To what extent does compliance to HRO also stimulate the development of a safety culture and if so, why and if not, why not?

An insight into a High Reliability Organisations operating in the European Civil Aviation Sector

To what extent does compliance to HRO also stimulate the development of a safety culture and if so, why and if not, why not?

Universiteit Leiden

Crisis and Security Management, Master Thesis Author: Amir Kennedy Ripon, S2116383

Supervisor: Dr Jaap Reijling. 2nd reader: Dr Joery Matthys

TABLE OF CONTENTS

Acknowledgement 4

Overview Tables and Figures 5

List of Abbreviations 6

Abstract 8

1 Introduction 10

1.1 The Important Relationship between Management

and Frontline employees 11

1.2 Managerial Top-Down Approach 13

1.3 Research Question and Relevance 15

1.4 Societal and Scientific Relevance 15

1.5 Readers Guide 16

2 Theoretical Framework 17

2.1 Safety Culture 17

2.2 The Theory of Planned Behaviour (TPB) 21

2.3 High-Reliability Organisation (HRO) Theory 26

2.3.1 HRO/NAT Debate 27

2.3.2 Five Characteristics of HRO Theory 29

2.4 Conceptual framework 32 3 Research Methodology 36 3.1 Design 36 3.2 Data Collection 37 3.2.1 Documents 37 3.2.2 Survey Questionnaire 39 3.2.3 Interviews 41 3.3 Data Analysis 42 3.3.1 Document Analysis 42 3.3.2 Survey Analysis 45 3.3.3 Interview Analysis 46

3.5 Limitations 50

4 Analysis 52

4.1 Compliance to HRO Characteristics 52

4.1.1 Anticipation 52

4.1.2 Containment 56

4.1.3 Sub-Conclusion HRO Characteristics 59

4.2 Development of Safety Culture 60

4.2.1 Informed Culture 60 4.2.2 Reporting Culture 63 4.2.3 Just Culture 65 4.2.4 Learning/Adaptable Culture 67 4.3 Conclusion 72 4.3.1 Research Question 75 5 Discussion 75 5.1 Scientific Relevance 76 5.2 Recommendation 77

5.3 Recommendations for further studies 79

6 References 80

Appendix 1. Senior Safety Management Structure 85

Appendix 2. The Managerial Chain of Command Structure

of the Inflight Services (IFS) Department 86

Appendix 3. A Safety Culture's (4) Components and (12) Elements 87 Appendix 4. 12 Questions in Relation to his 4 Subcultures of Safety Culture 88

Appendix 5. Illustrative Summary of HIRA Process 89

Appendix 6. Empirical Managerial Indicators that Comply

with HRO Characteristics 90

Appendix 7. Survey Questions Results 92

Appendix 8. Transcript One 93

Appendix 9. Transcript Two 104

Acknowledgement

This master thesis is original unpublished independent work by the author, A.S.K. Ripon. It is part of the Master Crisis & Security Management of Leiden University, Faculty of

Governance and Global Affairs. As part of the capstone on High Reliability.

I owe a large extent of gratitude to my supervisor: Dr Jaap Reijling, who consistently offered his academic expertise and incredible patience during this research, which I have been privileged to have received. Additionally, I would like to thank my second reader: Dr Joery Matthys, who supported this thesis process with valued academic insights. To both, I owe my

sincere gratitude. Additionally, I also thank Leiden University for this opportunity and the wonderful city of Den Haag. I would like to think my immediate family and close friends who have been very supportive, especially my friend Verena Stuber who has offered a great sense

of encouragement throughout. Last but certainly not least, thank all the respondents who participated with the survey and interviews process.

Overview Tables and Figures

Tables

Table 1. Indicators that Identify HRO Themes within Aer Lingus. 44 Table 2. The Relationship between the Survey Questions and Safety Culture. 45 Table 3. The Relationship between a Safety Culture Traits

and HRO Characteristics. 47

Figures

Figure 1. Reporting as a Reciprocal System between Employee and Employer 12

Figure 2. Safety Culture Characteristics. 18

Figure 3. The four Sub-Cultures for Aviation Safety Culture 20

Figure 4. Theory of Planned Behavior Model (PPB) 24

Figure 5. The Five Characteristics of HRO 30

List of Abbreviations

CCI - Cabin Crew Instructions

CCLOB - Crew Line Operations Bulletin DSS - Director of Safety & Security EASA - European Aviation Safety Agency FAA - Federal Aviation Administration

FDM - Flight Data Monitoring

GCC - Operations Control Dispatch

HIRA - Hazard Identification and Risk Assessment

HRO - High Reliability Theory

IAA - Irish Aviation Authority

IATA - International Air Transport Association

IC - Informed Culture

IFS - Inflight Services Department

JC - Just Culture

LAC - Learning/Adaptive Culture

LSS - Line Standards Supervisor

NAT - Normal Accident Theory

RC - Reporting Culture

SEP - Safety Emergency Procedures

SOP - Standard Operation Procedure SPRP - Safety Plan Progress Report

TPB/PBT - Theory of Planned Behaviour/Planned Behaviour Theory

ABSTRACT

This research set out to answer several questions. First of all, it examines if the company under review complies with HRO characteristics. Secondly, it looks at the perception of frontline staff of their safety culture. Based on the questions above, this research will attempt to answer to; what extent does compliance to HRO also stimulate the development of a safety culture and if so, why and if not, why not?

In answering this question, this research first examines three theories, namely

High-Reliability Organisation Theory (HRO), Planned Behaviour Theory (TPB) and the Normal Accident Theory (NAT). Furthermore, an overview of safety culture, including its four subcultures reporting culture, informed culture, just culture and learning/adaptive culture are given (refer to Appendix 3. A Safety Culture`s (4) components and (12) elements).

A case-study approach focusing on a medium-sized commercial airline was selected. A multiple methods approach was conducted, such as interviews, surveys and a document study. The theoretical framework was applied to analyse the collected data.

The findings indicate that the company complies significantly with HRO characteristics. Furthermore, support the development of a safety culture in most areas. Additionally, the survey results illustrated that frontline staff do have, to a large extent confidence, and perceive their safety culture positively.

However, although there is company compliance with HRO theory and this system design per se is successful, it was identified that some frontline staff do not have confidence in some areas, such as a confidential reporting system. The results of this research also point out that elements of complacency exist at lower levels of management, which undo the work of the senior safety department officers.

