ACAC SMS Training

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1

TRAINING IN SAFETY

MANAGEMENT SYSTEMS

ARAB CIVIL AVIATION CONFERENCE

Amman, Jordania 19-23 July 2009


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2ACAC, Safety Management Systems Training

Welcome to SafetyManagement

System Workshop


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Speakers:

CHRISTER PRAHLATM Safety Expert

Electronic Engineer

Degree in Communication

Degree in Networking

Pilot (IFR rated)


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Speakers:

MICHAEL NIELS THORSENATM Safety Expert

Master of Science in Engineering

Expert International Cooperation

Expert Safety Management Implementation

Expert Organisational Structures


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Round the table

Name and Position


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Agenda for today:

Wrap - Up16.30 17.00

The Safety Management System15.30 16.30

Break15.00 15.30

The Safety System14.00 15.00

Lunch12.30 14.00

ICAO presentation on Safety Management System

SES Regulations

11.00 12.30

Break10.30 11.00

Registration and Welcome09.00 10.30


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Objectives of the workshop

Provide participants the knowledge of SafetyManagement Concept and ICAO Standards andRecommended Practices (SARPs) on safety management inAnnexes 6, 11 and 14 and related guidance material

AND TO

Develop participants knowledge to certify and overseethe implementation of key components of an SMS, in

compliance with relevant ICAO SARPs.


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ICAO - Safety Management System

What is Safety? Zero Accidents?

Freedom from danger or risks?

Error avoidance?

Any suggestions?


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According to ICAO Doc 9859:

Safety is the state in which the risk to harm the

persons or property damages is reduced, and

maintained at or below, an acceptable level

through a continuing process ofhazard

identification and risk management.


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Asafety management system (SMS) is an organised approach to

managing safety, including the necessary organisational structures,

accountabilities, policies and procedures.

(ICAO Doc 9859 - Safety Management Manual)

The objective of a Safety Management System is to provide a

structured management approach to control safety risks in operations.

Effective safety management must take into account the organisationsspecific structures and processes related to safety of operations.


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Safety Management SystemStructure and Contents

1: SMS course

introduction

2: Basic safety

concepts

3: Introductionto safety

management4: Hazards

5: Risks 6: SMS regulation7: Introduction to

SMS

8: SMS planning 9: SMS operation

10: Phased approach

to SMS

Implementation


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Safety Management ManualObjectives

Objectives of the Safety Management Manual are to provide States:

Knowledge of safety management concepts, the ICAO Standards andRecommended Practices (SARPs) on safety management contained in Annexes

1, 6, 8, 11, 13 and 14, and related guidance material;

Guidance on how to accept and oversee the implementation of the keycomponents of an SMS in compliance with the relevant ICAO SARPs;

Guidance on how to develop and implement an SSP in compliance with therelevant ICAO SARPs.


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Safety Management ManualConcept

SMS/SSPImplementation

ICAO SARPS Safety Concepts


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Generic SMS Requirements

ICAO requirements for implementation of SMS are currently applicable to:

Air Traffic Service Providers (Annex 11)

Aerodrome Operators (Annex 14, Volume 1)

Amendment to Annex 1, 6, 11, 13 and 14 are proposed in order to harmoniseand extend provisions relating to safety management.


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SES Regulation - Objectives

The second SES package has been put forward by the European

Commission in order to make the European sky safer and more

sustainable by:

Introducing a performance framework for European ATM with quantifiedtarget setting;

Creating a single safety framework to enable harmonised development ofsafety regulations and their effective implementation;

Opening the door to new technologies enabling the implementation ofnew operational concept and increasing safety levels by a factor of ten;

Improving management of airport capacity.


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The 1st SES legislative package

The legislative package adopted in 2004 comprises four base regulations,

which reinforce safety and foster the restructuring of European airspaceand air navigation services. The regulations provide the framework for thecreation of additional capacity and for improved efficiency andinteroperability of ATM system in Europe.

The Framework regulation (EC No 549/2004) - laying down theframework for the creation of the single European sky;

The Service provision regulation (EC No 550/2004) - laying downcommon requirements for the provision of air navigation services;

The Airspace regulation (EC No 551/2004) - on the organisation anduse of airspace in the Single European sky;

The Interoperability regulation (EC No 552/2004) - on theinteroperability of the European Air Traffic Management network.


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(EC) No 549/2004 - FrameworkThe objective of the Framework regulation is to enhance current safety

standards and overall efficiency of the general air traffic in Europe,

to optimise ATM system capacity and minimise air traffic delays by

establishing a harmonised regulatory framework for air trafficmanagement in Europe.

The Framework regulation establishes harmonised institutional, regulatory

and consultation arrangements to enable the creation of the Single European

Sky.

In brief these are: National Supervisory Authorities (NSA)

Single Sky Committee

Military Issues

Industry Consultation Body

Implementing Rules

Performance Review

Safeguards


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(EC) No 550/2004 Provision of AirNavigation Services in SES

The Service provision regulation establishes common requirements to ensurethat air navigation services are provided safely and efficiently, on a continuous and

interoperable basis, throughout the European Community. It introduces aharmonised system of certification and lays down rules for designating serviceproviders.

The stipulations of this regulation apply to the provision of air navigation

services to General Air Traffic (GAT) and can be summarised as follows:

National Supervisory Authorities (NSA)

Licensing of Controllers

Common Requirements

Certification of Air Navigation Service Providers (ANSPs) Designation of Air Traffic Service Providers

Relations between Service Providers

Transparency of Accounts

Access to and Protection of Data

Charging Schemes


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(EC) No 551/2004 Organisationand use of Airspace in SES

The objective of the Airspace regulation is to put an end to the fragmentation of European

Union (EU) airspace and to create an efficient and safe airspace without frontiers. Theorganisation and management of airspace should be improved by merging all the nationalflight information regions (FIRs) into a single portion of airspace within which ATS will beprovided according to the same rules and procedures.

