Safety Management System Manual

Safety Management System Manual

Revised: 07/08/2020


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Preface

SMS Safety Policy StatementGulfstream will develop, produce, and service the best business jet aircraft in the world, while operating in a manner that continuously promotes the safety of our products and our employees. Gulfstream is committed to the implementation and continuous improvement of an effective Safety Management System (SMS) aligned with applicable global aviation standards.

Refer to Chapter 3 for more details


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Appleton, WI Brunswick, GA

Dallas, TX Lincoln, CA

Long Beach, CA Luton, UK

Savannah CompletionsSavannah, GA

Savannah Service CenterSavannah, GASt. Louis, MO Teterboro, NJ

Van Nuys, CAWestfield, MA

West Palm Beach, FL

CRS#G1FR100Y CRS#GR4D216M CRS#VJ1R560KCRS#2GDR216BCRS#EC3R470LCRS#EASA.UK.145.00883CRS#6D1R324D

CRS#GR4R216M

CRS#8GUR243DCRS#LEGD039GCRS#EC3D470LCRS#LEGR039GCRS#PB8R624N

Approved Repair Station

Note: This manual is developed for use and adherence by GAC repair stations which have undergone extensive set-up and training specific to the enterprises overall approach to SMS.


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Proprietary Notice

This data and information contained herein is proprietary data of Gulfstream Aerospace Corporation. Neither this data nor the data contained herein shall be reproduced, used, or disclosed to others without the express written authorization of Gulfstream Aerospace Corporation. This material is proprietary and confidential.


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1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

2. Safety Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

3. Safety Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20

4. Safety Culture Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24

5. Hazard and Near Miss Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28

6. Risk Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32

7. Incident Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37

8. Hazard/Near Miss & Accident/Incident Investigations . . . . . . . . . . . . . . . . . . . . . . . . . . . .42

9. Safety Performance Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49

10. SMS Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53

11. Training, Awareness and Competence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58

12. SMS Information Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .64

13. SMS Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68

14. Aircraft Accident Emergency Response Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71

Table of Contents

Safety Management System Manual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ii

Approved Repair Station . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii

Proprietary Notice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv

Table of Contents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .v

Signature Page . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi

Revision Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

Records of Revision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii

Master List of Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

Master List of Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .x

Master List of Updates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi

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Signature PageBelow is the Repair Station Accountable Manager and SMS Manager/Coordinator acknowledgement for this Safety Management System Manual. Electronic verification of acknowledgement is main-tained within the Q-Pulse Documents Module.

Site Repair Station Number

Accountable Manager (Name & Title)

SMS Manager (Name & Title)

Appleton, WI G1FR100Y Ron Aldrich Vice President

Gena Process SMS Coordinator

Brunswick, GA GR4D216M Becky Elliott Director

Danny Johnson SMS Coordinator

Dallas, TX VJ1R560K Naveed Aziz Vice President

Rafael Monroy SMS Manager

Lincoln, CA 2GDR216B Janna Greenstreet General Manager

Tarah Reckard SMS Coordinator

Long Beach, CA EC3R47OL Tom Anderson Vice President

Shelly-Ann Cawley SMS Coordinator

Luton, UK EASA.UK.145.00883

Clarke Mouncher Managing Director

Nicola Impey SMS Coordinator

Savannah, GA Completions 6D1R324D Melisssa Grant

DirectorSteven Mentzer

SMS Coordinator

Savannah, GA Service Center GR4R216M Joe Rivera

Vice PresidentPaul Ashburn SMS Manager

St. Louis, MO 8GUR243D Murtaza Hassan General Manager

Kent Manning SMS Coordinator

Teterboro, NJ LEGD039G Fran Ahern General Manager

Linus Kuplast SMS Coordinator

Van Nuys, CA EC3D470L Kevin Fletcher| General Manager

Shelly-Ann Cawley SMS Coordinator

Westfield, MA LEGR039G Fran Ahern General Manager

Linus Kuplast SMS Coordinator

West Palm Beach, FL PB8R624N Mark Bates General Manager

Phil Panzarella SMS Coordinator


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Revision ProcessThe SMS Manual revision process consists of submitting a Change Request form. The requestor shall complete the form filling in the revision description, any regulatory impact, process change, or any other consequence of the revision. To submit a request for revisions, please utilize the Change Request form within the Documents module of Q-Pulse.


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Records of RevisionManual Holder: Manual Number:Note:

Revision Number

Dated Date Filed Filed By

Original July 10, 2012 July 10, 2012 Doug Dettenmayer Corporate SMS Manager

1 November 16. 2012 November 16. 2012 Doug Dettenmayer Corporate SMS Manager

2 February 5, 2013 February 5, 2013 Doug Dettenmayer Corporate SMS Manager

3 March 31, 2014 March 31, 2014 Cedric Hunt Corporate SMS Manager

4 March 1, 2015 March 1, 2015 Prasant Bhandari Corporate Aviation Safety Analyst

5 January 20, 2016 January 20, 2016 Prasant Bhandari Corporate Aviation Safety Analyst

6 March 8, 2017 March 8, 2017 Prasant Bhandari Corporate Aviation Safety Analyst

7 August 22, 2018 August 22, 2018 Prasant Bhandari Corporate Aviation Safety Analyst

8 January 29, 2019 January 29, 2019 Prasant Bhandari Corporate Aviation Safety Analyst

9 January 20, 2020 January 20, 2020 Prasant Bhandari Corporate Aviation Safety Analyst Sr

9.1 February 3, 2020 February 3, 2020 Prasant Bhandari Corporate Aviation Safety Analyst Sr

9.2 July 8, 2020 July 8, 2020 Prasant Bhandari Corporate Aviation Safety Analyst Sr


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Appendix

Master List of AcronymsThe following acronyms apply to all related information in the manual:

ALARP As Low As Reasonably PracticableAOG Aircraft on GroundAPPM Aviation Policy and Procedure ManualASR Air Safety ReportASRS Air Safety Reporting System (NASA)CAA Civil Aviation AuthorityCAPA Corrective and Preventive ActionCoA Certificate of AirworthinessCPM Customer Program ManagerCRS Certified Repair StationCSR Customer Service RepEASA European Aviation Safety AgencyEHS Environmental Health & SafetyEIS Entry into ServiceERT Event Review TeamFAA Federal Aviation AdministrationGAC Gulfstream Aerospace CorporationGM General ManagerGSR Ground Safety ReportICAO International Civil Aviation OrganizationIP Initial PhaseNAA National Aviation AuthorityNTSB National Transportation Safety BoardOSHA Occupational Safety & Health AdministrationPOAC Previously Owned AircraftSARPS Standards and Recommended PracticesSMS Safety Management SystemSMT Site Management TeamSSC Site Safety Council SSR SMS System Action RequestVP Vice President


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Appendix

Master List of AppendicesPreface

Master List of Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

Master List of Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .x

Master List of Updates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi

Appendices1-1 Chapter Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

1-2 Compliance with the SMS Manual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

1-3 Safety of Flight Examples . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

2-1 Chapter References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

2-2 Corporate SMS Contacts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18

2-3 Corporate SMS Organizational Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19






8-1 Chapter Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48


10-1 Chapter References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57


11-2 SMS Required Training Matrix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .62





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Appendix

Master List of Updates

The following updates are incorporated to this edition of the SMS manual:

Section Update DetailsPreface Repair Station information updated1.7 SMS Reference Documents updated to include CP 12-12 and CP 12-132.5 SMS roles updated for Aviation Safety Officer and Site EHS Representative3.0 Safety Policy updated4.0 Safety Culture Policy updated5.5 Hazard reporting process updated7.5 Removed manual applicability to non-Gulfstream aircraft8.4 SMS investigation process updated8.6.1 Added statement to closing investigation stages


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Introduction

1. Introduction

1.1 Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

1.2 Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

1.3 Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

1.4 General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

1.5 Issue and Update . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

1.6 Scope of the Safety Management System (SMS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

1.7 Reference Documents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

1.8 Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Appendices1-1 Chapter Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

1-2 Compliance with the SMS Manual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

1-3 Safety of Flight Examples . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8


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Chapter OneIntroduction

1.1 Reference Safety Management System (SMS).

1.2 PurposeThis manual describes the Safety Management System supporting the operation of Gulfstream Aerospace Corporation (GAC) Repair Stations.