Even though a company may prove a significant level of compliance with HRO

characteristics and a system design per se, it does not indicate frontline staff perceptions will follow in this alignment direction. Although company compliance with HRO characteristics does support the development of a safety culture, there are some frontline staff who remain unconvinced. The relevance of the HRO/NAT debate is that a system design may be fine, and the system designer per se may tick all the boxes. However, complacency may be the culprit and not the system designers, which HRO theory would posit. Complacency can occur down

the management chain of command, and not necessarily at the frontline. It is important to know that within this study, some frontline staff did not have full confidence that their department, team managers processed their reports confidentiality. Such results indicate merely lower level managerial complacency and not a system design error per se.

1. Introduction

One area that has become increasingly complex with added tight couplings is the aviation sector. Tight coupling refers to a "system that is interactively complex" whereby,

"independent failure events can interact in ways that cannot be predicted." (Marais, Dulac, and Leveson, 2004, p01-02).

The airline industry has become progressively dependent on the infrastructure that serves it, such as technology. This dependency leads to a certain level of vulnerability which is going to increase in the near future. Furthermore, the increase in the number of flyers, along with the airlines' strategic business shift towards increasing the frequency of flights, means more planes and more passengers with increased air congestion (Zhang, Lemoine, and Mitchell, 2018). As the airline sector continues to expand rapidly, while catering for the needs of the growing global populations, airlines as such are being simultaneously and increasingly tested. With such unprecedented and foreseeable growth of the airline industry, record numbers of passengers are expected to double from 4 billion up to 7.8 billion by 2036 (IATA, 2017).

To counter these increased risks, the application of HRO theory (Weick & Sutcliffe, 2011) can assist airlines in integrating efficient methods that support good safety culture. This solution-based approach can help organisations tackle unwanted dangers and hazards, particularly in the face of immense pressure and increasing challenges placed upon the aviation industry at large. This paper shall offer a specific insight within the airline industry by assessing one active and rapidly evolving airline by collecting and applying empirical data. This paper is not an audit; however, an attempt to see if a given European airline works towards endorsing appropriate mechanisms that comply with HRO theory and whether they support the development of a safety culture.

Nowadays, two conflicting theories, the Normal Accident Theory (NAT) and High-Reliability Organisation (HRO) theory exist to explain crisis management within

organisations that operate in potentially unsafe environments. Both schools of thought and their debate contribute to the essential cornerstone of the development of efficient

organisational safety cultures. HRO theory believes in the effective use of redundancy, where the redundancy is protecting against accidents caused by an individual or random component failures rather than system design errors (Leveson, Dulac, Marais & Carroll, 2009). On the

other hand, NAT upholds that 'system design failures' are accountable for organisational accidents. Both theories are explored further in chapter 2.

A typical central feature of all these theories is the strengthening of a safety culture within the organisations, either by organisational design or through quality systems of some sort. Wang (2018) defines a safety culture as "the status of an organisation free from potential hazards, and secondly, culture is made up of the behavioural norms at play […] the formation of a safety culture should be a role modelling process that consists of a belief, attitude, and

recognition of the core-value of safety, commonly shared by members of the organisation, i.e. frontline staff. When such a role model is emulated and behaves as a norm, a successful Safety Management Systems (SMS) implementation is featured within an organisation." Due to the common feature to the safety culture, this research will also explore and measure the safety culture perceptions of an airline.

The relevance of this research is to see the extent to which management implements HRO characteristics and the level of compliance that exists. The results should allow this study to contribute to the understanding of how the implementations of HRO characteristics from a top-down perspective supports the development of a safety culture and if so, why and if not, why not?

1.1 The Important Relationship between Management and Frontline Employees In order to look at the research question, the following paragraphs explain the importance of organisational foresight and related policies. Organisational policies are adjusted according to reports gathered from frontline reports. Revised policies as such, are regularly implemented within the Standard Operational Procedures (SOPs) by management. The SOPs are a guideline or manual in order for frontline staff to conduct their job function safely and are implemented in order to reduce potential risk from occurring. These SOPs are consequently being revised at a declaratory level and executed by frontline staff at a practical level. Therefore, this study must look at the relationship between frontline employees and their management to see the extent to which a reporting culture exists. Organisations should encourage their frontline employees to report their safety concerns. As a general rule, company support towards the staff that report their concerns is transparently outlined in policy format, within their SOP manual.

It is expected that the organisation can then establish a safety culture by gathering regular reports from its staff openly and honestly without fear of punishment.

The system-model below (figure 1) gives an idea of how to engineer a safety culture (Wang, 2018). Frontline employees must be willing to report recognised errors, mistakes or near misses. Additionally, frontline staff must be encouraged to divulge information about all safety hazards affecting a system. This provides them with the opportunity to express their ideas about what should be done to mitigate against potential risk. A reporting culture as such depends crucially upon the way that an organisation handles reports (Wang, 2018). When these reporting structures are followed within an organisation, they should benefit the safety culture. Moreover, a reporting culture leads to an informed culture insofar as it helps the company to analyse further and learn from these reports and re-address any safety concerns to its frontline staff. Therefore, a good reporting culture per se is a reciprocal system, as illustrated below.

HRO theory argues that the establishment of a mindful reporting culture decreases accidents and therefore increases overall safety. HROs have been "characterised especially by

flexibility and redundancy, in pursuit of safety and performance" (La Porte, 1996, p10). Therefore, the HRO theory sees safety achievements as fundamentally reliant upon frontline employees and their behavioural intent, one which promotes a safety-conscientious approach within their working environment. The HRO theory believes that frontline employees and their safety awareness contributions (at the mere micro-level) influences and forms part of the bedrock of an organisation's safety culture achievements. This behavioural intent or safety-conscientious behavioural traits support an overall 'informed culture' which are considered to be a vital linchpin in HRO theory

Aurigemma (2013) posits that behavioural intent is an essential factor affecting the

organisation's safety culture. Aurigemma (2013) says that the Theory of Planned Behaviour (TPB) links an employees' behavioural intent with how they execute their tasks. This is important to consider, as it determines whether staff will embrace elements that management wishes to establish from a top-down approach, that promotes a safety culture. Ajzen believes that "intentions to perform behaviours of different kinds can be predicted with high accuracy from attitudes toward the behaviour, subjective norms, and perceived behavioural control. These intentions, together with perceptions of behavioural control, account for considerable variance in actual behaviour.[…] attitudes, subjective norms, and perceived behavioural control are shown to be related to appropriate sets of salient behavioural, normative, and control beliefs about the behavior" (Ajzen, 1991, p179). Furthermore, the PBT links behavioural intent with expected behaviour among frontline staff within a given HRO.