The Airspace regulation forms part of the first package of legislation on air traffic management

designed to create a SES. This objective will make for improved safety, optimum use ofEuropean

airspace, reduced air traffic delays and sustainable air transport growth.

The following is summarising this regulation:

Establishment of European Upper Flight Information Region (EUIR) Reconfiguration of Upper Airspace

Optimised Route and Sector Design in the Upper Airspace

Flexible Use of Airspace

Safeguards


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(EC) No 552/2004 Interoperabilityof the European ATM Network

The aim of the Interoperability regulation is two-fold:

To achieve interoperability between the different systems, constituents andassociated procedures in the European ATM network by establishing aharmonised system for certification of components and systems;

To ensure the introduction of new agreed and validated concepts of operationsand technology in air traffic management.

The following topics summarise the Interoperability regulation:

Essential Requirements

Implementing Rules for Interoperability

Community Specifications EC Declaration of Conformity of Suitability for Use of Components

Safeguards

Transitional Arrangements


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The SES Implementation

Implementing the provision of the SES regulations would bring a number of

significant benefits:

Improved level of safety of air navigation services;

A more effective and integrated air traffic management architecture;

Demand driven air navigation service provision;

Enhanced cross-boarder co-ordination;

Improved decision-making and enhanced enforcement in ATM.


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Regulations, Directive andImplementing Rules

Regulations: Mandatory to the letter

Directives: Mandatory with National exemptions

Implementing Rules: Guidelines


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The 1st SES legislative package

The First Report on the implementation of the Single Sky Legislation

was published in December 2007.

It presents:

the achievements,

identifies new challenges

proposes the way forward.

Based on the report findings, the Commission came forward withproposals for a 2nd Single Sky package, including extension of EASA

competencies to ATM and adoption of the European ATM Master Plan.


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The 2nd SES legislative packageTo tackle issues such as traffic increase, financial burden and

environmental awareness, the Commission has come up with 2nd SES

legislative package aimed to:

Create a single safety framework to enable harmonised developmentof safety regulations and their effective implementation;

Improve the performance of the ATM system through setting oftargets;

Open the door to new technologies enabling the implementation ofnew operational concept and increasing safety levels by a factor of

ten; Improve management of airport capacity


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(EC) No 2096/2005 Common Requirementsfor the Provision of Air Navigation Services

The objective of this Regulation is to establish common requirements for the safe and

efficient provision of air navigation services in the European Community and to set uniformand high safety standards for ANSPs.

The common requirements cover the follow ing areas:

Technical and operational competence and capability

Organisational structure and management Safety and quality management Security Human resources Financial strength Liability and insurance cover

Quality of services

Reporting requirements

The common requirements do not cover military operations and training and do not apply toactivities or resources allocated to activities outside the provision of air navigation services.


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The Regulation identifies and adopts the mandatory provisions of the following

EUROCONTROL Safety Regulatory Requirements (ESARRs) which are relevant for thecertification of air navigation service providers:

ESARR3 - on the use of safety management systems by air traffic management(ATM) service providers;

ESARR4 - on risk assessment and mitigation in ATM;

ESARR5 - on ATM services' personnel, in particular the requirements for engineeringand technical personnel undertaking operational safety related tasks.

The detailed requirements relating to safety of services are contained in Annex II tothe Regulation.


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Subjects summarising (EC) No 2096/2005 are as follows:

Certification of ANSPs

Derogations Demonstration of Compliance

Compliance Monitoring

Peer Review of NSAs


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Similarities and Differences betweenICAO and SES

EUROCONTROL Methodology (ESARR)

ICAO Methodology

Step0:

Planning

Step1:

SystemDescript

ion

Step2:

HazardIdentifica

tion

Step3:

SeverityAssessm

ent

Step4:

LikelihoodAssessment

Step5:

SystemDescript

ion

Step6:

RiskMitigatio

n

Step7:

Documentatio

n

FunctionalHazard Assessment

(FHA)

PreliminarySystem SafetyAssessment

(PSSA)

System SafetyAssessment

(SSA)

Whatcan

gowrong?

What

canw

e

doabouti

t?


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ICAO Safety Regulation

ICAO Annex 11 Paragraph- 2.26 ATS Safety Management

includes relevant requirements related to ATS

Para 2.26.1 requires the States to implements systematic andappropriate Safety Management Programmes, further detailed in

Para 2.26.4

Para 2.26.2, requires States to establish the acceptable level ofsafety and safety objectivesapplicable to the provision of ATSwithin their airspace and at their aerodromes with acceptable level

of safety further detailed in 2.26.3


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ICAO Provisions

Para 2.26.5 requires that any significant safety-related change to

the ATC system shall only be implemented after a safetyassessment has demonstrated that an acceptable level of safety willbe maintained.

Para 2.26.5 also requires that the responsible authorities shallprovide for post-implementation monitoring to verify that thedefined levels of safety continues to be met


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ICAO Provisions

PANS-ATM doc.4444 includes in Chapter 2 requirements for:

ATS maintaining acceptable level of safety (section 2.1)

Implementation of systematic Safety Management Programmes (section 2.1)

ATS Safety Management Activities (section 2.3)

Monitoring of Safety Levels (section 2.4) Safety Reviews (section 2.5)

Safety Assessments (section 2.6)

Safety-enhancing measures (section 2.7)


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ICAO Provisions

PANS-ATM Doc 4444 clarifies a significant safety-related change as

(examples):

A new operating procedure, including departure and arrival procedures, tobe applied within an airspace or at an aerodrome;

A reorganization of the ATS route structure;

A resectorisation of an airspace;

Physical changes to the layout of runways and /or taxiways at anaerodrome; and

Implementation of new communications, surveillance or other safety-

significant systems and equipment, including those providing newfunctionality and or capabilities.