1.3 ResponsibilitiesSee Safety Management System Manual, Chapter 2. Safety Responsibilities.

1.4 GeneralThis manual establishes the SMS policies and procedures for all employees employed by GAC Repair Stations including:

• Employees performing maintenance, preventive maintenance and alteration on civil aviation products under the repair station certificate.

• Employees performing functions that require other regulatory training, such as hazardous materials and confined spaces.

• Employees who provide services that support the repair station’s activities.

This manual also provides the means for establishing employee training requirements. It is the tool for management to assess both new employee and current employee capabilities and competency related to SMS.

1.5 Issue and Update The control of this manual is in accordance with the procedure for SMS Information Management specified in Safety Management System Manual, Chapter 12. SMS Information Management. This manual will be reviewed (including the SMS Safety and Safety Culture Policies) annually by the Gulfstream Corporate Safety Management System personnel and updated as necessary.

Employees may request an SMS Manual update/change by contacting a GAC Corporate SMS Manager (Refer to Appendix 2-2 Corporate SMS Contacts) or by submitting a Document Change Request through Q-Pulse.

Immediate changes to this manual may be authorized by the GAC Director of Environment, Health & Safety (EHS) in the form of a signed SMS Manual Immediate Change Memo. Gulfstream Corporate SMS will communicate immediate changes to the sites through e-mail and a SMS Web Site Posting.

1.6 Scope of the Safety Management System (SMS)The SMS has been established consistent with the business needs of the company to meet the requirements of the International Civil Aviation Organization (ICAO) Standards and Recommended Practices (SARPS),

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See the following Annexes to the Convention on International Civil Aviation:

• ICAO Annex 6 - Aircraft Operations, Maintenance and General Aviation,

• ICAO Annex 8 - Type Design or Manufacture of Aircraft, Airworthiness of Aircraft (Amendment 101)

• ICAO Annex 13 - Aircraft Accident and Incident Investigation

• ICAO Annex 19 - Safety Management

The SMS is designed to reduce safety risks to an acceptable level through a continuing process of hazard identification and safety risk management through achievement of the following goals:

• Reducing flight safety, employee, and environmental risks by better managing Gulfstream’s corporate safety risks and setting goals to eliminate or reduce these risks.

• Communication of these safety risks to employees and their roles and responsibilities related to these risks.

• Increase awareness of safety issues at all levels of the Company, thereby providing a better framework/structure for management to play a key leadership role in addressing safety concerns.

• Continuous improvement of Gulfstream’s SMS and risk controls.

• Compliance with applicable safety laws and regulations.

• Foster a culture of change management so that safety issues are identified and risks are eliminated or reduced in the planning process and delays or other impediments to business goals are avoided.

The SMS applies specifically to all Gulfstream facilities that fall under US and Foreign Regulatory approvals regarding the maintenance of aircraft. See Appendix 1-2 Compliance with the SMS Manual for a listing of included GAC facilities.

1.7 Reference DocumentsThe following documents are to be used in conjunction with this manual:

• ICAO DOC-9859 Safety Management Manual

• SMS Practitioners Guide.

• SMS Assessment & PVI Procedures Manual (SMS-APVI-PM-001).

• Corporate Policy CP-12-7 Accident/Incident Responsibilities and Reporting.

• Corporate Policy CP-14-13 Airplane Accident Response Plan.

• Corporate Policy CP 12-12 AviationSafety Management System

• Corporate Policy CP 12-13 External Safety Management System Activities

Note: These documents can be found either within the Q-pulse documents module, SMS webpage, or the corporate policy webpage.

1.8 Definitions The following definitions apply to all related information in the manual.

Accident – An occurrence associated with Aircraft Accident, Environmental Event, Recordable Injury,

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Physical Property Damage, and Product/Aircraft Damage.

Air Safety Report (ASR) – A report used anytime there is a hazard identified in the course of a flight. The report is normally initiated by the flight crew within 48 hours of incident if conditions allow.

Aircraft Accident – An occurrence associated with the operation of an aircraft which takes place between the time any person boards the aircraft with the intention of flight and all such persons have disembarked, and in which any person suffers death or serious injury, or in which the aircraft receives substantial damage.

As Low As Reasonably Practicable (ALARP) – A risk management term normally used in the context of defining a primary objective of an organization’s SMS e.g. to ensure that an identified risk is ALARP. Consideration should be given to both the technical feasibility of further reducing the risk, and the costs.

Disposition Period – Time frame allocated to accept or reject a report.

Environmental Event – Any release of a hazardous substance into the environment. (See GAC Corporate Policy (CP-12-7) for a listing of what a release includes.

Error – An action or inaction by an operational person that leads to deviations from organizational or the operational person’s intentions or expectations.

Ground Safety Report (GSR) – A report used for hazards that occur prior to flight, that normally gets reported by Flight Operations or Flight Test personnel within 48 hours if conditions allow.

Gulfstream Accident/Incident Report (GA 3558) – The form used during accident/incident investigation.

Gulfstream University (GU) – A classroom, computer-based training (CBT), and distance-learning courses system. Gulfstream University provides teambuilding and organizational development (OD) consulting services. GU’s primary makeup includes three organizations: Leadership and Organizational Development, Technical Process and Quality Training, and Compliance Training.

Hazards – Conditions, objects or situations that have the potential to harm people, property, reputation, or the environment; and can increase liability to the corporation.

Investigation – A searching inquiry for ascertaining facts; detailed or careful/systematic examination.

Investigator – Formally trained individual who will conduct a systematic inquiry to discover the Root Cause of an incident/accident and identify causal factors as they apply to the incident/accident.

Near Miss Incident – Any event where the potential for an injury, an environmental event, significant physical property damage or product /aircraft damage existed and was not realized.

New Report – Any event reported in Q-Pulse that is not yet accepted is categorized as new.

Open Report – Any accepted report in Q-Pulse that is pending open within the target date

Overdue Report – Any accepted report in Q-Pulse that is pending open beyond its target date. New reports not accepted within their disposition period will be considered overdue.

Physical Property Damage – Any accident resulting in damage, other than aircraft product damage, to other non-product property, equipment or facilities (e.g., tooling damaged by forklift, vehicle accidents).

Product/Aircraft Damage – Any damage caused to a Gulfstream or customer aircraft (or removed components) during the build, assembly, production, maintenance, test, service or Gulfstream-controlled maintenance and/or flight phases. (See GAC Corporate Policy (CP-12-7) for categories of damaged caused.

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Q-Pulse – An electronic Risk Management database serving both as a risk registers and risk management tool for reported hazards, near misses and events. Q-Pulse’s design allows for reporting of risk ownership to appropriate personnel as a referral.

Recordable Injury – A work-related injury or illness that results in either death, days away from work, restricted work or transfer to another job, medical treatment, loss of consciousness, or a significant injury or illness diagnosed by a physician or other licensed health care professional.

Repair Station – Aviation Facility engaged in maintenance, preventive maintenance or alterations of an aircraft, airframe, aircraft engine, propeller, appliance or component part: To which FAR Part 43 applies.

Reporting Manager – The manager who is responsible for the person, property or product involved in the incident/accident or in whose general physical area the event occurred (including a hazard report where applicable). If more than one manager meets the definition, the next level of management will designate the role of ‘Reporting Manager’.

Risk – The likelihood of harm to personnel, damage to equipment or structures, loss of assets, or reduction of an ability to perform a prescribed function. Defined in terms of: severity of consequences (how much harm) & likelihood (the probability of suffering harm).

Risk Assessment – The process of estimating the probability and impact for each hazard identified to ensure that they are understood and the risk potential is identified and prioritized.

Root Cause – is an initiating event(s) aligned in a causal chain, leading to an outcome or effect of interest (i.e., the most basic reason, which if eliminated, would prevent recurrence).

Safety – The state in which risks associated with aviation activities, related to, or in direct support of the operation of aircraft, are reduced and controlled to an acceptable level.

