[ For internal circulation only]
November 2018
- Compiled and developed by stakeholders of safety operations of Vietnam Airlines.
- Compiled by inputs from the CEO’s presentation on Just Culture, jointly developed by AAPA Flight Operations & Safety Working Group (FOSWG)
- Derived from a document from which permission to reprint was given by the Global Aviation Information Network (GAIN).
- Reviewed by 5Echo Inc. (Singapore)
FOREWORD
CONTEXT
“A safety culture depends critically upon first negotiating where the line should be drawn between unacceptable behaviour and blameless unsafe acts. There will always be a grey area between these two extremes where the issue has to be decided on a case by case basis. A large number of aviation organisations 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 reported without fear of sanction. Once this trust culture has been established, the organisation 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. There will be setbacks and challenges along the way, but engineering a Just Culture is the all-important early step, as so much else depends upon it.”
– James Reason
Any effective safety information system depends heavily on the willing participation of the workforce, the frontline workers who are in direct contact with hazards. In aviation organisations, these are air traffic controllers, pilots, flight crew, maintenance personnel and others who can provide key information about aviation safety problems and potential solutions. Achieving this reporting culture requires an organisational climate in which people are willing to report their errors and incidents. A successful Just Culture must draw the line between acceptable and unacceptable behaviour, then encourages compliance with appropriate regulations and procedures, foster safe operating practices and promote the development of internal evaluation programs.
On May 12th 2018, the CEO of Vietnam Airlines, Mr. Duong Tri Thanh, had a session discussing the basic concepts of Just Culture, indicating his acknowledgement of the Just Culture development process to be a long and challenging journey.
His vision can be demonstrated in the following graph:
The ‘Just Culture line’ is indicated as the balance
between ‘blame-free culture’ and punitive culture