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Safety Management Manual

The new Manual on Safety Management for Aerodromes and Air

Traffic Services (Doc 9859)

Provides detailed guidance on implementation of the provisions of Annexes

6, 11, 14 and the PANS-ATM

First Draft was endorsed by 11th Air Navigation Conference (Montreal, Sep/Oct 2003)

Current version in ICAO NET web

Based on the same approach to safety as recommended by the ATM Operational Concept(Doc 9854)


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The Concept of Safety Management

SafetyMonitoring

SafetyAssessment

SafetyAuditing

SafetyPromotion

SupportingOrganisationalRequirement

Safety Management

SafetyCulture

SafetyPolicy

PhilosophyOf Safety

Management

Maintenance ofImprovement of

Safety Performance


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Legal and Regulatory Foundationfor Safety Management

Implementation of safety management programs refers to the day

to day keep safety oversight management by the service providers

States shall establish systemic and suitable ATS safety managementprograms with defined levels and objectives (PANS-ATM, in force since

November 2003) The acceptable level of safety shall be established by the States. Asappropriate, the target levels of safety (TLS) will be established throughregional air navigation agreements.

Prior to any significant change to the safety-related ATC system, a safety

assessment will be carried out, proving that an acceptable safety level maybe obtained

SMS includes the establishment of runway safety programs.


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The Safety System Global Safety System

Organizational structure - Staffing, documentation, resources and leadership commitment

must be sufficient to support the desired process. Planning - Strategic planning and development of appropriate activities must be based onsystematic and comprehensive assessment of risks.

Management personnel standards - Safety must be integrated into line and operatingmanagement responsibilities, and their roles must be clearly defined in written standards ofperformance.

Training for operations and emergencies

Procedures - The organization must develop written procedures for design, operations andmaintenance activities to control routine work and probable emergencies.

Management of change Mechanical integrity - The organization must establish systematic and comprehensive

means to assess the integrity of process equipment. Management of contractors - Safety must be a prominent consideration in the selection of

contractors, and appropriate means to monitor the work of contractors must be in placeand working. Involvement of the work force Accident/incident reporting, investigation and follow-up - Monitoring and auditing methods

must be in place to monitor the on-going, day-to-day performance of the safety system, aswell as to audit thoroughly compliance to all requirements on a periodic basis.


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Global Safety SystemDocumentation:

ICAO

EASA

EUROCONTROL

EC

States

Ministries

CAA

Guidelines

RegulationsRequirements, EU OPS

RecommendationsLegislation

National LegislationNSA

Service Providers

ManualsWorking Procedures

Documentation

AD Technical Implementing Rules

Guidance Material Acceptance Means of Compliance Notices of proposal amendments

Aviation LawAirport Law

RegulationsStandards


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Global Safety SystemOrganisation:

The world global Safety System consist of allthe existing safety management systems onall levels in all the areas of aviation like theservice providers, the airspace users, themaintenance organisations etc.


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Global Safety SystemSupporting Issues:

Auditing

Inspections


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Global Safety SystemSecurity:

Improved security of ATM systems andinformation

Provides assistance and information In Flight Emergency Response

ICAO Annex 17


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Until the events of11 September 2001, the ICAO model was regarded as adequate andsufficient to ensure the safety of passengers, aircraft and goods. However, in December2001 the ICAO adopted anAmendment 10 to Annex 17, which set out a number ofadditional safety and security requirements. These include the following:

1. Aircraft security check2. Background check

3. Screening4. Application of Security5. Security Restricted Areas6. Objectives7. International cooperation

8. National Organization and appropriate authority9. Airport Operations10. Quality Control Programme11. In-flight aircraft security measures


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ContingencyPlan

AirportEmergency

Plan

National Civil Aviation Security Program

AirportSecurityProgram

OperatorSecurity

Programs

NationalTrainingProgram

QualityControlProgram

Airport SecurityCommittee

Authority

National Aviation Security Committee

ICAO Security Concept:


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Global Safety SystemQuality Definitions:

Quality the totality of features and characteristics of a product or service that bear onits ability to satisfy a given need.

Quality Policy the overall quality intentions and direction of an organisation as regardsquality, as formally expressed by top management.

Quality Management that aspect of the overall management function that determinesand implements the quality policy.

Quality System the organisational structure, responsibilities, procedures, processes andresources for implementing quality management.

Total Quality Management a management approach of an organisation centred onquality, based on the participation of all its members and aimed at long term success

through customer satisfaction and benefits to the members of the organisation and society.

Quality Assurance the activities an organisation carries out to provide to external andinternal parties confidence that the organisation will consistently meet the requirements forquality.


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Global Safety SystemQuality:

Airport Quality P rocess:

Evaluation of user needs and expectations

Design and implementation of service

Operation and achievement of service

Measurement of quality of service

Evaluation and Corrective action


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Global Safety SystemQuality Definitions:

Airport Quality Elements:

Safety

Security

EfficiencyService

Capacity

Environment

Health


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Global Safety SystemQuality:

The implementation of QMS, completed in March 2002, included data and

product quality assurance and control processes. These processes drew onthe following existing resources:

day-to-day consistency checking systems for both data and products, forecast verification system developed in 2000 which gave for each

forecast a score relative to the ICAO desirable accuracy for each of theweather elements. The QMS also included on-going review processes for continual

improvement and for the provision of adequate resources to sustain theQMS.

Further, as important components of the QMS, customer needsassessment and satisfaction survey became an institutionalized part of thesystem.


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Global Safety SystemSafety:

The world global Safety System consist of all

the existing safety management systems onall levels in all the areas of aviation like theservice providers, the airspace users, the

maintenance organisations etc.

