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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 LIST OF FIGURES LIST OF TABLES TITTLE CHAPTER Rationale Literature review Research Aim Research Objectives Research Scope Structure of the thesis CHAPTER I: THEORETICAL BACKGROUND 1.1 Safety culture definition 1.2 A Just Culture definition 1.3 Benefits of Just Culture 1.4 Principles of Just Culture 1.5 Distinguish acceptable and unacceptable behaviors 1.6 Just Culture decision tree 1.7 Creating and implementing Just Culture CHAPTER II: METHODOLOGY 2.1 Research approach 2.2 Data collection 2.2.1 Secondary 2.2.2 Primary d 2.2.3 Interview preparation 2.2.4 Sampling 2.2.5 Pilot test 2.3 Interview implementation 2.4 Method of analysis 2.5 Research ethics CHAPTER III: JUST CULTURE PRACTICE IN THE AVIATION INDUSTRY 3.1 History of Just Culture in the world aviation industry 3.2 Just Culture Practice in the world aviation 3.2.1 Legal Asp 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 Summary 64 Limitations and Direction for further researches 64 REFERENCE .66 APPENDIX 1: INTERVIEW SCHEDULE .72 APPENDIX 2: INTERVIEW TRANSCRIPT 73 LIST OF FIGUR Figure Safety culture com Figure Just Culture safety Figure Reason‟s Decision acts Figure Thematic analysis‟s Figure Safety and Quality Figure Safety and Quality Figure The „Just Culture l Figure Just Culture of Vie Figure Vietnam Airlines in Figure 10 IATA Operations S Figure 11 IATA Operations S Figure 12 Vietnam Airlines S Figure 13 Mandatory Occurr Figure 14 Vietnam Airlines‟ LIST OF TABLES Na Table Main features of inductive Sauders et al 2011) Table The main features, advant quantitative research meth Table Different types of intervie Table Steps to build a Just Cultu Table Main ideas to develop and Table The development process Table Acceptable & Unacceptab TITTLE CHAPTER 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 and how to 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 copypasting 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 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 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 Provide sufficient time/overlap for shift handovers; Include team aspects (e.g group decision making, interpersonal skills) in human factors training; Establish a mature safety culture which disseminates to the teams; Provide leadership courses to supervisors; Establish a code of conduct to respectfully approach colleagues of different cultural or ethnic backgrounds; Use historical data (actual aircraft departure/arrival time) in scheduling of pilots and pursers 63 CONCLUSION Summary In summary, this research project has discussed some of the ways in which the topdown nature of safety management systems may be used to create a Just Culture within organizations in the aviation industry Research data gathered in this paper has considered several aspects of a safety culture in aviation management The research has also suggested some of the strategies for a Just Culture that can be designed and implemented In the aviation industry, safety is regarded as the reduction of overall risk levels Organizations in the aviation industry aim at having the lowest levels of risk In this research paper, Just Culture is a new development in management theory especially in corporate workplaces In the past, workplaces operated under the mutual understanding that employees will not inform or report to authorities, as well as, management about situations and conditions that required improvement This research paper has showed that, in some cases, these conditions and situations may be irritating to workers However, in other cases, these conditions at the workplace may be actively dangerous to employees and the public Reporting of errors will ensure that they are addressed accordingly and prevented from taking place in the future The researcher has used a semi-structured interview approval by Vietnam Airlines top managers and tried to analyze those data to go deep inside the Just Culture and its characteristics; and use the answers of Vietnam Airlines particpipants as fundamental materials for discussions and findings Limitations and Direction for further researches This study has been investigated under tight control; however, it still has some limitations need to adjusted in the further research Firstly, there is a lack of previous researches on this subject in Vietnam The reason is that Just Culture is rapidly emerging in aviation organizations; hence, it is quite new topic for researchers While the studies about the Just Culture in other Western countries are not really well adopted in the Vietnam aviation context Secondly, this study has some limits in which the findings can be apply Given that, purposive sample technique was utilised for collecting survey sampling in this study some bias may be present in the research results As the author and most of his acquaintances are come from Hanoi – the North of Vietnam, 90% of interview participants are from Hanoi or the immediate surrounding districts Recognising the culture differences 64 internationally or even within this country, the finding maybe only appropriate for only the North of Vietnam rather than the South of Vietnam or other parts of the world Based on the research finding and above