Safety Culture – See Safety Management System Manual, Chapter 4 Safety Culture Policy

Safety of Flight Event – Any condition or situation which, if not corrected, would endanger/threaten the safe flight of an aircraft, its occupants or any other person. See Appendix 1-3 Safety of Flight Examples.

Safety Management System (SMS) – A documented process for proactively managing risks that integrates operations and technical systems with the management of financial and human resources to ensure aviation safety or the safety of the public.

Site – A business unit, operation, department, area or site (i.e., the workplace or organization)

NOTE: for the purpose of standardization and continuity, Corporate SMS has chosen the term “site” or “organization” to be an interchangeable term.

Standard Event – A minimal risk hazard where the actions taken by the person reporting the hazard have mitigated the risk to As Low As Reasonably Practicable (ALARP) requiring no further action. If a system is in place to mitigate the reported hazard to ALARP, requiring no further actions, the event may also be considered a standard event.

System Safety – An approach to accident/incident prevention involving detecting deficiencies in system components and operations which have an accident potential.

Training – The process used by employees to gain skills or knowledge with the opportunity to demonstrate competency.

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Appendix

1-1 Chapter Reference

Introduction


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Appendix

1-2 Compliance with the SMS Manual

The Corporate SMS Manuals are developed for use and adherence by various GAC sites which have undergone extensive set-up and training specific to the enterprises overall approach to SMS. As of this publication date, the site(s) noted below are required to adhere to this Corporate GAC Safety Management System Manual.

1. Gulfstream Aerospace – Appleton, WI, CRS#G1FR100Y2. Gulfstream Aerospace – Brunswick, GA, CRS#GR4D216M 3. Gulfstream Aerospace – Dallas, TX, CRS#VJ1R560K 4. Gulfstream Aerospace – Lincoln, CA, CRS#2GDR216B5. Gulfstream Aerospace – Long Beach, CA, CRS#EC3R470L 6. Gulfstream Aerospace – Luton, UK, CRS#EASA.UK.145.008837. Gulfstream Aerospace – Savannah Completions, GA, CRS#6D1R324D 8. Gulfstream Aerospace – Savannah Service Center, GA, CRS#GR4R216M9. Gulfstream Aerospace - St. Louis, MO, CRS#8GUR243D10. Gulfstream Aerospace – Teterboro, NJ, CRS#LEGD039G11. Gulfstream Aerospace – Van Nuys, CA, CRS#EC3D470L12. Gulfstream Aerospace – Westfield, MA, CRS#LEGR039G 13. Gulfstream Aerospace – West Palm Beach, FL, CRS#PB8R624N

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Appendix

1-3 Safety of Flight ExamplesGeneralThe following are examples of potential safety of flight events that should be reported or submitted for review as a potential safety related issue. If in doubt, contact site management, Quality Control and the SMS Manager/Coordinator for guidance as soon as these types of events are discovered or observed:

Aircraft Maintenance and Repair• Incorrect assembly of parts or components of the aircraft found during an inspection or test procedure.

• Hot bleed air leak resulting in structural damage.

• Any damage or deterioration (e.g. fractures, cracks, corrosion, de-lamination, dis-bonding etc.) resulting from any cause (e.g. as flutter, loss of stiffness or structural failure) to:

º A primary structure or a “PSE” (principal structure element) (as defined in the Structural Repair Manual) where such damage or deterioration exceeds allowable limits specified in the SRM and requires a repair or complete or partial replacement.

º A secondary structure which consequently may endanger the aircraft the engine or auxiliary power unit.

• Any failure, malfunction or defect of any system or equipment, or damage or deterioration thereof found as a result of compliance with an airworthiness directive or other mandatory instruction issued by a regulatory authority, when:

º It is detected for the first time by the reporting organization implementing compliance.

º On any subsequent compliance, it exceeds the permissible limits quoted in the instruction and/or published repair/rectification procedures are not available.

• Failure of any emergency system or equipment, including all exit doors and lighting, to perform satisfactorily, including when being used for maintenance or test purposes.

• Non-compliance or significant errors in compliance with required maintenance procedures.

• Misleading, incorrect or insufficient maintenance ATA or procedures that could lead to maintenance errors.

• Products, parts, appliances and materials of unknown or suspect origin.

Aircraft Systems and Propulsion:• Any system operation (motion) that appears to have been un-commanded by pilot or normal system

functionality.

• Any condition in which an injury or potential injury was experienced.

• Loss of any component from the aircraft on ground or during flight.

• Any un-annunciated failure of an essential or critical function.

• Any power wire chafing or arcing against oxygen, hydraulic or fuel lines.

• Any in-flight emergency.

• Aircraft departure from paved surface.

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ATA 21: • Uncontrollable cabin temperature.

• Uncontrollable or loss of cabin pressurization.

• Emergency descent mode activation.

• Deployment of 02 masks.

ATA 22:• Failure of auto-pilot to disengage.

• Auto-pilot hard-over (has disconnect a/p due to un-commanded inputs).

• Significant/abrupt non-commanded control excursions.

• Failure of more than one attitude, heading, airspeed or altitude instrument or source.

ATA 24:• Dual electrical system failure.

• Black cockpit or cabin.

• Operation on batteries or emergency power only.

ATA 26:• In-flight engine/APU fire warning that requires the engine or APU to be shutdown.

• Any event involving smoke or fire in any system or area.

ATA 27/55:• Hops activation.

• Stiff or jammed flight controls.

• Stall barrier/ground spoiler malfunction.

• Severe flight control buffet/vibration.

ATA 28:• Severe in-flight fuel imbalance.

• Significant fuel leaks.

• Fuel leakage in areas where ignition source is present.

• Fuel leakage onto sensitive components.

• Un-commanded or inoperative fuel jettison system.

ATA 29:• Complete loss of any one system.

• Significant leakage onto sensitive components.

Introduction


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ATA 30:• Failures of heated air ducting resulting in overheat annunciation.

ATA 31:• Loss of all displays.

• Failure of more than one attitude, heading, airspeed or altitude instrument or source.

ATA 32:• Landing gear failure to extend/retract.

• Abnormal operation or failure of emergency extension system.

• Significant misalignment.

• Loss of directional control (Nose Wheel Steering) during taxi or landing.

• Loss of braking during taxi or landing.

• Tire, brake or wheel fire/failure.

ATA 35:• Major or complete loss of oxygen in flight.

• Failure of emergency deployment/function.

ATA 36:• Dual bleed air system failure.

• Failures of heated air ducting resulting in overheat annunciation or damage.

ATA 52:• MED failure to open normally.

• Failure of any emergency door or window to properly open.

ATA 56:• Failure of any emergency door or window to properly open.

• Cockpit windshield or window failures that substantially interfere with crew vision.

• Failure of any structural pane.

ATA 71-80:• In-flight engine shutdown or un-commanded rollback.

• Failure to achieve commanded power setting.

• Any engine vibrations outside Aircraft Flight Manual limitations.

Aircraft Ground Handling and Servicing:• Failure, malfunction or defect of ground equipment used for the testing or checking of aircraft systems and

equipment when the required routine inspection and test procedures did not clearly identify the problem,

Introduction


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where this results in a hazardous situation.

• Non-compliance or significant errors in compliance with required servicing procedures.

• Loading of contaminated or incorrect type of fuel or other essential fluids (including oxygen and potable water).

• Unsatisfactory ground de-icing/anti-icing.

Introduction


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Safety Responsibilities

2. Safety Responsibilities

2.1 Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

2.2 Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13


2.4 General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

2.5 Organizational Levels and Roles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

2.5.1 Corporate Organizational Roles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

2.5.2 Site (Repair Station) Roles and Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14

Appendices2-1 Chapter References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

2-2 Corporate SMS Contacts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18

2-3 Corporate SMS Organizational Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19


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Chapter TwoSafety Responsibilities

2.1 ReferenceSafety Management System.

2.2 PurposeTo establish accountability for safety.

2.3 ResponsibilitiesEstablished in this section.

2.4 GeneralMembers of the Gulfstream Leadership Team are champions of safety and provide resources to implement control and oversee the Safety Management System (SMS), including: financial resources, training, human resources, specialty services, and technical and informational services. The President has designated the Senior Vice President, Administration and General Counsel as responsible for ensuring that:

• The SMS requirements are established, implemented and maintained, in accordance with applicable international standards.

