case basis. Thus, it is necessary to agree with a set of principles for drawing this line.
First of all, the author will define the “negligence”, which includes a harmful consequence
that a “reasonable” and “prudent” person would have foreseen. And the definition of
“Recklessness” is the person who takes a deliberate and unjustifiable risk. According to
Reason (1997), the line between “unacceptable” and “acceptable” behavior should be
drawn after clarifying substance abuse for recreational and “malevolent damage”. A
successful Just Culture must draw the line between acceptable and unacceptable behavior,
then encourages compliance with appropriate regulations and procedures, foster safe

operating practices and promote the development of internal evaluation programs.
11


This is especially due to the fact that the “Blame Culture” still plays a crucial role,
regarding incident/ accident investigations, as well as the prosecution cases. A large
number of aviation organizations have embarked upon this process, and the general
indications are that only around 10% of actions contributing to bad events are judged as
culpable. In principle, this means that the large majority of unsafe acts can be reports
without fear of sanction.

Figure 2: Just Culture safety behavior definition model (author derived based on Reason
1997)
In this model, a positive behavior is considered as such when it generates positive
benefits to the organization. All good activities, assignments and behaviors should be
recognised and rewarded.While below expectation behavior includes all other types of
unintentional behaviors, which usually generates unsafe instances in the organisation. This
could range widely from errors caused by the system, honest individual mistakes or
behaviors that can be categorized as both.
In this thesis, the author also introduces Vietnam Airlines‟s Just Culture following
this behavior definition model. Each Department Divisions in Vietnam Airlines to be
required continuously update the safety behavior examples of themselves in each
categories follow Just Culture Definition Tree and dissemeniate them internally for all
employees to understand what exactly positive behaviour, acceptable or unacceptable
behaviour.
12


1.6. Just Culture decision tree
The Decision tree is created by Professor James Reason with the aim of determining

the culpability of unsafe acts. In order to decide whether a particular behavior is culpable
enough to require disciplinary action, a policy is required to decide fairly on a case-by-case
basis. Reason‟s Culpability Decision Tree follows, representing a structured approach for
determining culpability. The assumption is that the actions under scrutiny have a
contributed to an accident or to a serious incident. There are likely to be a number of
different unsafe acts that contributed to the accident or incident, and Reason believes that
the decision tree should be applied separated to each of them. The concern is with
individual unsafe acts committed by either single person or by different people at various
points of the event sequence
The 5 stages include:
Step 1: Intended act: The first question in the decision tree related to intention. If both
actions and consequences are intended, it is possibly criminal behavior and should be dealt
with outside of the company
Step 2: Under the influence of alcohol or drugs: Known to impair performance at the
time that the error was committed. A distinction is made between substance abuse with or
without “reasonable purpose”, which is still not blameless, but not as serious as taking
drugs for recreational purposes
Step 3: Deliberate violation of rules: did the system promote the violation or discourage
the violation or had the behavior become automatic or part of the local working practices
Step 4: Substitution test: could a different person (equally motivated, competent and
qualified) have made the same error under similar circumstances (determined by peers). If
“yes”, the person who made the error is likely to be blameless. If “no”, were there systeminduced reasons (insufficient training or positioned)? If not, negligent behavior should be
considered
Step 5: Repetitive errors: The final question asks whether the person has committed
unsafe acts before. This does not presume culpability, but may imply that additional
training or counseling is required

13

Figure

3:

Reason‟s

Decision

Tree

for

determining

14

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.
15


Lack of reported events does not necessarily indicate a safe operation (Dekker, 2012).
Likewise, increased reporting on events does not indicate a decrease in the level of safety.
Even reporting illuminates the potential safety concerns an organization has. Increased
reporting should be seen as a healthy, safety indicator (Eurocontrol, 2006).
Step 2: Determine roles, responsibilities and tasks
A number of different people needs to be involved in the development,
implementation and maintenance of the safety reporting system. A person has to be
appointed who is responsible for the development, implementation, promotion and
management of the safety reporting system. This person ensures confidentiality of
reporting and reports directly to the board of directors to highlight (potential) safety issues
and trends. At management level, a person has to be assigned the responsibility to decide if
disciplinary actions have to be taken after errors, incidents or accidents.
To support the safety reporting system, personnel have to be appointed to perform
the activities of collecting, assessing, analyzing and monitoring of safety reports and
trends, and circulating safety information in the organization.
Step 3: Reduce legal barriers
The first step to be taken for consideration is the legal aspect of Just Culture. An
organization has to have in place a disciplinary framework that supports reporting of
incidents. This will significantly reduce any legal impediments to reporting. The first
significant step in changing the legal aspects may entail substantiating the current legal
situation and establishing whether it needs to be changed.
In order to reduce the legal barriers to reporting and assessment of safety occurrences
and trends, the two most important issues are: indemnity against disciplinary proceedings
and a legal framework that supports reporting and investigation of incidents. Without these

aspects firmly established in the organization, ramp personnel may not report errors and
incidents because of fear of legal proceedings.
Step 4: Establish methods of reporting and assessment
Another important step is selecting the reporting method to be used. Some of the
issues the organization may consider with regard to the method by which reports are
collected are the rapid, usefulness and intelligible feedback of the reporting community.
The organization should also consider the ease at which reports are generated. This is
because; voluntary reporting is often perceived an extra task (Bayuk, 2007). Therefore, the
organization will require a clear and unambiguous direction for reporting and accessing to
reports. Reporting of safety issues should be a clearly described and easy process, safety
16


reports should be professionally assessed and managed, and feedback should be rapid,
useful, accessible and intelligible to all personnel.
Step 5: Develop reporting form
Although safety issues could be reported verbally, it is beneficial to also develop a
reporting form that encourages accurate and complete reporting (e.g. questions that are
understandable) and is easy to fill in; otherwise reporters may provide erroneous or
misleading responses. The objective of the safety reporting system has to be carefully
considered when deciding on what information is required to reach this objective.
Step 6: Develop template for feedback to potential users
It is important that reporters and other ramp personnel know as soon as possible that
an occurrence has been investigated and that the root cause is solved. Feedback may be
given on individual reports, but also in a combined form by means of regular safety letters
or memos.
Step 7: Develop plan for educating users and implementing the system
Potential reporters have to be informed about the safety reporting system and know
how to submit their information. This may include induction courses and periodic
awareness sessions to remind ramp personnel of the importance of reporting and to ensure

that all ramp personnel are familiar with the reporting procedures.
Step 8: Develop and maintain a Just Culture
A number of additional issues concerning the „cultural‟ aspects of reporting are
necessary in order to maintain motivation to report, such as trust between the reporters and
their supervisors, and between the supervisors and their managers. This is a precondition
for the safety reporting system to function. The main objectives are to develop an open
culture in which people feel able to trust the system and to develop new ways to motivate
people to use the system.
Continuous management commitment has to be ensured. To maintain and improve
management commitment to safety, management has to be continuously involved in the
reporting process to show visibly that they believe in and are willing to promote the Just
Culture. Simultaneously, commitment to safety of ramp personnel has to be ensured by
actively involving them in the assessment of safety issues and development of corrective
actions.
Although above steps are based upon the GAIN roadmap to a Just Culture (GAIN,
2004), it is clear that they have interactions with a variety of safety culture aspects. In
particular, a large number of these steps are related to what Reason calls „engineering a
reporting culture‟ (Reason, 1997). This thesis also tries to check the implementation of Just
Culture in aviation industry through these seven-steps.
17


CHAPTER II: METHODOLOGY
This chapter will describe the methodology undertaken in this study. In the first
section, research approach will be given, followed by the discussion of secondary and
primary research. Data collection and data analysis are outlined in the following section.
Research limitations and ethnic considerations are discussed in the fourth section followed
by summary of the methodology chapter
2.1. Research approach
With regard to research approach, deductive approach and inductive approach are

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

Deductive approach

Theory follows data

Data follows theory

Less structured methodology

Structured methodology

A small sample of subjects

A large number of samples

Little attention to generalisation

Generalisation

Develop

in-depth

understandings

human‟s emotion and perceptions.

of Enable

cause-effect

link

between

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