1.2 Managerial Top-Down Approaches

There is arguably nothing more critical to the successful implementation of a safety

management system (SMS) than gaining the support of senior management. Without it, even the most well-thought-out program is doomed to fail. The chief executive officer (CEO) must be invested in the safety management system (SMSs) success by promoting and supporting the safety policy, and importantly, committing the resources of the organisation. In short, it must be a top priority in word and in deed (Stolzer, 2017). "A positive safety culture is generated from the top-down. Senior leadership must set the stage for a positive safety

culture. Through words, (verbal and documented) and actions. Management at all levels must clearly demonstrate its commitment to safety in all its decisions. This includes directing the

resources of the organisation to address safety concerns. Senior management establishes safety as a core value and provides strong safety leadership" (Stolzer, 2017, p46) (refer to 'Appendix 1. Senior Safety Management Structure' and 'Appendix 2. The Managerial Chain of Command Structure of the Inflight Services (IFS) Department' for a top-down illustration).

Although frontline staff deserve a significant portion of the credit for maintaining an organisation's safety culture, HRO theory posits that a safety culture could not exist unless management lay-down the fundamental criteria for establishing and supporting the

development of a safety culture system. The HRO theory and its five characteristics support the development of a safety culture when implemented by management. The five

characteristics are divided into two categories, 'Anticipation' and 'Containment'. Anticipation comprises three sub-elements 1) Preoccupation with failure, 2) Reluctance to simplify operations, 3) Sensitivity to operations. Containment comprises two sub-elements, 4) commitment to resilience, 5) Deference to expertise. Although this theory continues to develop, it is believed that when these five characteristics are implemented by management, they theoretically manifest and establish an organisation that should, in theory, be able to operate in a highly reliable and safe manner and avoid incurring their fair share of accidents.

If management implements these HROs characteristics, it is contemplated that they support the development of a safety culture from a top-down approach. This approach is believed to provide some groundwork for a given safety culture to be born. A safety culture can be further supported by ensuring a high priority is placed on safety, attention to problems, and a learning orientation (Leveson et al., 2009) where frontline staff share a common vigilant and mindful outlook. Therefore, it is increasingly accepted that the mechanisms management adopts, supports the development of a safety culture and is an influential factor in shaping "good" safety performance within HROs (Cox, Jones and Collinson, 2006). Additionally, Weick and Roberts (1993) posit that HROs companies and their management can become highly reliable and avoid system accidents by supporting preferential behaviours and attitudes (Leveson et al., 2009). For example, establishing a genuine just culture policy that

encourages and even rewards staff for reporting their own poor behaviour and those of their peers as an incentive, should not be frightened to file their report. Transparent reporting encourages frontline employees to help circumvent 'foolish' rules in order to maintain safety, especially during a crisis (Leveson et al., 2009). Moreover, frontline staff can use their knowledge and judgment to maintain safety (or reliability) during emergencies. In some

cases, during crises, some decision-making efforts are afforded to the frontline workers who have the necessary judgment to make decisions (Leveson et al., 2009, p228).

1.3 Research Question

To what extent does compliance to HRO also stimulate the development of a safety culture and if so, why and if not, why not?

1.4 Societal and Scientific Relevance

In the following paragraphs, the societal relevance of this study, followed by the research question and a reader's guide is presented. This study will examine 'how' a sample of frontline employees perceive their given safety culture. Their understanding and

interpretation are essential because employees' perceptions in-effect, shape how they execute their every action, within the workplace.

The societal relevance of this study is to offer the airline industry some methods in which they may be able to build upon their organisational safety culture. In attempting to do so, this research will be looking to see the extent to which managerial mechanisms comply with HRO theory. If there is no compliance at the organisational level (management) and the five HRO characteristics, then it is expected that the cultural level (frontline employees) will be affected by an inadequate safety culture and will perceive it as such. However, if there is an alignment, this will be analysed to see the extent to which alignment exists between the frontline staff and the four subcultures (refer to Appendix 3. A Safety Culture's (4) Components and (12) Elements) that when present, should establish a safety culture. If managerial policies comply with any one of the five HRO characteristics, the mechanisms that shape this should be seen as positive indicators. Management must support the

development of a safety culture, and they can achieve this with compliance to the developing HRO theory characteristics. Frontline employees also have a role to play in the development of their safety culture, at the mere organisation's cultural level.

Moreover, Frontline employees also craft their safety culture with the attitude they adopt, which consequently determines their behaviour and in-turn; this behaviour gives a good indication of how an employee will execute their task on the day. This process is relevant as it will offer a more in-depth understanding of how the company attempts to support the development of a safety culture through its policies and frontline employees.

This research will inspect how a given organisation with little room for error, sets out to establish a safety culture, and see if they align with academic expectations. Moreover,

explore how good employees' attitudes lead to good behaviours that assist the implementation of a successful safety management systems and consequently, work towards establishing a distinctive organisational safety culture. HRO theory provides a template on which to understand better how safe and reliable performance under trying conditions may be achieved. This may be useful to researchers and caregivers who seek to improve safety and reliability (Sutcliffe, 2011).

Most of the literature surrounding HROs focuses on the military and medical industries notwithstanding, nuclear energy operations in general. There is a gap in the literature that examines a European regulated airline. Moreover, a lack of study exists on understanding how companies manage and establish their safety culture from a top-down approach, and if their practices genuinely establish a safety culture in a way that management designed it to deliver. In answering this latter question, this study will also examine frontline employees. This research approach examines many areas to understand if HRO mechanisms have actively been implemented, and to what extent they improve safety. Understanding how HROs work in the airline industry will help airlines and their staff to become more aware of their safety culture.

1.5 Readers Guide

In this chapter, this exposition continues with a theoretical framework in chapter 2 explaining the phenomenon in scientific terms. Moreover, a connection will be made, with the

importance of examining if necessary managerial safety measures have been exercised. In chapter 3, the operationalization linking theory and practice will be specified in detail. In chapter 4, the outcomes shall be presented and evaluated, which will include company documents, three interviews and one survey conducted with 112 respondents. In chapter 5, a conclusion will be delivered with due reflection upon the research methods applied, and the findings obtained. This research shall offer its assessment and suggest recommendations based on its findings for further research and safety improvements within the European aviation industry and beyond.

2 Theoretical Framework

As alluded to within the introduction, this research has identified three fundamental theories that surround the development of safety cultures - High-Reliability Organisation (HRO) theory, Normal Accident Theory (NAT) and the Planned Behaviour Theory (PBT). This study shall apply these theories and view them through a scientific lens per se. Particularly when looking at the safety culture of one particular organisation. The following paragraphs will firstly discuss all aspects of a safety culture and then discuss each of the theories in more detail.

2.1 Safety Culture

The most challenging element for companies within the aviation industry is to encompass all the relevant safety components which establish a safety culture. The safety culture concept has been discussed among experts from the Federal Aviation Administration (FAA) who say a safety culture is the cornerstone of accident prevention. Moreover, a healthy safety culture is the most effective and systematic method for mitigating accidents and incidents across the industry. For a safety culture to truly unfold and function effectively, articulate attention needs to support all efforts that implement and strengthen the entire organisation's safety culture. This can be challenging as the battle between protection and production remains (Stolzer, Halford, and Goglia, 2011).