• The Gulfstream EHS Department is responsible for the management of the corporate SMS program and presents periodic SMS performance reports (including recommendations for improvement) to upper management for review.

2.5 Organizational Levels and RolesEach of the significant organizational levels required to facilitate the GAC SMS are described below, along with their respective roles in facilitating an effective SMS.

2.5.1 Corporate Organizational Roles º President - Provides the strategic direction for safety policy, risk mitigation, safety assurance and safety

promotion. Ultimately accountable for safety program implementation and performance. Supports and financially enables efforts to comply with all Gulfstream corporate policies and processes specifically related to the Safety Management System.

º Senior Vice President, Administration and General Counsel - Provides senior leadership direction to ensure that: (1) the SMS requirements are established, implemented and maintained, in accordance with applicable international standards, and (2) the Gulfstream EHS Department is responsible for the management of the corporate SMS program and presents periodic SMS performance reports (including recommendations for improvement) to upper management for review.

º GAC Leadership Team - Assists in the establishment of SMS goals, monitors progress and ensures adequate resources for implementation. Periodically reviews SMS performance and goals to ensure continuing suitability, adequacy and effectiveness.

º VP Operations, VP Customer Support and Service - Communicates and enables corporate safety policy



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related to the SMS. Promote product safety, environmental responsibility and employee health and safety on and off the job. Promote a work environment in which flight safety and employee safety hazards and risks are continuously identified and eliminated or, at a minimum, controlled through regular assessment and oversight; ensure employees receive appropriate safety training related to the SMS and other corporate requirements.

º Director, Customer Support - Directs the overall operation of Technical Services. Supports the daily review of the in-service Fleet Status Report to include the review of all Air Safety Reports and Field Service Reports for potential safety or airworthiness issues in the fleet. Coordinates the appropriate response activity to include an engineering review of potential safety or airworthiness issues to determine root cause and corrective actions. Communicates all issues to the fleet along with corrective actions.

º AOG Duty Manager - Communicates with the Leadership Team and the VP for Flight Operations and/or designated representative as required by situation all In-Flight Emergencies and any reported safety related issues/incidents on aircraft operating in service.

º Director, Environmental, Health & Safety - Provides leadership in the operation and performance of SMS; develops and implements innovative strategies that foster continuous SMS improvement in a manner that supports departmental, customer, and corporate business plans, goals and objectives.

º Corporate SMS Senior Manager - Provides leadership in the implementation, operation, and performance of the SMS as directed by the Director, Environmental Health and Safety. Additionally, the Corporate SMS Senior Manager manages the SMS Implementation Project Plan to ensure that project milestones are achieved on time. The Corporate SMS Senior Manager guides the site senior leaders and GAC Leadership Team on the SMS implementation progress, SMS effectiveness and assists site management with safety performance oversight and monitoring.

º Corporate SMS Manager - Provides daily corporate-level operational oversight and execution of SMS program directives for GAC affected business units.

º Corporate SMS Consultant - Manages all of the electronic SMS analysis processes, tools, and audit related activities. These activities may be site specific or cross-site involving some or all Gulfstream certification and airworthiness organizations.

º Corporate Aviation Safety Analyst - Provides daily corporate-level safety analysis for SMS program.

º Manager, Environmental Health and Safety - Manages functions related to the EHS aspects of the SMS including; managing staff in support of emergency preparedness and response planning, compliance, fire safety and industrial hygiene. Implements and coordinates safety and medical programs and related activities to minimize or eliminate occupational accidents, illnesses and financial losses. Complies with corporate goals and legal and other requirements. Supports requirements of Safety Management System.

º GAC Aviation Safety Officer - Acts as independent safety advisor to the GAC Senior VP of Innovation, Engineering and Flight regarding the efficacy of safety programs, primarily within Flight Test, Flight Operations, and Flight Sciences/Engineering Safety. In concert with Director of EHS, promotes a robust safety culture company-wide.

2.5.2 Site (Repair Station) Roles and Responsibilities º Site VP/GM/Accountable Manager - Provides site leadership in the implementation, operation and

performance of the SMS as directed by the VP Customer Support and Service and relevant National



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Aviation Authority approvals (NAA). Also, this role guides the site management team and advises the GAC Leadership Team on the SMS implementation progress, SMS effectiveness, and directs the site safety performance oversight and monitoring.

º Site Chief Inspector - Assists site management with airworthiness safety performance oversight and monitoring and serves as point of contact with the national airworthiness authorities that provide regulatory oversight for the site.

º Safety Management System (SMS) Manager / Coordinator - Serve as focal point of contact for SMS activities. Coordinate activities with SMS related teams and management as applicable. Promote SMS activities and sustain SMS operations locally.

º Site EHS Representative / Coordinator - Manages functions related to the EHS aspects of SMS including: coordinating emergency preparedness and response planning, compliance, hazardous materials management, fire safety and industrial hygiene.

2.5.3 Site SMS Councils/Teams and other º Site Safety Council (SSC) - Meets to review site Hazard/Near Miss and Incident Reports. Conducts risk

assessments and post-risk assessments. Implements safety enhancement processes and improvement initiatives. Provides investigation referrals to Site Event Review Team (ERT) whenever individual involvement may have contributed to the overall event.

º Site Event Review Team (ERT) - Meets to review investigation details upon referral from the Site Safety Council. The ERT will review the results from the investigation to determine if administrative action is to be taken and determine whether employee discipline is appropriate (discipline is NOT assigned by this team).

º Site Management Team (SMT) - Each sites management team supports the SMS implementation through participation in and oversight of the SSC and ERT. The Site Management Team takes input and recommendations from the SSC and ERT and is charged with championing/sponsoring and providing overall support for SMS activities, to include proliferation of resources, monetary or otherwise.

º Sr. Managers and Managers - Communicate and enable corporate safety policy related to the SMS. Promote product safety, environmental responsibility and employee health and safety on and off the job. Promote a work environment in which flight safety and employee safety hazards and risks are continuously identified and eliminated or, at a minimum, controlled through regular assessment and oversight; actively participate in or lead safety-related event investigations; ensure employees receive appropriate safety training related to the SMS and other corporate requirements.

º Service Team Managers and Team Leads - Promote product safety, environmental responsibility and employee health and safety on and off the job. Promote a work environment in which flight safety and employee safety hazards and risks are continuously identified and eliminated or, at a minimum, controlled through assessment and oversight; actively participate in or lead safety-related event investigations; ensure employees receive appropriate safety training related to the SMS and other corporate requirements.

º All Technicians (e.g. Aircraft, Interior, Support Shops, and Avionics) - Conduct work in the safest manner possible in accordance with approved technical data, Gulfstream policies, and in a manner that enhances their own/other employees’ health and safety, product safety and promotes risk reduction; participate openly in safety-related event investigations, and immediately report workplace hazards



Revised: 07/08/2020 16

and make suggestions for their control; cooperate and contribute toward the overall success of the SMS program at the local level.

º All Site Personnel: Conduct work in the safest manner possible in accordance with approved site procedures, Gulfstream policies, and in a manner that enhances their own/other employees’ health and safety, product safety and promotes risk reduction; participate openly in safety-related event investigations, and immediately report workplace hazards and make suggestions for their control; cooperate and contribute toward the overall success of the SMS program at the local level.