As stated before:


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Global Safety SystemSafety Versus Quality and Security:

It is accurate to say that SMS and QMS share many commonalities. They both:

a) have to be planned and managed;b) depend upon measurement and monitoring;

c) involve every function, process and person in the organization; and

d) strive for continuous improvement.

SMS differs from QMS in the fol low ing way:

a) SMS focuses on the safety, human and organizational aspects of an organization(i.e. safety satisfaction);

while

b) QMS focuses on the products and services of an organization (i.e. customersatisfaction).


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Safety Management System

Safety The state in which the risk of harm to persons

or property damage is reduced to, and maintained at orbelow, an acceptable level through a continuing processof hazard identification and risk management.

ManagementAllocation of resources.

System Organized set of processes and procedures.

SMS An organised set of processes and procedures,based upon a principled allocation of resources, that allows

the control of safety risks to an acceptable level


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The Safety Management System

What is SMS?

A system for managing safety as part of the overallmanagement objective and policy;

Why SMS? To regulate airport operations and improve safety levels,

especially in areas not covered by applicable ICAO orapplicable national standards and regulations;

How? Existence of comprehensive technical

Standards/specifications, a safety management policy, theirimplementation and maintenance at all times.


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The Safety Management SystemSMS Tool-box: The scope of SMS encompasses most of the activities

of the organization.

SMS must start from senior management, and safety

must be considered at all levels of the organization.

SMS aims to make continuous improvement to the

overall level of safety.

All aviation stakeholders have a role to play in SMS.


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The components of SMS:

1) Safety policy and objectives

2) Safety risk management

3) Safety assurance

4) Safety promotion


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The Safety Management SystemSMS at glance:

Safety

Effectiveness Efficiency

ManagementCommitment

Safety RiskManagement

Safety Promotion

Safety Policy andObjectives

Safety Assurance

Aviation Community Stakeholders


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The Safety Management SystemThe Elements of SMS:

Safety policy and objectives

Management commitment and responsibility

Safety accountabilities of managers

Appointment of key safety personnel SMS implementation plan

Coordination of emergency response planning

Documentation


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The Safety Management SystemThe Elements of SMS:

Safety risk management Hazard identification processes

Risk assessment and mitigation processes

Safety assurance

Safety performance monitoring and measurement

The management of change

Continuous improvement of the SMS

Safety Promotion:

Training and Education

Safety Communication


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Safety Risk Management

What is Risk Management?

The identification, analysis and elimination, and/ormitigation to an acceptable level of risks that threaten thecapabilities of an organization.

What is the objective of Risk Management?

Aims at a balanced allocation of resources to address allrisks and viable riskcontrol and mitigation.

Why is Risk Management important? A key component of safety management systems. Data-driven approach to safety resources allocation, thus

defensible and easier to explain.


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Safety Risk Management

Four steps for hazard identification process:

1. Reporting hazards, events or safety concerns.

2. Collecting and storing the data.

3.Analyzing reports.4. Distributing the information distilled from the analysis.


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Safety Risk ManagementRisk Assessment and Mitigation Process

Risk Assessment:

Regularly

Commitments

Documentation

Mitigation:Measures to address the potential hazard or toreduce the risk probability or severity.

Risk mitigation = Risk control


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Risk Management SystemRisk Management at glance:

Hazard Identification

Risk AnalysisProbability

Risk Analysis

Severity

Risk Assessment andTolerability

RiskControl/Mitigation

Equipment, Procedures, Organisation, etc

Analyse the likelihood of the consequenceoccurring

Evaluate the seriousness of the consequence

if it occurred

Is the risk assessed acceptable and withinthe organisational safety performance criteria

Yes, Accept the risk

No, take action in order to reduce the risk toan acceptable level


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Risk Management SystemRisk Mitigation at glance:

Hazard identification andRisk Assessment

Assessment of thedefences within the

safety system

Control andMitigation of the risks

Accepting the mitigationsof the risk(s)

H H H H

Each Consequence

R R R R

Each Risk

TechnologyTraining

Regulations

IntolerableRegion

TolerableRegion

AcceptableRegion

Does it addressthe risk(s)?

Is it effective?Is it appropriate?

Is additional mitigationwarranted?

Do the mitigationsStrategies generate

additional risks?Etc

Feedback safety assurance


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Risk Management Assessment There is no such thing as absolute safety In aviation it is not possible to

eliminate all risks.

Risks can be managed to a levelas low as reasonably practicable(ALARP)

Risk mitigation must be balanced against: Time

Cost Difficulty of taking measures to reduce or eliminate the risk (i.e. managed).

Effective risk management seeks to maxim ize the benefits of accepting arisk

(a reduction in time and cost) while minimizing the risk itself.

Communicate the rationale for risk decisions to gain acceptance by stakeholdersaffected by them.


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Safety Assurance

Safety Assurance is built upon the following:




S f t A


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Safety Assurance


The process by which the safety performance of theorganization is verified in comparison to the approved safetypolicies and objectives.

Safety reporting Safety studies Safety reviews Audits

Surveys Internal safety investigations

Safet Ass ance


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Safety Assurance

Safety Audits are used to ensure that the structure of the SMS is sound in terms of:

Levels of staff;

Compliance with approved procedures and instructions;

Level of competency and training to:

Operate equipment and facilities; and

Maintain their levels of performance.

Safety surveys examine particular elements or processes of a specific operation.

Problem areas or bottlenecks in daily operations.

Perceptions and opinions of operational personnel.

Areas of dissent or confusion.

Check listQuestionnaires

Informal confidential interviews

Safety Assurance


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Safety Assurance

Internal safety investigations include occurrences or events

that are not required to be investigated or reported to State.