According to Stolzer et al. (2011), a strong safety culture helps prevent accidents. The problem, however, is that even if there is a zero-accident rate, it is difficult to prove that this is attributed to the establishment of a safety culture. Safety experts have the problem that they are not able to show senior management how many accidents have been prevented. However, if one accident occurs, it becomes evident that there is a flaw in the organisation's safety culture. The NAT debate would argue that a system design would be a fault, while HRO looks at the component failure elements.

While this research points out what a good safety culture should be, it is important to indicate what a poor safety culture looks like. Moreover, Wang (2018, p106) posits that "a poor safety culture apparently is unable to provide the adequate safety tools, program, equipment and protective method, so employees are unable to proactively deal with possible system deficiencies in a defenses-in-depth concept."

According to Wang (2018, p111), "a safety culture is a sub-facet of organisational culture, which is thought to affect members attitudes and behaviour." Additionally, he states "a safety culture brings together shared behaviours, beliefs, attitudes and values." In order to establish a good safety culture, Wang (2018) believes the development of a safety culture relies mainly on four subcultures that have to be implemented. Those subcultures are (1) Informed Culture, (2) Reporting Culture, (3) Just Culture, (4) Learning/Adaptable Culture. When all these subcultures are established within an organisation, whether it be initially through policies, departments that oversee change or where human resources are put into place to support these developments indicates efforts made towards supporting the development of a safety culture. Those four identified characteristics are essential and alluded to in figure 2.

Figure 2. Safety Culture Characteristics.

(Reason, 1997)

According to Dhabbari (2018, p67), "a safety culture development requires an understanding of safety culture characteristics." Reason (1997), considered that an organisation with a positive safety culture would have an informed workforce with an

effective safety information system which collates and analyses data about incidents and near misses. It will have a culture of reporting in which people, who are in direct contact with hazards, are willing to report their own errors and near misses. However, this also depends on how errors and near misses are handled.

Reason (1998, p293) says "a reporting culture is dependent upon a safety culture, that is consequently underpinned by a just culture." The most important factor for a successful reporting culture is trust between employer and employee. Trust gives employees or

crewmembers the chance to express their ideas in regards of what could be done to mitigate a hazard (Wang, 2018). This means that an atmosphere of trust where people are encouraged and even rewarded to provide related information that strengthens a company's resilience must be created. Organisations need a just culture where people are encouraged to report errors and near misses and are rewarded for doing so, rather than receiving blame and punishment. A learning/adaptive culture is another sub-element that helps establish a more significant safety culture, where people have the ability to draw the right decisions from the organisation's safety information system and thereby improve safety.

It is argued that a safety culture is also an informed culture. However, for a culture to be informed, all employees must be willing to report any safety-related concerns. This means that a reporting, as well as a learning/adaptive culture, should exist. Within a good safety culture, organisational members must share the behavioural norms, same ideas and beliefs about risks, accidents and ill-health that increase employee's commitment to safety. All of these not only help an organisation to attain its goal in promoting its safety culture but they are also intended to direct people's attention and actions towards the management of safety (Cooper, 2000). Favourable behavioural norms within an organisation's and its safety culture can be compared to the analogy insofar as like nationalism or patriotism, people believe in a greater cause, a collective goal. This patriotism among frontline employees seeks to protect their safety culture by reporting issues to management. This in-turn assists the management to anticipate and contain challenges posed from environmental factors to a great extent. Without frontline employees reports, the safety department would be effectively blind, deaf and dumb and consequently ill-equipped to deal with potential risks and hazards along the horizon.

According to Wang (2018), another element that establishes a safety culture is a

learning/adaptive culture. This is whereby, a learning/adaptive culture is a flexible process seeking the balance point between daily practices, known hazards and the dynamic agreement between top management people and frontline workers. By implementing all these practices collectively, one then creates what is referred to as an informed culture. Additionally, an informed culture is whereby "system managers and operators have current knowledge […] that determine system safety as a whole." (Cooper, 2000, p112). It is furthermore important

for frontline staff to understand the essence of a safety culture as they have to put these standards into practice (Cooper, 2000).

While trust is essential to formulate a safety culture, an organisational [safety] culture does not spring up ready-made. Organisations, like organisms, adapt. Safety cultures evolve gradually in response to local conditions, past events, the character of the leadership and the mood of the workforce (Reason, 1998). Moreover, a safety culture cannot easily be created or engineered. The creation or enhancement of a safety culture is dependent upon the deliberate manipulation of various organisational characteristics that impact safety management

practices. This is where the HRO theory template becomes a beacon of light.

The following figure (figure 3) gives an overview of different cultures contributing to a safety culture:

Figure 3. The four Sub-Cultures for Aviation Safety Culture.

Wang (2018, p105) states that a safety culture has two concepts. Safety is thereby defined as a status where potential hazards are absent and whereby culture acts as the behavioural norm. These concepts and the overall safety culture need to be directed by a role-modelling process, consisting of belief, attitude, and recognition of the core-value of safety, all of which should be a and shared intervention.

This belief and attitude bring us to the theory of planned behaviour (TPB). TPB posits that a person's attitude determines what their behaviour will be. Therefore, the PBT also comes to the forefront, as it connects the importance of behaviour and the development of a safety culture.

2.2 The Theory of Planned Behaviour (TPB)

According to Ajzen (1991), the theory of planned behaviour believes that a core factor is a person's actual intention on how they decide to behave. A person's intention influences their impetus which determines their behaviour. Moreover, it stipulates the degree to which or how much effort a person is willing to perform within their chosen behaviour. The higher the intention to participate in a given behaviour, the more influence it has on its performance. This links the process of behavioural control with higher performance. Moreover,

behavioural control influences the extent to which a person is motivated to try in the way that the higher the behavioural control, the higher the performance (Ajzen, 1991).

Based on Ajzen, (1991), Moan, and Rise, (2011) suggest someone's proximal determinant of behaviour can determine their intention to engage in a particular behaviour.

Aurigemma, (2013, p5) says "that a person's intention to take action, given some actual control over the behaviour in question, generally leads to that actual behaviour taking place. As such, the planned behaviour theory (PBT) links behavioural intent with expected

behaviour." Understanding this link between behavioural intent with expected behaviour is crucial in a highly reliable organisation and its associated safety culture. It enables an organisation to understand how their frontline employees will execute their safety-related tasks.