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Appendix

2-1 Chapter References


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Appendix

2-2 Corporate SMS Contacts

Name Role/Location NumberPaul Dellinger GAC EHS Director / Savannah, GA 912-965-2982Fred Etheridge Corporate SMS Senior Manager / Savannah, GA 912-965-7396

Christopher Hallman Corporate SMS Program Manager / Savannah, GA 912-677-0171Scott Wyman Corporate SMS Manager / Savannah, GA 912-965-4495Cedric Hunt Corporate SMS Manager / Savannah, GA 912-965-6406

Prasant Bhandari Corporate Aviation Safety Analyst Sr / Savannah, GA

912-251-1973


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Appendix

2-3 Corporate SMS Organizational Structure

President

Senior Vice President Administration & General

Counsel

Director Environmental, Health & Safety

Corporate SMS Senior Manager

Corporate SMS Consultant

Corporate SMS Managers

Corporate Aviation Safety Analyst

Site SMS Managers/Coordinators

Corporate SMS Organizational Chart


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Safety Policy

3. Safety Policy

3.1 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21

3.2 Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21


3.4 General SMS Safety Policy Statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21

3.5 Values & Guiding Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21

Appendices3-1 Chapter References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23


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Safety Policy

Chapter ThreeSafety Policy

3.1 ReferencesSafety Management System.

3.2 PurposeTo establish SMS Safety Policy.


3.4 General SMS Safety Policy StatementGulfstream will develop, produce, and service the best business jet aircraft in the world, while operating in a manner that continuously promotes the safety of our products and our employees. Gulfstream is committed to the implementation and continuous improvement of an effective Safety Management System (SMS) aligned with applicable global aviation standards. The primary objectives of the Gulfstream SMS are to:

• Promote early identification of safety hazards and risks

• Take proactive steps to reduce identified safety hazards and risks

• Promote and enhance our safety culture to support the SMS

• Establish and continuously maintain an acceptable level of safety within Gulfstream

Gulfstream will provide the necessary resources to implement, control and oversee the Safety Management System (SMS), including financial and human resources.

Through execution of our SMS, Gulfstream will implement and sustain safety risk reduction practices into our business management decisions, including design, test, production, maintenance and customer support, to further promote our aviation safety objectives.

3.5 Values & Guiding Principles• Integrity: The success of our SMS depends on all employees proactively identifying and reporting safety

hazards and risks within the workplace, while also conducting themselves in a way that enhances safety of all employees. Gulfstream will actively foster our SMS by holding all employees accountable to support this principle. Accountability starts with the president and leadership team and applies to all management and non-management employees.

• Commitment to Safety of Flight: Gulfstream will strive to be a leader in reducing safety of flight risk in all our products. We will do this by proactively identifying and managing issues that affect the safety or integrity of our aircraft in all design and manufacturing activities, as well as during maintenance activities for all customer and company owned aircraft.

• Commitment to Employee Safety: Gulfstream will strive to be a leader in the industry by promoting health and safety in the workplace and providing a work environment in which workplace hazards are identified,


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Safety Policy

eliminated or, at a minimum, controlled.

• Commitment to Continuous Improvement: Gulfstream will review its safety levels on a regular basis and establish goals for continuous improvement of the SMS.

• Commitment to Compliance: Gulfstream will operate its business in compliance with all applicable laws, regulations and other requirements in a way that continuously promotes the safety of our products and our employees. This includes training our employees to comply with the SMS requirements and applicable federal, state and local laws and regulations and other requirements to which the company subscribes.

[Signature and Original Copy on File]_______________________________

Mark Burns, PresidentJanuary, 2020


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Safety Policy

Appendix



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Safety Culture Policy

4. Safety Culture Policy

Appendices


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Chapter FourSafety Culture Policy

4.1 ReferenceSafety Management Systems.

4.2 PurposeThis policy identifies the Gulfstream philosophy and processes required to establish and maintain an appropriate safety culture (just culture) that supports our Safety Management System (SMS) through proactive risk identification and hazard and event management.


4.4 General Safety Culture PolicyGulfstream is committed to creating and sustaining a safety culture environment that supports our Safety Management System and recognizes that a number of principles enable the development and sustainment of a positive safety culture, including:

• Recognition that fair and equitable treatment of all employees encourages sharing of safety related information

• Creating and sustaining an environment that actively seeks out risk and supports hazard and event reporting (including “near-miss” events) without fear of retribution

• Recognition that inappropriate disciplinary measures can suppress open reporting of risks that may exist

• Creating and sustaining an environment where there is recognition that human errors will occur

• Creating and sustaining an environment that promotes openness and learning from events

At Gulfstream, there is an expectation that all employees actively promote safety in everything they do. This includes two explicit duties that are the responsibility of all employees:

• To report any hazard, near-miss, unsafe condition or incident that occurs, or is otherwise known about

• To openly and honestly participate in any investigation that may arise as a result of any reported hazard, near-miss or event that occurs

Gulfstream recognizes that employee actions that contribute to hazards and events may be the result of a wide spectrum of behaviors. Some of these include unintentional error, not recognizing the risk involved, moving away from desired behavior, or engaging in at-risk behavior that places employees or products at risk.

The Gulfstream policy regarding these behaviors is as follows:

• Unintentional human error will be investigated and feedback given

• Moving away from desired behavior or engaging in at-risk behaviors will be subject to the Progressive Counseling/Corrective Action policy


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We are committed to creating an open and fair safety culture within Gulfstream that supports our Safety Management System. In continuation of this policy, we pledge that our first response to any event will be to investigate fairly the circumstances involved.

[Signature and Original Copy on File]_______________________________

Mark Burns, PresidentJanuary, 2020


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Appendix



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Hazard and Near Miss Reporting

5. Hazard and Near Miss Reporting

5.1 Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29

5.2 Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29

5.3 Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29

5.4 General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29

5.5 Hazard / Near Miss Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29

5.5.1 Q-Pulse Hazard / Near-Miss Reporting Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . .30

5.6 Hazard / Near Miss Report Follow-on Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30

Appendices5-1 Chapter References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31


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Hazard and Near Miss Reporting5.1 ReferenceSafety Management System.

5.2 PurposeTo establish the process of hazard and near miss reporting for the Gulfstream Safety Management System (SMS) and to supplement the requirements of Corporate Policy CP-12-7, Accident/Incident Responsibilities and Reporting.


5.4 GeneralThe Gulfstream Safety Management System (SMS) requires proactive reporting of safety hazards or safety concerns on the part of all Gulfstream employees.

NOTE: Gulfstream requires that any employee who becomes aware of a hazard, sees a safety event occur, or has a safety concern to report it immediately. See Safety Management System Manual, Chapter 4. Safety Culture Policy.

NOTE: Under no circumstances will employees be retaliated against for the act of reporting safety hazards or potential hazards.

5.5 Hazard / Near Miss ReportingThe Gulfstream SMS contains both proactive and reactive ways to identify safety hazards and near miss events, including review of safety trends and relevant hazards identified by external sources (FAA, NTSB, etc.). The knowledge derived from proactive hazard /near miss reporting can provide significant insights into potential risks and furthermore allows for the continuous improvement of Gulfstream’s SMS. While post-event accident/incident investigations reveal a great deal about safety hazards, we cannot rely exclusively on accident/incident data to show all of the risks that we need to know about across our organization.

When any employee becomes aware of a hazard or near miss, they shall submit a report within eight business hours or end of the shift using one of the following:

• Q-Pulse SMS Database (Gulfstream’s preferred method).

• Supervision/Management, site SMS Coordinator/Manager, Site Safety Council Members or the functional area safety representative. This must be reported in Q-Pulse by one of the parties involved.

• Gulfstream’s Ethics Hot-line


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5.5.1 Q-Pulse Hazard / Near-Miss Reporting ProceduresThere are three ways to submit a Hazard / Near Miss Report through Q-Pulse:

• Hazard Reporting – the reporter’s name is associated with the report.

• Anonymous Reporting - the reporter’s name is not associated with the report.

For hazard reporting, an email feedback process is in place to notify personnel that their report has been received and to keep them updated on its progress and outcome; see Safety Management System Manual, Chapter 10. SMS Communication.

Due to the nature of anonymous reporting, direct feedback to the reporter is impossible. Feedback will be provided through their respective site SMS communications, see Safety Management System Manual, Chapter 10. SMS Communication.

Once a Hazard / Near Miss Report is submitted, the SMS risk register (Q-Pulse Database) is automatically updated and can be reviewed by Corporate SMS and the SMS Manager/Coordinators.

5.6 Hazard / Near Miss Report Follow-on ProceduresThe respective SMS Manager/Coordinator will review the reports for their site/business unit. All accepted hazard and near miss reports will be risk assessed (see Safety Management System Manual, Chapter 6. Risk Assessment) and investigated to the appropriate level, in order to address the hazard or safety concern (see Safety Management System Manual, Chapter 8. Hazard/Near Miss and Accident/Incident Investigation).