In-flight turbulence (flight operations)

Frequency congestion (ATC)

Material failure (maintenance)

Ramp vehicle operations (aerodrome)

Safety Information Sources


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Safety Information Sources

The protection of safety information from inappropriate use is essentialto ensure its continued availability in future, since the use of safety

information for other than safety-related purposes may reduce theavailability of such information, with an undesirable effect on safety.

During the 35th Assembly of ICAO, it was noted that existing nationallaws and regulations in many States may not address adequately the

protection of safety information from inappropriate use.

Following the Assembly, ICAO has produced a legal guidance for theprotection of information from SDCPS and it is included in Attachment Eto Annex 13.

Annex 13


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Annex 13

General Principles The sole purpose of protecting safety information from inappropriate use is to ensure its continued

availability so that proper and timely preventive actions can be taken and aviation safety improved.

It is not the purpose of protecting safety information to interfere with the proper administration of justicein States.

National laws and regulations protecting safety information should ensure that a balance is struckbetween the need for the protection of safety information in order to improve aviation safety, and theneed for the proper administration of justice.

National laws and regulations protecting safety information should prevent its inappropriate use. Providing protection to qualified safety information under specified conditions is part of a States safety

responsibilities.Principles of Protection Safety information should qualify for protection from inappropriate use according to specified conditions

that should include, but not necessarily be limited to: the collection of information was for explicit safetypurposes and the disclosure of the information would inhibit its continued availability.

The protection should be specific for each SDCPS, based upon the nature of the safety information itcontains.

A formal procedure should be established to provide protection to qualified safety information, inaccordance with specified conditions. Safety information should not be used in a way different from the purposes for which it was collected. The use of safety information in disciplinary, civil, administrative and criminal proceedings should be

carried out only under suitable safeguards provided by national law.

Annex 13


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ACAC, Safety Management Systems Training

Annex 13

Principles of Exception Exceptions to the protection of safety information should only be granted by national laws and

regulations when: There is evidence that the occurrence was caused by an act considered, in accordance with the

law, to be conduct with intent to cause damage, or conduct with knowledge that damage would

probably result, equivalent to reckless conduct, gross negligence or wilful misconduct; An appropriate authority considers that circumstances reasonably indicate that the occurrence

may have been caused by conduct with intent to cause damage, or conduct with knowledge thatdamage would probably result, equivalent to reckless conduct, gross negligence or wilfulmisconduct;

A review by an appropriate authority determines that the release of the safety information isnecessary for the proper administration of justice, and that its release outweighs the adverse

domestic and international impact such release may have on the future availability of safetyinformation.Public Disclosure Subject to the principles of protection and exception outlined above, any person seeking

disclosure of safety information should justify its release. Formal criteria for disclosure of safety information should be established and should include, but

not necessarily be limited to, the following:

Disclosure of the safety information is necessary to correct conditions that compromise safetyand/or to change policies and regulations;

Disclosure of the safety information does not inhibit its future availability in order to improvesafety;

Disclosure of relevant personal information included in the safety information complies withapplicable privacy laws;

Disclosure of the safety information is made in a de-identified, summarized or aggregate form.

Annex 13


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Annex 13

Responsibility of the Custodian of Safety Information Each SDCPS should have a designated custodian. It is the responsibility of the custodian of safety

information to apply all possible protection regarding the disclosure of the information, unless: The custodian of the safety information has the consent of the originator of the information for

disclosure; or The custodian of the safety information is satisfied that the release of the safety information is in

accordance with the principles of exception.

Protection of Recorded Information Considering that ambient workplace recordings required by legislation, such as cockpit voice

recorders (CVRs), may be perceived as constituting an invasion of privacy for operationalpersonnel that other professions are not exposed to:

Subject to the principles of protection and exception above, national laws and regulations shouldconsider ambient workplace recordings required by legislation as privileged protected information,i.e. information deserving enhanced protection; and

National laws and regulations should provide specific measures of protection to such recordingsas to their confidentiality and access by the public. Such specific measures of protection ofworkplace recordings required by legislation may include the issuance of orders of non-publicdisclosure.

Change Management Process


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Aviation organizations experience permanent change due

to expansion, introduction of new equipment or procedures.

Changes can have the following output:

Introduce new hazards.

Impact the appropriateness of risk mitigation.

Impact the effectiveness of risk mitigation



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Mentioned Changes can be:

External changes Change of regulatory requirements. Security.

Reorganization of air traffic control

Internal changes Management changes

New equipment. New procedures



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A formal management of change process should:

identify changes within the organization which mayaffect established processes and services.

prior to implementing changes describe thearrangements to ensure safety performance.

Improvement Process


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Improvement Process

Continuing improvement aims at:

Determining the immediate causes of below standardperformance and their implications in the operation ofthe SMS.

Rectifying situations involving below standardperformance identified through safety assuranceactivities

Improvement Process


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Improvement Process

The mentioned improvements are achieved through:

Proactive evaluation of facilities, equipment,documentation and procedures through audits andsurveys.

Proactive evaluation of the individuals performance, toverify the fulfilment of their safety responsibilities.

Reactive evaluations in order to verify the effectiveness

of the system for control and mitigation of risks, forexample: accidents, incidents and major eventsinvestigations

Safety Promotion


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Safety PromotionTraining and Education

Who?

Operational personnel Managers and supervisors Senior managers Accountable executive

Why? To ensure that personnel are trained and competent

to perform the SMS duties.

How much? Appropriate to the individuals involvement in the

SMS.

Safety Promotion


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Safety PromotionTraining and Education

A building b lock approach:

Operational personnel Organization safety policy

SMS fundamentals and overview

Managers and supervisors

The safety process

Hazard identification and risk management


Senior managers Organizational safety standards and national regulations

Safety assurance

Safety Promotion


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ySafety Communication

Safety communication aims to:

Ensure that all staff are fully aware of the SMS.