According to Aurigemma (2013) and the PBT, an employee's behaviour establishes how they will execute their tasks at an operational level. With the absence of mindfulness behaviour among frontline employees, a safety culture could not be established in a way that offers highly reliable operations to coexist in harsh, challenging environments. Managerial efforts that are directed 'down the pyramid' (chain of command) must be appropriately interpreted

and implemented by frontline staff competently. If administrative directives are executed successfully, then the establishment of a safety culture is expected to occur. This approach will allow this study to answer the question: To what extent does compliance to HRO also stimulate the development of a safety culture, and if so, why and if not, why not?

It is important to note that as external agencies shape and craft people's attitude, which is then converted into their actual behaviour and one's inevitable action. When putting this into the perspective within the workplace, these external agencies are managerial policies and the people are the frontline employees. Managerial policies can determine an employee's behaviour and action. If managerial policies are interconnected with HRO characteristic attributes, then it is expected that an employee's behaviour is positive with regards to the external managerial agencies. This would indicate that the company supports the

development of a safety culture, which would suggest that employees actions would align reciprocally back with HRO traits.

In summary, if HRO traits coexist alongside managerial policies, it is expected that a safety culture will exist and then there should be alignment. This is referred to as a reciprocal engineered system, as illustrated in figure 1.

The PBT "is made of elements such as perceived behavioural control, which includes, attitudes, subjective norms, and behavioural intentions. These four elements together are considered to be the primary constructs that establish the Planned Behavior Theory (PBT). According to the PBT, perceived behavioural control, together with behavioural intention, can be used directly to predict behavioural achievement" (Ajzen, 1991, p184). This means that an employee's perception will determine and predict their actions such as executing their tasks. That is why this study measures employee perceptions. Employees perceptions can be seen as potential indicators as to what extent their perceptions align with safety culture characteristics.

Ajzen, (1991, p179) posits that "intentions to perform behaviours of different kinds can be predicted with high accuracy from attitudes toward the behaviour, subjective norms, and perceived behavioural control; and these intentions, together with perceptions of behavioural control, account for considerable variance in actual behaviour." Moreover, he states that the "perceived behavioural control is the extent to which an individual believes she/he can control a behaviour at will. Attitudes are the affective (emotion-laden) and instrumental

(relating to benefits and costs) evaluations associated with the performance and consequences of the behavior. Subjective norms are the perceptions of influence an individual feels from the social environment (typically, close others) to either refrain from a behavior or engage in a behavior. Greater perceived behavioural control, endorsement of positive attitudes, and greater perceptions of social endorsement influence the formulation of intentions, which are general goals related to an individual's planned level of engagement in a behaviour." Furthermore, Ajzen, (1991, p181) states that "it should be clear, however, that a behavioural intention can find expression in behaviour only if the behaviour in question is under

volitional control."

If management expectations identified within the company's policies align with employee perceptions, then staff will execute their tasks at the practical level in line with managerial expectations. This would indicate that a safety culture is not only 'theoretically applied' moreover, engaged at a practical level. If the research's results indicate that employee-management alignment does not transpire then the safety culture is at odds with management's perceptions.

This is important because an employee's subjective norms are influenced by their perceived behavioural control. At this point, the employee will formulate their intention, which will determine their attitude towards the behaviour and consequently, how they will execute their job function. According to Aurigemma, (2013) the PBT, human behavioural intention to perform an action is guided by subjective norms, attitude towards the behaviour, and perceived behavioural control the PBT is depicted in figure 4.

Figure 4. Theory of Planned Behavior Model (PPB).

(Aurigemma, 2013)

The link between the Theory of Planned Behaviour and Safety Culture

Park (2000) believes an employees choice, with regards to their own behavioural intention, can be referred to as a subjective norm. It is essential to understand the subjective norm concept because it is a good way in predicting if, or how the person will engage in a

behaviour. The individual's behavioural intention is initially and, subconsciously triggered by their positive or negative attitude towards the behaviour. Moreover, their evaluation of the consequences of performing the behavior" (Park, 2000, p163).

An employee's viewpoint or attitude with relation to behaviour can be explained by

illustrating its two components. Firstly, the yield or extent to which an employee thinks they can get away with behaving in a particular way within the environmental, social norms and pressures that exist and exert upon the individual—secondly, an employee's belief concerning whether the outcome is favourably accepted or rejected. Park, (2000, p163) says "both

personal and social factors influence an individual's likelihood of wanting to engage in a specific behaviour. Moreover, "the normative beliefs about the social expectations of significant others (e.g., spouses, parents, close friends) and an individual's motivation to comply with those significant others" (Park, 2000, p163).

Park, (2000, p163) also states that "favourable consequences for highly likely outcomes of a behaviour increase a person's intention to engage in the behaviour. This is important to note because "a person's attitudes towards behaviour and subjective norms are sufficient

determinants of his/her behavioural intention." Moreover, behavioural intention is a predictor of engaging in a behaviour, and is directly affected by both personal and social variables, the individual's attitudes towards a behaviour and subjective norms."

This brings the relevance of attitude and behaviour to the forefront of this study. An employee's normative beliefs, subjective norms construct a person's attitudes which in-turn establishes their behavioural intention. Management must encourage and implement

mechanisms that are parallel to HRO theory characteristics. This should, in theory, assist an employee's normative beliefs, subjective norms and engineer a positive attitude/behaviour respectfully.

Moreover, Aurigemma, (2013, p13) says "when an individual's attitude and normative beliefs is more positively accepted within their social surroundings, the greater the feelings of

behavioural control over those actions, the stronger the intention to comply."

In essence, Aurigemma is bringing Wang's theory one step further, in the sense that it shows when people genuinely act. He believes "human behavioural intention to perform an action is guided by subjective norms, attitude towards the behaviour, and perceived behavioural control" (Aurigemma, 2013, p13). Moreover, posits that when people perceive to have

control of their given behaviour, it is highly anticipated that the individuals as such, will carry out these intentions when required. Aurigemma (2013) notes that "behavioural intention is assumed to be the immediate antecedent of actual behaviour" (Aurigemma, 2013, p13).

Aurigemma (2013, p13) says that the "theory of planned behaviour (TPB) is considered one of the most influential frameworks for the study of human action." Aurigemma sees

employees' behaviour as being the cornerstone in how they will execute their tasks on the job. Similar to Aurigemma, Wang, (2018, p105) believes that a "culture is the behavioural norm and that the formation of a safety culture should be a role-modelling process that consists of belief, attitude and recognition of the core-value of safety commonly shared by members of the organisation." This belief and attitude bring one back to Aurigemma's (2013) TPB and the importance of measuring frontline perception, as to understand the safety culture.