A hazard or a near miss report maybe closed as a standard event if the actions taken by the person reporting the hazard have mitigated the risk to ALARP, requiring no further action. If a system is in place to mitigate the hazard reported to ALARP, requiring no further actions, the report may also be closed a standard event. A near miss report or a hazard report where no mitigating action has been taken by the person submitting the report shall not be closed as a standard event.

If an accident/incident is submitted as a hazard report, the hazard report will be rejected and a new accident/incident report shall be submitted in accordance with Corporate Policy CP-12-7. Under no circumstance will a Hazard/Near Miss Report be deleted from Q-Pulse without documented concurrence for this action from the Corporate SMS Department.

NOTE: For detailed procedures for submitting hazard or near miss events, reference the SMS Practitioners Guide and the SMS website Tools section.


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Appendix



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Risk Assessment

6. Risk Assessment

6.1 Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33

6.2 Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33


6.4 General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33

6.5 Risk Register . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33

6.6 Risk Assessment Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33

6.6.1 Risk Assessment Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33

6.7 Change Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35

6.8 Risk Assessment Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35



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Risk Assessment

Chapter SixRisk Assessment


6.2 PurposeTo establish risk assessment policy and protocol.


6.4 GeneralAll identified and accepted hazards, near-miss situations and airworthiness safety events that occur across Gulfstream shall be risk assessed proactively. Also a proactive risk assessment will be done as a part of each site’s routine safety oversight and performance monitoring program and should drive change management (see Section 6.7 Change Management).

6.5 Risk RegisterEach site is required to maintain a risk register on which to record and track the results of the risk assessments conducted at their site. Each site’s risk register and other associated tools are included in the Q-Pulse SMS Database. Q-Pulse provides direct access to all associated data for the purpose of monthly reviews and appropriate revisions.

6.6 Risk Assessment ProceduresRisk assessments of reported hazards, near misses, or airworthiness safety events, relative to the probability and severity of injury to personnel or damage to property, may be made through:

• Direct observation of the event.

• Knowledge of the department’s operations and the potential of exposure to the identified event.

• Interviews or discussions with department employees and management who have voiced concerns regarding an event.

• Consultation with the Site Safety Council regarding the potential exposure to the identified event.

6.6.1 Risk Assessment ProcessThe risk assessment process used within the GAC SMS consists of 6 basic steps:

Step 1 - Identify initial hazard by:• Direct observation walking around the workplace or by identifying them during the performance of a task.

• Asking other employees what they think.

• Consult with the Site Safety Council.


Revised: 07/08/2020 34

• Comparing a condition against technical data or procedures (e.g. manufacturer’s instructions, OSHA/EHS guidance, Trade associations etc.)

• Assessment / Audit by internal (GAC) or external party (e.g. EASA, FAA, NAA, OSHA).

Step 2 - Decide who/what might be harmed. Identify groups:• On-site employees.

• Off-site employees.

• Risk Assessment.

• Members of the public.

• Customers.

• Aircraft.

• Project how the hazard could cause harm to persons or property.

Step 3 - Decide what to do about the condition: • List what is already in place to reduce the risk.

• List what should be done immediately to reduce risk.

• List what can be done in the short or long-term to reduce risk.

Step 4 - Record the conditions/actions to be taken:• Using the risk assessment workflows established in the Q-Pulse SMS database, calculate an initial risk

assessment score.

• Prioritize the conditions and actions to be taken based upon the initial risk assessment score.

• Deal with those hazards that are high-risk and have serious consequences first.

Step 5 - Implement the recommended actions to reduce or eliminate the condition:• Make sure that risk has been reduced “as low as is reasonably practicable” (ALARP).

Note: An easy way of doing this is to compare what is already being done with best practice. If there is a difference, list what needs to be done to close the gap.

Step 6 - Perform post-implementation risk assessment and revise as necessary:• Conduct post risk assessment on all hazards that require risk mitigation action(s).

• Review the initial risk assessment by performing a post-implementation risk assessment to make sure the actions implemented have the intended effects and the risk has been reduced to an acceptable level.

• If risk has not been reduced to acceptable levels, conduct additional research and ensure that risk is mitigated to ALARP and contact Corporate SMS Manager.

• If there is a significant change in the workplace environment or conditions, remember to review the original risk assessment form and amend it where necessary.

Risk Assessment


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6.7 Change ManagementNew or revised activities are identified through the safety oversight and performance monitoring processes at each site including the review of new or revised Standard Operating Procedures (SOP’s), facility projects and other process changes through ongoing communication with operational groups. These identified activities will receive a proactive risk assessment following the procedures in Section 6.6 Risk Assessment Procedures, above.

6.8 Risk Assessment MonitoringThe risk scores for each site risk register and area of activity, the significant risks and the risk controls shall be reviewed and revised as necessary by the site safety council and site management on no less than a monthly basis.

The risk assessment and risk control processes shall be reviewed and revised:

• As a part of the monthly site safety review process.

• As applicable due to new or revised activities or procedures.

• Annually by the Site Senior management, SMS Manager/Coordinator and/or EHS Department.

NOTE: For detailed procedures on conducting Change Management, reference the Corporate SMS Standard Operating Procedures 18.0 Change Management on Q-Pulse Document mod-ule.

NOTE: For detailed procedures on conducting risk assessments, reference the SMS Practi-tioners Guide and the SMS website Tools section.

Risk Assessment


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Risk Assessment

Appendix



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Incident Reporting

7. Incident Reporting

7.1 Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38

7.2 Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38


7.4 General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38

7.5 Incident Reporting Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38

7.5.1 Employee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38

7.5.2 Reporting Manager/Supervisor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38

7.5.3 Reporting Manager’s Supervisor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39

7.5.4 Site SMS Manager/Coordinator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39

7.6 Incident Report Follow-on Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40



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Incident Reporting

Chapter SevenIncident Reporting


7.2 PurposeTo establish the process of event reporting for the Gulfstream Safety Management System (SMS) and to supplement the requirements of Corporate Policy CP-12-7, Accident/Incident Responsibilities and Reporting.


7.4 GeneralThe SMS is designed to identify hazards and mitigate risks in our organization. Once a hazard has been identified the associated risk must be mitigated to ALARP. A site’s ability to understand all circumstances surrounding an incident and the resulting causal factors will increase the overall effectiveness of mitigating strategies.

7.5 Incident Reporting ProceduresThe Gulfstream Safety Management System (SMS) requires reporting of all product damage; physical property damage and safety of flight incidents using the Q-Pulse database (see Appendix 1-3 Safety of Flight Examples). At each sites discretion Q-Pulse may be used to report recordable injury and environmental events using the procedures contained herein.

NOTE: In the event that any Gulfstream employee has what they reasonably believe to be the initial notification of a Gulfstream aircraft accident that has recently completed maintenance or service at a Gulfstream facility shall immediately follow the procedures in Safety Manage-ment System Manual, Chapter 14. Aircraft Accident Emergency Response Plan.

7.5.1 EmployeeWhen an employee becomes aware of any product/aircraft damage, physical property damage, or safety of flight event they must immediately report the incident to their supervisor or appropriate management person.

7.5.2 Reporting Manager/SupervisorThe Reporting Manager is responsible for immediately accomplishing the following:

• As applicable, secure medical assistance from the appropriate site EHS/medical facility/provider.


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Incident Reporting

• Using Q-Pulse, complete the Initial Investigation Report (page 1) of the GA 3558 Accident/Incident Form within eight business hours of the incident (or end of the shift) Note: A Reporting Manager/Supervisor may assign a designee to complete the initial GA 3558 (page 1) information; this does not relieve them of their responsibilities detailed herein.

• Ensure all applicable sections of the GA3558 are fully completed – including:

º Type of Event – Injury, Product Damage, etc.