Convey safety critical information.

Explain why particular actions are taken.

Explain why safety procedures are introduced or changed.

Convey nice-to-know information.

Safety Promotion


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ySafety Communication

The means to communicate may include:

Safety policies and procedures News letters

Bulletins

Website

Safety communication is an essential foundation for the

development and maintenance of a positive culture.

Maintenance


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Internal Evaluation Process

Management commitment

Just culture

Established processes

Maintenance


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Internal Audit Process

An annual audit program should include:

Definition of the audits, in terms of;

criteria,

scope,

frequency, and methods;

Description of the processes used to select the auditors;

The requirement that individuals shall not audit their own work;

Documented procedures for assignment of responsibilities, planningand conduct of audits, reporting results and maintaining records;

Audits of contractors and vendors.

Maintenance


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External Audit Process

Surveillance and compliancethe authority needs to ensure that international, national and local

standards are complied with prior to issuing any licence or approval andcontinue to be complied with afterwards;

Areas and degree of riskthe audit should assess how risks are identified and how any necessarychanges are made to ensure that all safety standards are met;

Competencethe audited organisation should have adequately trained staff for allsafety related positions

Safety managementensure that the organisations SMS is based on sound principles and

procedures, and that the organisation is meeting its safety performancetargets.

Maintenance


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Proactive and Reactive Evaluations

Proactive before something has happened

Taking actions

Mitigate

Training

Reactive after something has happened

Investigate why it is as it is

Make improvements

Organisation


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Cultural Levels of the organisation

The characteristics of a good company safety culture include:

Informed - Managers know what is really going on and workforce iswilling to report their own errors and near misses

Wary - ready for the unexpected Just - a no blame culture, with a clear line between the acceptable

and unacceptable Flexible - operates according to need Learning - willing to adapt and implement necessary reforms

Organisation


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The values of an Organisation:

The safety management organisation is definingresponsibilities, competence, commitment and communication ofthe involved organisations or persons.

The culture is expressed by all parts of the organisation

Flight deck

Cabin crew

Maintenance

Ground staff

The cabin staff and check-in personnel provide the main indicationof the culture to the paying public

Organisation


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Top-down

Managers

Flight Crew

Engineers

(Maintenance)

Ground Staff

(Luggage Personnel)

Managers influencing and motivating allactors to take responsibility for theirwork and taking into account thesafety.

ProceduresS f P


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Safety Programme

Safety Programme is an integrated set of regulations and activities

aimed at improving safety.States are responsible for establishing a safety programme,

encompassing the following responsibilities:

Safety regulation

Safety oversight Accident/incident investigation

Mandatory/voluntary reporting systems

Safety data analysis and

exchange Safety assurance

Safety promotion

State Safety Programme - SSP


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State

States shall establish a State safetyprogramme (SSP), in order to achieve anacceptable level of safety (ALoS) incivil aviation.

Acceptable level of safety (ALoS) to beachieved shall be established by theState.

Service Prov iders

States shall require as part of theirState Safety Programme (SSP) that aService Providers implement SafetyManagement System acceptable to theState that as minimum:

identifies safety hazards;

ensures the implementation ofremedial action necessary tomaintain agreed safetyperformance.provides for continuing monitoringand regular assessment ofthe safety performance; andaims at a continuous improvementof the overall performance of the SMS.

P d


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ProceduresStates safety programme

Develop the States safety programme around the

following four components:1. States safety policy and objectives

2. States safety risk management

3. States safety assurance

4. States safety promotion

ProceduresDiff b t St t d S i P id


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Differences between State and Service Providers

Legal considerations States

Establishing acceptable level(s) ofsafety does not replace legal,

regulatory, or other already

established requirements, but it

must support compliance with them.

Establishing acceptable level(s) of

safety for their safety programme

leaves unaffected the obligations of

States, and does not relieve States

from compliance with SARPs

Operators and service providers

Establishing acceptable level(s) of

safety for their safety management

system leaves unaffected the

obligations of operators or services

providers and other related parties,

and it does not relieve the operator,services providers and other related

parties from compliance with SARPs

and/or national regulations, as

applicable.

ProceduresStates safety programme + Service providers SMS


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States safety programme + Service providers SMS =

Integrated safety system

State SafetyProgramme

Organisations Safety

ManagementSystem (SMS)

Organisations

ProductionProcesses

OversightAcceptance

Oversight

Risk ManagementSafety Assurance

Objective:Public Safety

Objective:

Manage andcontrolsafety risks

Objective:

Achieve

commercialgoals andcustomersaftisfaction

Safety Policy


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A typical safety policy document would consist of a policy statement that isfurther expanded by a number of basic safety management principles to be

followed: commitment to safety, safety priority, safety responsibility, planning for safety,

safety management, safety standards, safety achievement, safety assurance and safety promotion

Safety Policy - A statement of the organisations fundamentalapproach to achieve acceptable or tolerable safety.

A written document that describes the generic principles upon which theSMS is build and operated upon.

Risk Management


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Risk management - The identification, analysis andelimination (and/or mitigation to an acceptable or tolerable level) of thosehazards, as well as the subsequent risks, that threaten the viability of anorganisation.

Risk Management consists of the following three elements:

Hazard identification

Risk assessment

Risk mitigation

Risk Management SystemRisk Management at glance:


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Risk Management at glance:

Hazard Identification

Risk AnalysisProbability

Risk Analysis

SeverityRisk Assessment and

Tolerability

RiskControl/Mitigation

Equipment, Procedures, Organisation, etc

Analyse the likelihood of the consequenceoccurring

Evaluate the seriousness of the consequence

if it occurredIs the risk assessed acceptable and within

the organisational safety performance criteria

Yes, Accept the risk

No, take action in order to reduce the risk toan acceptable level

Safety Assurance


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Safety assurance - all planned and systematic actions necessary toafford adequate confidence that a product, a service, an organisation or afunctional system achieves acceptable or tolerable safety

The objectives of Safety Assurance is to implement dedicated surveillance anddocumenting procedures and processes in order to ensure that risk arebeing properly managed.