Wang (2018) believes that a person's attitude determines what their behaviour will be. Therefore, the TPB comes to the forefront, as it connects the importance of behaviour with that of assessing the level of which a safety culture exists. For employees to execute their tasks favourably with a conscientious safety manner, employees must be aware and have the right behaviour in mind. Wang (2018) applies the following four subcultures - reporting, just, learning, and flexible cultures. Together these four subcultures interact to create an informed culture that equates with the term safety culture. This study connects and applies these subcultures within a survey to measure frontline employees perceptions with regards to each element. Wang's (2018) survey will measure the staff's perception and show what their perception is. In using Aurigemma, (2013) PBT model to better to illuminate the constructs of normative beliefs, attitude and perceived behavioural control, one can see that the TPB extends the theory of reasoned action, which states that reasoned action leads to human action.

If a lack of adequate behaviour exists or the company does not provide the tools necessary for a safety culture to flourish then in both cases, it will cease to exist. According to Reason, (1998) "a poor safety culture apparently is unable to provide the adequate safety tools, program, equipment and protective method, so employees are unable to deal with possible system deficiencies in a defence-in-depth concept proactively." One way of understanding how frontline perceive their safety culture is to look at their perception of Wang's (2018) subcultures (reporting, just, learning, and flexible cultures). Together these four subcultures interact to create an informed culture that equates with the term safety culture.

2.3 High-Reliability Organisation (HRO) Theory

High-reliability organisation theory argues that some organisations appear to encounter sporadic problems, dispute operating in daunting hazardous environments, and believe these HROs must be doing something right in avoiding these problems (Leveson et al., 2009). HRO theory encompasses five essential characteristics: 1) Preoccupation with Failure, 2) Reluctance to Simplify, 3) Sensitivity to Operations, 4) Commitment to Resiliency and 5) Deference to Expertise.

The characteristics above stimulate the development of a safety culture if an organisation implements them into practice. Such organisations are seen as highly reliable because they

maintain a record of consistent safety over long periods of time. HRO theory treats safety and reliability as equivalent (Leveson et al., 2009).

A large extent of HRO discourse talks about a culture of reliability. High-reliability organisations rely on every employee to maintain a level of mindfulness. If each frontline employee operates with a mindful attitude, then accidents can be significantly reduced. Mindfulness is one crucial micro aspect of establishing a culture of reliability. Therefore, HRO theory encourages frontline employees to behave mindfully.

Moreover, a conscientious, mindful behaviour enhances situational awareness of an employee's working environment, which increases the chances to recognise potential risks hazards that could occur. If these staff members collectively report safety-related concerns consistently without any fear, a culture of reliability has been established. Leveson and colleagues (2009) believe that this approach protects organisations against unreliable

components leading to accidents. HRO theory believes that frontline staff are the last line of defence who can prevent an accident from occurring if other safety mechanisms fail. Leveson and colleagues (2009, p233) define redundancy as "the ability to provide for the execution of a task if the primary unit fails or falters." HRO theory relies on frontline employees to not only act as a last line of defence, moreover report any potential risks or concerns they have. These reported concerns are ultimately examined and contained by management.

HRO theory posits that a safety culture can be cultivated through good managerial policies. These policies can be further developed by those frontline employees who will execute the policy procedures into practice. Management must take necessary measures (top-down) that cultivate and support an informed reporting culture. If this is achieved, then frontline

employees execute these policies at a (bottom-up) approach and remain mindful and report everything. When both elements come together, they help an organisation to anticipate risks and contain them where possible, which should stimulate the development of a safety culture.

2.3.1 HRO/NAT Debate

Even though HRO theory is closely related to Planned Behaviour Theory (PBT), it differs considerably with the NAT theory. This is because the PBT suggests that behaviour-related consequences manifest in one's attitude toward behavioural intent. An employee will instinctively make a cost-benefit analysis within their own affective and cognitive

overall assessment after that may be either favourable or unfavourable (Aurigemma, 2013). Moreover, Wang (2018) says the core value behind successful, well-executed safety

management in an organisation is its safety culture and self-improving safety assurance.

Although this may appear to relate to NATs' system design' assumption closely, NAT fails to focus on the individual employee and centres upon the system design offering conflicting assumptions when contrasted with PBT and HRO theory respectfully. PBT would support the premise that compliance to HRO theory stimulates the development of a safety culture. Moreover, it suggests that a "safety culture is the status of an organisation free from potential hazards" (Wang, 2018, p105). Compliance to HRO theory stimulates the development of a safety culture because Wang (2018, p105) posits that "culture is made up of the behavioural norms at play. The formation of a safety culture should be a role modelling process that consists of a belief, attitude, and recognition of the core-value of safety commonly shared by members of the organisation, i.e. frontline staff. When such a role model is emulated and behaves as a norm, a successful Safety Management Systems (SMS) implementation is therefore featured within an organisation."

NATs "argument involves classifying industries by the amount of complexity and coupling" [...] and believes that risk is greater in those industries with high complexity and tight coupling (Leveson, Dulac, Marais and Carroll 2009, p229). NAT focuses more on the actual incident and its associated design per se rather than those that execute the design.

Moreover, NAT argues that the more complex a system is, the less one knows about that system. The bigger the complexities that exist within an organisation, the more variables (known unknowns) will exist as not all potential interactions can be fully understood. As a result, more incidents should be expected to arise. NAT differs considerably with HRO theory because NAT posits that the redundancy (frontline employees) cannot protect an organisation against system design errors (Leveson, 2009). Moreover, NAT believes good system design stimulates the development of a safety culture and that the design is held solely responsible if anything goes wrong.

Furthermore, NAT tends to blame the 'system design'. It believes that those who established and designed the system, bear full responsibility if an accident arises. NAT tends to blame system failures for incidents or issues and will be useful within this study to see if the

company designs are resilient or if they encompass HRO traits. It could be the case where the case study has no HRO characteristic traits and is managed with rigid, resilient system

designs. Therefore, it is also essential to include the NAT system as an alternative way of looking at managerial systems.

Even though those two theories have both their eligibility, the HRO theory seems to be at the upper side when offering solutions to problems faced in crisis management. Compared to the HRO theory, the NAT theory tends to blame a system design rather than offer any solution. Therefore, this study will primarily have a look at HRO theory and look at how its alignment may provide a solution-based approach to help to create a safety culture in HROs.

2.3.2 Five Characteristics of HRO Theory

Organisations that operate within extreme environments are rigorously challenged.

Organisations as such implement and maintain essential HRO characteristics that support the development of safe operations. For these reasons HROs perform well in complex conditions that are inherently hazardous and highly technical, under conditions of tight coupling and severe time pressure (Rochlin, La Porte and Roberts, 1987). HROs manage to perform well, as they share a common trait, that is, they all operate and operationalise their business practices by applying an essential number of these elements referred to as HRO

characteristics/themes. If HROs fail to execute these characteristics, they are theoretically susceptible and can do enormous harm to themselves and their encircling environments (Roberts, 1990). As alluded to, there are five HRO characteristics, and when put into practice, supports the development of a safety culture that in-turn also establishes safer working

conditions and a happier workforce.