limitations, some recommendations for further research are raised Firstly, the limit about the sample could be solved by applying mixed technique As qualitative data collection methods such as interview or group focus requires a small number of participants, the author is possible of choosing equal participant groups between region Qualitative data collection also effectively help author to understand participant insight more precisely and comprehensively While quantitative techique with questionaire study could help author to collect a large sample in a scale of the whole organization Thus, future research could be undertaken with quantitative methods or mixed method to measure the success of a Just Culture program under the view of all organization staffs Secondly, as this research confirms the role of Just Cuture in enhancing safety culture in an aviation industry, future research is proposed to focus on how Vietnam Airlines educates their staff about Just Culture and how effective is human factor training program in building a strong Just Culture in such a big aviation organization 65 REFERENCE Adjekum, D.K., 2014 Safety culture perceptions in a collegiate aviation program: A systematic assessment Journal of Aviation Technology and Engineering, 3(2), p.44 Akselsson, R., Koornneef, F., Stewart, S and Ward, M., 2009 Resilience safety culture in aviation organisations HILAS (Human Integration into the Lifecycle of Aviation Systems) 2009: Chapter 2; draft version Alasuutari, P., Bickman, L and Brannen, J., 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To which extent you classify Vietnam Airlines as a good Just-Culture business? - If you class your business as a good Just-Culture business, to which extent your business can maintain and strengthen Just Culture? In-depth questions Policies encourage people to o raise safety-related issues 1) How affective those Just-Culture-relating policies that put by Vietnam Airlines in encouraging everyone to raise safety-related issues? 2) Have these been recognized by everyone that small proportion of unsafe acts were indeed intentional and reckless and warrant punishment, but that the large majority of such acts are not intentional and should not attract punishment? A confidential and non-punitive safety reporting system 3) Did Vietnam Airlines have a safety reporting system that is clear confidential and non-punitive? 4) Which departments take responsibility to handle these reports? Indicate clearly the process to handle these reports? A Just-culture implementation roadmap 5) Did Vietnam Airlines have a clear roadmap to implement and maintain Just Culture in the long term? If have, please introduce Vietnam Airlines roadmap to implement Just-Culture 6) Defined potential obstacles to achieve a Just Culture at Vietnam Airlines 72 APPENDIX 2: INTERVIEW TRANSCRIPT Thank them for participation Introduce yourself and the project Answer any questions they may have prior to interview Ask for permission to record Emphasize the anonymous nature of research Remind they can stop and withdraw at any time General questions: - Tell me about when you started your job at Vietnam Airlines and how it has grown to date I worked as a member of human resource department at Vietnam Airlines 10 years ago and now I am among the top management of Safety - Quality Department - To which extent you would know about Just Culture? A “Just Culture” refers to a way of safety thinking that promotes a questioning attitude, is resistant to complacency, is committed to excellence, and fosters both personal accountability and corporate self-regulation in safety matters In my opinion, Just Culture is very important to build a strong aviation business in a long term because as a Just Culture supports learning from all safety events in order to improve the level of safety awareness through improved recognition of safety situation and helps develop conscious articilation and sharing of safety - To which extent you classify Vietnam Airlines as a good Just-Culture business? The CEO of Vietnam Airlines, Mr Duong Tri Thanh has presented his idea of building a Just Culture in his organization, in which the Just Culture line is indicated as the balance between “blame-free culture” and punitive culture Behaviour definitions and implementation guide of Just Culture issued by the President & CEO is attached to the Decision No 205/QD-TCTHK-ATCL dated February 25, 2019 with scope of application in all activities of Vietnam Airlines; and subjects of application are all Employees, Departments/Divisions of Vietnam Airlines We have also built a road map to implement and maintain Just Culture, which require the participation of all departments in the company So I think we are on the way to become a good Just-Culture business 73 In-depth questions Policies encourage people to raise safety-related issues 1) How affective those Just-Culture-relating policies that put by Vietnam Airlines in encouraging everyone to raise safety-related issues?” It is significant that reporting or making policies that encourage everyone in the aviation industry to raise safety and report about safety issues should be prioritized Thus, I believe that Just-Culture-relating policies that put by Vietnam Airlines in encouraging everyone to raise safety-related issues 2) Did this