º Accident/Incident Location

º Accident/Incident Description

º Employees Involved/Witnesses

º Aircraft Damage / Personnel injury Information

º Days/Hours worked information

• If the aircraft has received a certificate of airworthiness (e.g., Gulfstream, Previously Owned Aircraft (POAC) or customers’ aircraft), include the name of the aircraft owner in the accident/incident description section of the report. Ensure the individual responsible for communicating specific aircraft customer information Customer Program Manager (CPM), Customer Service Representative (CSR), Entry Into Service (EIS) Program Manager, etc.) informs the customer as appropriate.

• Include all known costs that will be incurred. Estimates are acceptable for the initial report but final cost reports must include a detailed breakdown of labor, materials, etc. Contact the sites business office support person to participate in the cost estimation, cost accrual, work order assignment and reporting process. Include the name of the business specialist on the initial report, if possible.

7.5.3 Reporting Manager’s SupervisorThe Reporting Manager’s direct supervisor, whether it is a Director, Site Manager or Vice President, as the circumstances and location dictate, is responsible for accomplishing the following:

• Ensure initial reporting is complete. Contact his or her counterpart if there is a reassignment of responsibility (e.g. from one site to another). If there are questions regarding the Reporting Manager roles or responsibilities, contact the Corporate SMS Senior Manager.

• Ensure Reporting Manager completes responsibilities described above and an appropriate team is available to conduct a thorough investigation. Business office participation is necessary for cost-tracking purposes.

7.5.4 Site SMS Manager/CoordinatorThe site SMS Manager/Coordinator is responsible for accomplishing the following:

• Assisting and advising the site VP/GM with incident reporting responsibilities.

• Assignment of Investigator(s) to the event, see Safety Management System Manual, Chapter 8. Hazard/Near Miss and Accident/Incident Investigations, 8.5.1 Site SMS Manager/Coordinator.

• Ensuring reporting policies are adhered to and review of incident reports for completion of applicable sections of the GA3558 Accident Incident Report Form.


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Incident Reporting

7.6 Incident Report Follow-on ProceduresOnce a Q-Pulse GA3558 Accident/Incident Report is submitted, emails are automatically sent to the GAC Corporate Leadership Team, Organization/Site Management Team, Organization/Site SMS Manager/Coordinator and the Corporate SMS Management Team noting the submission and details of the report. In turn the following actions will be initiated:

• Email notifications are in place that will notify personnel that their reports have been received and will keep them updated on the progress and outcomes of their report.

• Accident/ Incident details will be provided to site personnel through site SMS communications, see Safety Management System Manual, Chapter 10. SMS Communications, for more information.

• All reported incidents will be investigated (see Safety Management System Manual, Chapter 8. Hazard/Near Miss and Accident/Incident Investigation).

• Under no circumstance will an Accident/Incident Report be deleted from Q-Pulse without documented concurrence for this action from the Corporate SMS Department.

• If an aircraft damage event is rejected, the SMS Manager/Coordinator should leave a note with rejection details within the Properties section of the Q-Pulse occurrence module.

NOTE: For detailed procedures for submitting incidents, reference the SMS Practitioners Guide and the SMS website Tools section.


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Incident Reporting

Appendix



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Hazard/Near Miss & Accident/Incident Investigations

8. Hazard/Near Miss & Accident/Incident Investigations

8.1 Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43

8.2 Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43


8.4 General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43

8.5 Hazard and Accident/Investigation Procedures and Responsibilities . . . . . . . . . . . . . . . . .44


8.5.2 SMS Investigator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45



8.5.5 Site Safety Council (SSC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45

8.5.6 Site Personnel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45

8.5.7 Investigation Hand-off . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46

8.6 Hazard and Accident/Investigation Follow-on Procedures and Responsibilities . . . . . . . .46


8.6.2 SMS Investigator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46

8.6.3 Site Senior Management and Site Safety Council (SSC) . . . . . . . . . . . . . . . . . . . . . . . .46



8.6.6 Site Personnel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47

8.6.7 Corporate Quality and Product Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47

Appendices8-1 Chapter Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48


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Chapter EightHazard/Near Miss & Accident/Incident Investigations


8.2 PurposeIn order to promote the continuous safety performance improvement of Gulfstream’s SMS and to supplement the requirements of Corporate Policy CP-12-7, Accident/Incident Responsibilities and Reporting, GAC will promptly and thoroughly investigate events that result in safety of flight risk, product safety concerns, product damage, or near-miss incidents.


8.4 GeneralInvestigations are a methodical search into an event where information relating to factors that may have caused or contributed to it are discovered. The SMS uses a structured process within Q-Pulse for finding these contributing factors which is based upon the GA3558 Accident/Incident Report.

Accident/Incident investigations (GA3558) are to be completed per CP 12-7 and documented in the Q-Pulse SMS Database within 5 working days of the incident (Monday – Friday). A complete incident investigation is comprised of the following stages:

• Investigation

• Root Cause

• Preventative Strategies

Only GAC trained investigators will be assigned to Incident investigations (See Safety Management System Manual, Chapter 11. Training, Awareness and Competence). The assigned SMS Investigator shall complete the Investigation, Root Cause and Preventative Strategies Stages within Q-Pulse by the set Target Date (5 working days from the date of the incident).

For Hazard and Near Miss Reports a full investigation following the Accident/Incident Report (GA3558) guidelines may not be required. In this case, the site SMS Manager/Coordinator in conjunction with the site’s Site Safety Council (SSC) will determine the level of investigation appropriate to address the hazard or safety concern.

A Target Date for completion of all required Q-Pulse stages (Investigation, Implementation, etc.) will be set in accordance with the outcome of the Risk Assessment (see Safety Management System Manual, Chapter 6.

NOTE: The SMS Coordinator will maintain a current list of their formally trained investiga-tors within Q-Pulse.


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Risk Assessment).

8.5 Hazard and Accident/Investigation Procedures and ResponsibilitiesWhen an event is received through Q-Pulse appropriate e-mail messaging will be automatically sent to site designated personnel, Corporate SMS and in the case of Accident/Incident Reports (GA3558) to personnel required by CP 12-7, Appendix B. Also, personnel with Q-Pulse software loaded on their computer may review submitted Hazards and Accident/Incidents within the Occurrence or Incident Modules and Workload Tab.

8.5.1 Site SMS Manager/CoordinatorThe SMS Manager/Coordinator is responsible for accomplishment of the following for their site:

• Hazard/Near Miss Reports:

º Review Hazard/Near Miss Reports for completeness of data within a disposition period of 30 calendar days.

º As required, assemble and assign investigation team members or have a documented process for the assignment of investigators.

º Review ongoing Hazard/Near Miss investigations and related data.

º Conduct analysis of site Hazard/Near Miss Reports and prioritize Implementation Stage Actions, once entered, based on risk levels assessed, lessons learned and GAC/industry information.

º Close the event in Q-Pulse upon completion of all required stages.

• Accident/Incident (GA3558) Reports

º Review the Initial Investigation Report (page 1 of GA3558), found electronically in Q-Pulse Accident/Incident Reports for completeness of data within a disposition period of 1 working day.

º Assemble and assign investigation team members or have a documented process for the assignment of investigators.

º Review ongoing incident investigations and related data.

º Ensure all incident Investigation, Root Cause and Preventative Stage findings (of fact) are entered and Classified in the Q-Pulse SMS database.

º Implement prioritized Preventive Strategy Stage recommendations as agreed by the site senior management and Site Safety Council.

º Close the event in Q-Pulse upon completion of all required stages.

• Communicate safety of flight reports expediently to the appropriate Site Senior Leadership (i.e. Director, General Manager or Vice President).

• Liaise with GAC safety oversight processes as required to address flight safety risks as identified in the investigation process.

• Provide recurring reports on prevention strategy implementation to site senior management as required.

• Communicate events and safety information across sites and share this information as appropriate utilizing the Significant Occurrence Summary (SOS) process or communication mechanisms available in Q-Pulse


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SMS database, as well as local documented practices (see Safety Management System Manual, Chapter 10. SMS Communication).

8.5.2 SMS InvestigatorThe assigned SMS Investigator is responsible for accomplishment of the following:

• Review assigned Hazard or Accident/Incident Report for completeness of data.

• Conduct the investigation, all assigned actions and document within the Q-Pulse Database by the target date.

• Ensure all incident Investigation, Root Cause and Preventative Stage findings (of fact) are entered and Classified in the Q-Pulse SMS database.