The five HRO characteristics theory was derived by Weick and Sutcliffe's' (2007) who broke the theory into two subsets, (A) and (B). Part A deals with the initial anticipation process of preventing identified risks while part B focuses on the post-incident with the containment approach of managing the risk either identified in part A or after an accident occurs, therefore, it is predominantly dealing with post events or after significant knowledge is gained in identifying an imminent risk. Weick and Sutcliffe's' (2007) five characteristics of HRO theory can be better conceptualised using the following illustration below:

Figure 5. The Five Characteristics of HRO.

(Weick and Sutcliffe, 2007).

(a). Anticipation (Pre-incident) 1. Preoccupation with failure

2. Reluctance to simplify operations 3. Sensitivity to operations

(b). Containment (Post-incident) 4. Commitment to resilience 5. Deference to expertise

(a) Anticipation

Highly reliable organisations share in common a preoccupation with failure and work diligently to anticipate potential hazards. HROs are preoccupied with failure in three ways. First, they work hard to detect small, emerging failures because these may be a clue to additional failures elsewhere in the system. Second, they work hard to anticipate and specify significant mistakes that they do not want to make. Third, know that people's knowledge of the situation, the environment, and their own group is incomplete (Weick & Sutcliffe, 2001).

Incomplete, meaning that nothing is guaranteed, and a constant state of development with regards to safety standards are required.

Jacobson (2019) says that HRO organisations cherish the reluctance to simplify element which is close to their core beliefs. Moreover, HROs believe in tackling the more complex matters and facing them head-on and embracing complexity. High reliable organisations will dissect the complex matters in an attempt to analyse and understand it. They will conduct a rigorous analysis to understand the root causes that pose a potential risk or hazard and reject simple diagnoses. Leading figures within HROs are constantly open when it comes to

examining data and safety performance metrics. Leaders avoid any quick fix or simplification and strenuously 'seek discomfort' insofar as gathering vast sources of information and

articulately filter through it. This content source of information can be seen as a HROs five basic senses: touch, sight, hearing, smell and taste and assist a company to understand why problems exist.

Jacobson (2019) also believes that the last anticipation measure HROs take is sensitivity to operations. HROs appreciate that frontline staff are better positioned to recognise potential failure and identify opportunities for improvement. Their consistent concentration on

processes leads to observations that inform decision-making and new operational initiatives. Managers simultaneously do not wait for employees to report concerns. They actively create conditions for transparency to flourish, by openly communicating regularly with frontline staff and take all safety concerns seriously and provide follow-up feedback.

(b) Containment

Containment looks into how an organisation can contain risks and hazards according to the developing HRO theory.

High reliable organisations anticipate hazards and risks. They then proceed to contain unexpected risks as they happen as per the final process according to HRO theory.

A commitment to resilience encourages the use of individual initiative to maintain process improvements long-term. It promotes activities to prevent failures and relies on the expertise of frontline workers to reduce response time and counter immediate, evolving threats or absorb as much of the threat as possible (Hales and Chakravorty, 2016). This means that the greatest expertise at the lowest practical level of the organisation should be those who implement solutions because the HRO literature reports as they are the experts in a given

area. In HRO theory, this is referred to as a commitment to resilience where organisations that have created a high-reliability process must put forth an effort to maintain reliability. Action plans encourage resilience as they can contain a protocol that specifies the activities to be executed when a failure occurs. In doing so, it quickly recovers from a failure (Hales and Chakravorty, 2016).

A deference to expertise refers to using the highest level of recognised expertise in improving reliability, not necessarily the higher ranking leader. Moreover, discourages excessive formal ranks because the ranking individual may not be in the proximity when the event occurs, i.e. managers may be too detached from the event to respond quickly. Or may not possess the requisite knowledge. Instead, it relies on the lowest-level possible, i.e. frontline staff.

Collectively, these HRO subset decisions establish the best practices for the operation of a company at large. This also entails the possibility of contracting external expertise which a company may lack internally. Tasks are handed down based on skill level and expertise, and not based on authority and hierarchy. The most experienced person with the best expertise is utilised (High-Reliability Organising, 2013).

2.4 Conceptual Framework

The conceptual framework model in figure 6 illustrates how this research will observe the extent to which the five characteristics are being applied at the organisational level from a top-down analysis. It shows how the developing HRO and its associated five characteristics support the development of a safety culture.

Figure 6. Conceptualization Model

Within the conceptual model (figure 6), one can see a pyramid. At the top of this pyramid are Weick and Sutcliffe's (2001) five HRO characteristics or themes ((1) Preoccupation with Failure, (2) Reluctance to Simplify, (3) Sensitivity to Operations, (4) Commitment to Resilience, (5) Deference to Expertise). The top of the pyramid resembles the managerial or declaratory level of an organisation. To be more specific, it shows the chief executive officer (CEO) and senior members of the organisations management who draft and implement policies.

The bottom of the pyramid represents the lower end of the organisation (the lower end meaning the frontline employees in this case), otherwise called the practical level. At the practical level, frontline employees interpret the policies passed down from the top of the pyramid from management. The research looks at these managerial policies to see if they connect with any of the HRO characteristics. This is because these policies influence

frontline employees and give spark to the attitude/ behaviour frontline staff adopt, depending on how they perceive these policies, i.e. either in a positive light or negative perception. The frontline staff are essential in this equation as they are the ones who execute these policies in real-time. Therefore, this study also measures the behavioural perception among frontline staff. What we know is that behavioural intent among frontline staff is shaped by external elements such as how management implements and constructs the environment and working conditions in which frontline staff work within daily. It is also essential to see what the frontline staff have to say about their working environment, to be more specific, their safety culture. This is where the study will see if the policies are really put into practice by staff. This is determined by what the staff tells us via the perception results. If for example, the frontline employees' perceptions agree with the managerial and company stance, then the research could, for example, conclude that there is an extent to which the safety culture aligns with the HRO characteristics.

The term cultural level refers to frontline employees and their position within Aer Lingus, which encompasses the organisations' culture. As illustrated, the cultural level forms part of a bottom-up analysis. This is where frontline employees safety culture perceptions are

measured. Moreover, how staff perceive their safety culture per se determines the rate in which they report issues to management. This bottom-up analysis that measures how staff perceive their reporting culture is measured by looking at four components: i.e. just culture, informed culture and learning/adaptive culture. Due to the PBT, it can be assumed that a safety culture is dependent upon an attentive mindful frontline workforce and that an

employee's behaviour at a cultural level forms part of the cornerstone in the development of a safety culture. If it is found that the perceptions of frontline staff at the mere cultural level positively relate to managerial statements and policies, this would indicate that managerial measures are in compliance with HRO theory themes. When all these elements are

collectively combined, they are expected to establish an organisational safety culture.