According to ICAO State Letter SA include the following activities:


Management of change


Safety Assurance


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Safety Assurance components:

Safety Surveys Safety Monitoring

Safety Records

Regulators should continuously evaluate the implemented safetymanagement arrangements and processes by aviation serviceproviders by means of external regulatory safety auditing and othersafety oversight methodologies.

Safety Promotion


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Just culture

Key Performance Indicators

Processes

Thank You for youattention today


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attention today

Any Questions?See You tomorrow

Agenda for today:


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Wrap up

Evaluation

Hand over of Diploma

16.30 17.00

Joint session/discussions15.30 16.30

Break15.00 15.30

The Safety Components14.00 15.00

Lunch12.30 14.00

WS on Safety Culture11.00 12.30

Break10.30 11.00

Managing Safety09.00 10.30

Managing SafetySafety Responsibility and accountability


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Safety Responsibility and accountability

Safety responsibility: the obligation to carry forward an assignedsafety related task to its successful conclusion. With responsibility

goes authority to direct and take the necessary action to ensuresuccess.

Safety accountability: the obligation to demonstrate the taskachievement and take responsibility for the safety performance inaccordance with agreed expectations. Accountability is theobligation to answer for an action.

Clear and correctly allocated safety accountabilities and responsibilitiesare prerequisite for achieving the organisations safety objectives

and for implementing an effective safety management and safetyimprovement process

Safety Manager (SM)


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An individual, responsible for the development, operation and

continuous improvement of the safety management system deployed

by an operator/service provider.

He acts as a focal point for safety management issues in the

organisation.

The approach to the assignment of Safety managers responsibilities

may differ depending on the type, size of the organisation, its

mission, complexity of operations and operating environment.

Safety Managers

Responsibilities


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ResponsibilitiesThe appointment of the Safety manager (SM) is an essential step in the establishment ofthe SMS organisational structure and a prerequisite for an efficient safety planning

process. Irrespectively of any other duties that may be allocated to them, safetymanagers have the responsibility to:

Promote safety awareness within the organisation; Ensure that safety management has the same or higher priority level throughout

organisation as any other management and operational processes;

Manage all aspects of the organisations SMS, including: Monitoring the effectiveness of SMS; Initiating corrective actions when necessary; Providing safety reports on SMS performance on periodic basis; Providing safety advice to top management and proposing corrective actions on

safety related-issues as needed; Ensuring that safety-related documentation and records are available and up-to-

date.


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Safety Performance Targets


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Safety performance targets define the required level of safety performance of a

system. A safety performance target comprises one or more safety

performance indicators, together with desired outcomes expressed in terms of

those indicators.

Safety Targets can be presented in either:

Absolute (i.e. less than 1 fatal accident per 1 000 000 operating hours)

Relative Terms

Safety Indicators


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Definition on Safety Performance Indicators:A measure (or metric) used toexpress the level of safety performance achieved in a system.

Enable the organisation to measure and demonstrate the achievement ofthe set target levels.

Safety indicators differ among the various sectors of the aviation industrysuch as;

air navigation services provision,

airline operations and

aerodrome operations

Safety Levels


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The relationship between acceptable level of safety, safetyperformance targets and safety performance indicators, and

safety requirements is as follows:

acceptable level of safety is the overarching concept;

safety performance targets are the quantified objectives

pertinent to the acceptable level of safety; safety performance indicators are the measures/metrics used to

determine if the acceptable level of safety has been achieved

Key Performance Indicators


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Easy judgments

Confirmed values

Committed results

Promotion and Awareness


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Newsletters internal

Posters

Videos

Intranet Presentations???

Safety Culture


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A construct

An outcome, not a process The introduction of safety management concepts lays the

foundation upon which to build a safety culture

Safety culture cannot beSafety culture cannot bemandatedmandatedorordesigneddesigned, it, itevolves.evolves.

I t is generatedIt is generated toptop--downdown

Safety CultureHow to create a Safety Culture?


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Depends on where you are starting from - you dont get to theend in one step, unfortunately, all the steps have to be traversed

Becoming a Safety Culture involves acquiring and thenmaintaining a set of skills

The two major factors are information and trust, so these haveto be developed

Be systematic (SMS are a start) and then learn to operate withthe unknown as well

Have the program run right from the top Appoint a senior champion who is dedicated and willing to stick it

out, even when it gets hard

The champion reports direct to the board Recognise that it will be uncomfortable, safety cultures are

different, not just an add-on

Safety CultureA Way Forward developing a Safety Culture:


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Agree on ways to analyse incidents to reveal individual and system issues

Develop reporting systems that are easy to use (compact, open-ended,

impersonal) Encourage the workforce (air andground) to realise that allincidents are worth

reporting

Experiment with changes when new information comes in, dont be afraid toadmit failure first time round

Practice management in wanting to know from near misses beforethey becomeaccidents

Positive culture

Source: David Marx


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Positive

culture

Flexible culturePeople can adapt

organizational processes whenfacing high temporary

operations or certain kinds ofdanger, shifting from theconventional hierarchicalmode to a flatter mode.

Learning culture

People have the willingnessand the competence to draw

conclusions from safety

information systems and the

will to implement major

reforms.

Informed culturePeople are knowledgeable about the human,

technical, organizational and environmental factorsthat determine the safety of the system as a whole.

Reporting culture

People are prepared to

report their errors and

experiences

Just culturePeople are encouraged (even rewarded) for providing

essential safety-related information. However, there is a clear

line that differentiates between acceptable and unacceptablebehaviour.