recognize by everyone that small proportion of unsafe acts were indeed intentional and reckless and warrant punishment, but that the large majority of such acts are not intentional and should not attract punishment? Departments such as the air traffic control, pilots or vehicle drivers are legally bound to report any occurrence or incident Several task forces have been created within the aviation industry Most of these tasks forces have found out that punishing air traffic controllers and pilots with fines or suspending their licenses might have led to a reduction in the reporting of incidents and sharing of safety information Different tasks forces have recognized the need for an active culture that encourages honest reporting and one that has not yet been reconciled with the legislative powers or the judicial system Thus, the CEO of Vietnam Airlines, Mr Duong Tri Thanh has presented his idea of building a Just Culture in his organization, in which the Just Culture line is indicated as the balance between “blame-free culture” and punitive culture The shift from the traditional “Blame Culture” to a more constructive “Just Culture” can be expected to have tangible benefits that will contribute positively to the overall safety culture of an organization A confidential and non-punitive safety reporting system 3) Did Vietnam Airlines have a safety reporting system that is clear confidential and nonpunitive? Vietnam Airlines has had a safety reporting system only because it is required by law The current Vietnam Airlines safety reporting process is cumbersome and that Operations personnel may be more willing to report if the process was simplified by the implementation of an electronic, web ‐ based, lodgment system 4) Which departments take responsibility to handle these reports? Indicate clearly the process to handle these reports? 74 Safety-Quality Department of Vietnam Airlines take responsibility to handle these reports They evaluate the occurrences, follow-up on open reports; disseminate occurrence information through a range of publications; record reports in a database (names and addresses of individuals are never recorded in the database); monitor incoming reports and store data to identify hazards/potential hazards; and carry out searches and analyzes in response to requests within the Vietnam Airlines and industry Confidential reports are directed to and reviewed by the Head of SQD, who initiates a dis-identified record The Head of SQD contacts the reporter to acknowledge receipt and to discuss further; after discussions the report is destroyed; and the record is be processed as an occurrence, but annotated as confidential (only accessible by restricted users) A Just-culture implementation roadmap 5) Did Vietnam Airlines have a clear roadmap to implement and maintain Just Culture in the long term? If have, please introduce Vietnam Airlines roadmap to implement JustVietnam Airlines‟ Just Culture implementation roadmap can be simplified as the fivephase circle process - Phase 1: Effects of Just Culture implemented - Phase 2: Analytics of results & review of Just Culture definitions and evaluation procerdure - Phase 3: Clearly defined Just Culture definitions and expectations - Phase 4: Clearly defined Just Culture Implementation procedure - Phase 5: Implemenation phase 6) Potential obstacles to achieve a Just Culture at Vietnam Airlines can be discovered: - Changes to the legal framework that support reporting of incidents: For Vietnam Airlines, one of the main challenges of developing a Just Culture will be to change the legislation, especially because the changes are counter to societal expectations - Internal resistance: as one of the most senior and largest aviation organization on Vietnam, Vietnam Airlines will experience difficulties persuading senior management of the need for creating a Just Culture and to commit adequate resources - Choosing the right reporting system: Due to the low current number of reports across the organization, Vietnam Airlines may need to survey the needs of 75 potential users to better understand which reporting method would be best accepted - Determining “champions”: this requires conscious and real commitment from Vietnam Airlines‟s Management and staff, as having sufficient resources and having the right people who are well liked, well known and respected in the company may prove to be difficult - Designing the perfect reporting form: Reporting forms may be standardized among other airlines may not the best fit for Vietnam Airlines - Educating the users with regard to the changes and motives of the new system: This maybe difficult in a large organization with many subsidiaries like Vietnam Airlines, where information about the system may not be discriminated to a wide enough audience and a deep enough level within the organization - Methods for developing and maintaining a Just Culture: It takes time and persistence to try and change safety attitudes, and maintaining motivation throughout the organization can be a challeges CEO of Vietnam Airlines has already projected this to be a 10 year endeavour, not a short term issue 76 ... 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... 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... 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