In many aspects, a safety culture is dependent upon HRO theory themes being in place and to a reciprocal extent vice versa for the continued development of a safety culture. A safety culture upkeep is predominantly established and maintained by the frontline staff and their behaviour after management implements the supporting initial policies that give birth to the concept. This conceptual model illustrates how this research explores managerial designs (top-down) and if they are in compliance with HRO themes. These HRO characteristics or

themes help foster a vigilant, mindful behaviour at the cultural level. If these themes are present in policymaking, the frontline staff are expected to be more alert to potential risks and hazards. They are conscientious in ensuring they report their safety-related concerns without delay. The conceptual framework illustrates a reciprocal systematic system where HRO characteristics support the development of a safety culture at the cultural level, which is implemented through managerial initiatives. This safety culture in-turn better informs the management of potential risks and hazards through their encouraging reports as an example.

3 Research Methodology

3.1 Design

This research will examine a HRO from two perspectives. According to Swanborn (2010), explanations and interpretations are better grounded when using subsystems. In theme 1, from a top-down approach at the managerial level and then in theme 2, from a bottom-up perspective that consists of the frontline employees. The results will then be compared and contrasted against each other to see if frontline employees relate with the policies, and execute them accordingly or have different perceptions resulting in differing practices at the execution stage.

Therefore, this study examines what the companies managerial policymakers per se expect to happen against the backdrop of what actually happens on-the lines. Moreover, looking at ‘what should be done’ i.e. what is expected from management at a declaratory level to what is done in reality at a practical level, i.e. how the frontline staff in practice actually perceive their safety culture at a more micro. This is important because employee’s behaviour distinguishes how employees execute their tasks at a practical level.

A case-study approach was also chosen as the overarching research strategy to study a contemporary social phenomenon in its natural context. Due to the holistic approach, the behaviour of people can be explained even if the boundaries between the context and

phenomenon are not clear (Yin, 2009) and complex causes exist (Swanborn, 2010). Because of the complex set of causes, simple causal models which are often used for quantitative approaches, are not sufficient (Swanborn, 2010).

For a better understanding of the airlines in their function as HROs, an airline carrier, namely Aer Lingus, was chosen as a case. This study examined a small to medium-sized commercial airline carrier called Aer Lingus, which now forms part of the International Consolidated Airlines Group (IAG) since 2015. The airline is restricted insofar as its operating capacity as flights are limited to mainly Europe and North America. The reason a commercial airline was chosen was that they operate in various hazardous environments. They function in

environments that are challenged with adverse weather conditions, the use of highly flammable fuels and are faced with ensuring accurate engineering checks are consistently applied. A scheduled airline carrier must ensure safety as a priority policy at any given time.

3.2 Data Collection

A comprehensive overview, using multiple methods such as interviews, surveys and a document study were applied. Firstly, several documents were examined to determine whether managerial measures in addressing (potential) failures were directed, moreover, towards rules & regulation, learning or knowledge exchange. The online survey was conducted among 112 frontline staff to measure the perception of the safety culture. Additionally, three interviews were done among senior safety officers within the safety apparatus of the company. However, some documents contained classified information and could be used.

3.2.1 Documents

Document analysis is a form of qualitative research and allows the researcher to give meaning to a topic. They are an important part of most triangulations (Bowen, 2009). External sources are utilised to make a comparison with the academic literature and thereby give support or contradict theoretical arguments or theories (Verhoeven, 2010).

A vast array of company documents were examined through the company intranet, including the companies Standard Operating Procedures (SOPs), the Safety Manual, Safety Plan Update document, Quality and Compliance Procedures Manual, Compliance Monitoring Manual and the Safety Plan Progress Report. The SOPs is considered to be the general guideline among employees and that of the company's management. The SOPs cover almost all departments and their structure and will be regularly referred to within this section as the SOPs. The SOPs manual was applied to identify many of the indicators of HRO

characteristics. Therefore, this document proved essential in understanding how the company thinks and operates with regards to its policies, safety documents and responsible positions. A large extent of these positions is outlined within the SOP manual.

Furthermore, some policy documents such as the companies Whistleblower and Good Faith Reporting Policy and the Respect and Dignity Policy document will be examined to collect data on alternative methods in making reports externally to the media and government agencies. The company has a non-punitive Whistleblower policy.

Organisational charts were obtained from the SOP manual that illustrates people's tasks and responsibilities and structure (Appendix 1. Senior safety management structure). These charts show the company structure and safety department structure and how they operate.

The company's stance on promoting safety and preventing accidents does this by utilising its frontline employees. Implementing channels where safety-related information can be

communicated to employees is one way the company achieves this, mainly through its Hazard Identification & Risk Assessment (HIRA) system (Appendix 5.

Illustrative Summary of HIRA Process). The company HIRA process supports the

development of a mindful workforce. This is achieved when the company analyses all safety-related reports, filters and categorises them according to their associated risks. Reports can be based on three categories: low, medium and high. Based on this assessment, the safety

department can then prioritise as well as draft and implement policies if needed. Thereafter, these final reports made available to all staff in the Safety Plan Progress Report (SPRP). This final report facilitates staff to understand the current risks and hazards. This report is

conducted three times a year and additionally highlighted to all frontline employees during their annual recurrent Safety Emergency Procedures (SEP) training.

This study also looked at the communication channels Cabin Crew Line Operations Bulletin [CCLOB] and Cabin Crew Instructions (CCIs) which the company has in place. These channels are available online and in hardback copy within each relevant department. Both of them are used to communicate urgent changes to the SOP manual and/or legislative changes made by the European Union Aviation Safety Agency (EASA) and the Irish Aviation Authority (IAA).

Moreover, the company has an active compliance department which has its own internal auditors who board random flights and observe that SOPs and other safety-related practices. These audits take place in a completely discreet and unanimous manner.

The compliance department is responsible for monitoring the airline's failures by looking at the reports from various safety departments.

Some of the documents mentioned above cannot be disclosed in the appendix. The author cannot and will not release any sensitive documents or materials belonging to the company, such as the company's SOP manual. Due to their length but more importantly, its security they are not included in the thesis. No documents will be released that could in any way compromise the safety of Aer Lingus. Here the author respects in full the Aer Lingus safety and security and all company policies, notwithstanding the data protection act and the General Data Protection Regulation.