Just Culture


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Get rid of the idea that blame is a useful concept (this is hard to do)

Define clear lines between the acceptable and the unacceptable

Have those involved draw up the guidelines, do not impose from above ifyou want them to be accepted

Have clear procedures about what to do with other forms of non-compliance

Just Culture

Confidentiality


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Confidentiality People are reluctant to draw attention to errors made by themselves or their

colleagues, due to personal embarrassment. They must be confident that theiridentity, or the identity of any person implicated in the report will not be

disclosed without their permission or unless this is required by law. Anassurance should also be given that any subsequent safety action taken will, asfar as possible, ensure the anonymity of the persons involved.

Punitive Action A person who breaks the law or breaches a regulation or company procedure

through a deliberate act or gross negligence cannot expect immunity fromprosecution. However, if the offence was unpremeditated and unintentional, andwould not have come to light except for the report, he/she should be protectedfrom punishment or prosecution.

Loss of Licence The circumstances of a report may indicate that the performance of anindividual is below the acceptable level. This may indicate the need for furthertraining, or even cancellation of an individual's licence. Such action must neverbe punitive.

Workshop


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Safety Culture

Just Culture

PromotionSafety Awareness

The Safety Components


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Organizational cultural transformation is not for the faint of heart. In fact, manyattempts at transforming an organization fail, for a variety of reasons:

"Playing at it" or "dabbling" with it until it's no longer fun Not applying the kind of leadership that would best meet the needs of the

situation Intervening in the wrong places or at the wrong time Not taking this work seriously enough

Not giving it enough time or attention Senior leaders "delegating" this work (rather than committing and investing

their own time and energies) Knowing what needs to be done but being unwilling to do it...to go all the way Not having the people and tools available internally to get the job done

Inability to engage all the right people in the process Underestimating how big an undertaking this really is

Monitoring


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Continuous

Documented

Committed

Awareness


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Training

Pamphlets

News letters

Seminars

ReportingSafety Records


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The documents collected by ATM providers to demonstrate toall stakeholders that the operations have been and continueto be undertaken in a safe manner.

Safety Records are all documents developed under the

umbrella of Quality and Safety Management System.

Examples of Safety Records


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Safety Assessment Report

Incident Report

Accidents Training Records

Safety Performance MonitoringRecords

Safety Occurrence Report Safety Survey Report

Other Examples??Policies, Strategies,

Procedures

Training

Safety Monitoring

Safety Assessments

SAFETYRECORDS

Manual

Basic Safety Concept


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y p

Introduction to Safety Management

Hazards

Safety Risks

ICAO Safety Managementrequirements

Introduction to Safety ManagementSystem (SMS)

SMS Planning

SMS Operation

Phased approach to SMSimplementation

State Safety Programme (SSP)


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Joint Session / Discussion

Wrap - up


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Today were follow ing topics covered and

discussed:

ICAO Safety Management System

SES Regulations

The Safety System



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Any Questions?

See You Tomorrow


Use of SMS can be generally interpreted as applying a quality management

h t t l f t i k Si il t th t f ti f t


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approach to control safety risks. Similar to other management functions, safety

management requires planning, organising, communicating and providing direction.

The SMS development is built after the following structure:

1. Setting the Organisational Safety Policy

2. Safety Planning and Implementation of Safety Management Procedures

3. Risk and Quality Management methods

4. Safety Culture

Main SMS Components

In line with the guidance outlined in ICAO Doc 9859 - Safety Management Manual,the SMS components may be assigned to the following broad domains:


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the SMS components may be assigned to the following broad domains:

Safety Planning

SMS Organisational Structure Safety Achievement Safety Assurance Safety Promotion

A successful implementation and operation of an SMS is highly dependent onorganisational aspects such as individual and group attitudes, values, competencies andpatterns of behaviour which are frequently referred to as elements of the safetyculture.

A positive safety culture is characterised by a shared awareness of organisationspersonnel of the importance of safety in their operational tasks.

Organisational foundation for

Safety Management


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Organisational Processes

WorkplaceConditions

ActiveFailures

LatentConditions

Defences

Policy Making

Planning

Communication

Allocation of resources

Supervision

Activities over which any organisation has a reasonable degreeof direct control


Safety ManagementDeficiencies in

equipment design


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WorkplaceConditions

ActiveFailures

LatentConditions

Defences

Inadequate hazardidentification and riskmanagement

Normalization of deviance

Conditions present in the system before the accident, madeevident by triggering factors.

training deficiencies

Incomplete/incorrect standardoperating procedures

equipment design


Safety Management


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WorkplaceConditions

ActiveFailures

LatentConditions

Defences

Resources to protect against risks that organisations involved in theproduction activities generate and must control.

Technology

Training

Regulations


Safety Management


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WorkplaceConditions

ActiveFailures

LatentConditions

Defences

Workforce Stability

Qualifications and experience

Morale

Credibility

Ergonomics

Factors that directly influence the efficiency of people inaviation workplaces


Safety Management


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WorkplaceConditions

ActiveFailures

LatentConditions

Defences

Errors

Violations

Actions or inaction of people (pilots, ATCOs, maintenance engineers,Aerodrome staff, etc.) that have an immediate adverse effect


Safety Management


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WorkplaceConditions

ActiveFailures

LatentConditions

Defences

Accident / Incident

Monitor

IdentifyImprove

Contain Reinforce

SMS and QMS


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SMS results in the design and implementation of organizationalprocesses and procedures to identify safety hazards andcontrol/mitigate safety risks in aviation operation.

QMS provides a structured approach to monitor that processes andprocedures to identify safety hazards and control/mitigate safety

risks in aviation operations function as intended and, when they donot, to improve them.

ACAC SMS Training

Documents

Transcript of ACAC SMS Training