• Assist the SMS Manager/ Coordinator as requested.

8.5.3 Reporting Manager/SupervisorThe Reporting Manager/Supervisor is responsible for accomplishment of the following for their Accident/Incident reports submitted:

• Assist with the investigation as requested by the SMS Manager/Coordinator and/or assigned investigator.

• Monitor investigation progress and when complete, review findings and recommendations with SMS /Manager/Coordinator.

8.5.4 Reporting Manager’s SupervisorThe Reporting Manager’s Supervisor is responsible for accomplishment of the following for their Accident/Incident reports submitted:

• Monitor investigation progress and when complete, review findings and recommendations.

8.5.5 Site Safety Council (SSC)The Site Safety Council is responsible for accomplishment of the following for their site:

• Assist and advise Site Senior Management of Hazard and Accident/Incident reporting responsibilities.

• Assist with investigations as directed by the Site VP/General Manager/Director.

• Review ongoing event investigations and related data.

8.5.6 Site PersonnelSite personnel are responsible for accomplishment of the following:

• Assist with the investigation as requested by the SMS Manager/Coordinator and/or assigned investigator.

8.5.7 Investigation Hand-offRefer to Corporate SMS Standard Operating Procedure 13.0, Section 4.2, Investigation Reassignment or Hand-Off Procedures, and Sec. 4.3, Investigation Referral Process.

8.6 Hazard and Accident/Investigation Follow-on Procedures and Responsibilities8.6.1 Site SMS Manager/Coordinator


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When notified that the investigation has been completed, the SMS Manager/Coordinator will:

• Review classifications, investigation, root cause and preventative strategies along with all associated data/attachments for completeness.

• If more information is required, reopen the Q-Pulse Stage where information is needed and assign the investigator actions as necessary. Close the stage with the initial Closed Date.

• When the investigation is complete, update the Q-Pulse Database Status to Investigation Complete.

• Organize and schedule required Site Safety Council, Site Management Team and if required, Event Review Team meetings.

• Following the SSC, Site Management Team and Event Review Team Meetings, enter the agreed upon actions with their owners in Q-Pulse, update the Q-Pulse Required Actions Stage as actions are completed.

• When the investigation and all mitigating actions have been completed, review and verify the incident report is complete and close the incident within Q-Pulse.

If any investigation takes longer than the standard 5 business days to complete, the SMS Manager will provide status updates regarding the investigation delay on the Notes section of the Properties tab in Q-Pulse occurrence page.

8.6.2 SMS Investigator• As requested, present investigation details to the Site Safety Council and Event Review Team.

8.6.3 Site Senior Management and Site Safety Council (SSC)• Review the Investigation and Root Cause Q-Pulse Stages.

• Review the Preventative Strategies Stage within Q-Pulse.

• Decide upon the required actions needed and the owner(s) for each action. The site SMS Manager/Coordinator will document these actions and the associated owners in the Q-Pulse Required Actions Stage.

• Provide appropriate summary reports regarding site safety investigation performance.

8.6.4 Reporting Manager/Supervisor• Complete repairs or replacement as appropriate for product or property damage incidents and enter total

costs into the Q-Pulse Incident Report (GA3558) (Note: A Reporting Manager/Supervisor may assign a designee enter to final cost information; this does not relieve them of their responsibilities detailed herein).

8.6.5 Reporting Manager’s Supervisor• Ensure implementation of all corrective actions as outlined within Q-Pulse and agreed by site senior

management.

• Monitor progress of repairs or replacement as appropriate. Ensure all costs are captured and the final invoice cost closeout report and costs are submitted to the Legal/Risk Management department, Corporate SMS Senior Manager and Director, Quality and Product Safety.

8.6.6 Site Personnel


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• Assist with the post investigation process as requested; including completing any assigned Q-Pulse Database actions.

8.6.7 Corporate Quality and Product Safety• Compile and review reports and data regarding product damage.

• Conduct analysis and incorporate prevention strategy reviews based on lessons learned and industry information.

• Communicate lessons learned between sites.

• Provide recurring reports to Gulfstream senior management as required.

• Resolve issues with regard to Product Safety responsibilities and reporting.

NOTE: For detailed procedures for conducting investigations, reference the SMS Practitioners Guide and the SMS website Tools section.


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Appendix

8-1 Chapter Reference



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Safety Performance Monitoring

9. Safety Performance Monitoring

9.1 Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50

9.2 Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50


9.4 General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50

9.5 Safety Performance Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50

9.5.1 Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50

9.5.2 Targets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50

9.5.3 Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50

9.5.4 Sample of an Objective, Target, and Indicator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50

9.6 Safety Oversight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51

9.6.1 Corporate Safety Performance Oversight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51

9.6.2 Site Safety Reviews . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51



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Chapter NineSafety Performance Monitoring


9.2 PurposeTo establish policy for safety performance monitoring.


9.4 GeneralSafety assurance is the means to demonstrate that organizational arrangements and processes for safety achievement are properly applied and continue to achieve their intended objectives. This is achieved through a safety performance monitoring and measurement process by which the performance is verified against the safety policy, stated safety objectives and targets.

The safety assurance process within the GAC SMS is achieved by monitoring and measuring the outcomes of activities that operational personnel must engage in for the delivery of services by the organization.

9.5 Safety Performance Indicators9.5.1 ObjectivesThe overall Safety Management System objectives incorporated in the GAC Safety Policy should be supported by a set of underlying tangible safety objectives, typically set by the corporate senior leadership team. These cover relevant aspects of GAC’s safety vision, senior management commitments, realistic safety milestones and desired outcomes.

9.5.2 TargetsSafety performance targets are created in relation to each safety objective such that the organization remains aware of whether the relevant objectives are being met. These safety performance targets are measured and monitored in conjunction with the use of safety performance indicators.

9.5.3 IndicatorsSafety performance indicators are generally data based expressions of the frequency of occurrence of events, incidents or reports. The indicator(s) chosen should correspond to the relevant safety objectives.

9.5.4 Sample of an Objective, Target, and IndicatorThe following serves as an example only:


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• Objective: Reduce Aircraft Damage Monetary Losses.

• Target: 50% Reduction in Site Floorboard Damage Cases (compared to previous calendar year).

• Indicator: ≤ 3 damaged floorboard cases.

9.6 Safety OversightGulfstream obtains information for safety performance monitoring from a variety of sources including direct employee input, a hazard reporting system, meetings, or assessments/audits.

Each of these types of information sources may exist to some degree in every site and should be assessed on a routine and ad hoc basis for risk identification and trend analysis. Gulfstream will accomplish continual safety performance monitoring and oversight of the SMS in the following way:

9.6.1 Corporate Safety Performance OversightAs a part of the annual safety objectives and targets development process, GAC Environmental, Health and Safety (EHS) department, in coordination with the Corporate SMS department will establish the initial list of objectives and targets for the corporation in conjunction with the Leadership Team, Operational Leadership Teams and Corporate Safety Councils.

Each site or GAC location will establish its plan to achieve these objectives and targets. Once the objectives and targets are identified, GAC Corporate SMS will assist each site or location with monitoring of the objectives and targets.

9.6.2 Site Safety ReviewsMonthly reviews are scheduled by the local management team and Site Safety Councils (SSC), which look for effective safety performance and ways to continually improve safety performance. Sources of information include those listed above.

Once data from all safety-related activity is reviewed, the local management team and SSC will ensure that the site Risk Register is revised for each activity/item and that the appropriate information is communicated to the workforce. This includes updating the response/mitigation proposed and an assessment of the appropriateness and effectiveness of the mitigations to address the hazards or event contributing factors.

The mitigation will be considered as appropriate if it actually addresses the hazard. The mitigation will only be considered effective if it consistently manages the safety risks under normal operating conditions in order to reduce the safety risks to an acceptable level as defined by the risk assessment performed using the Risk Assessment Tool in Q-Pulse SMS database. The SSC will also propose prioritization of the responses/mitigations based on the risk assessment for each hazard.



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Appendix



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SMS Communication

10. SMS Communication

10.1 Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54

10.2 Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54

10.3 Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54

10.4 General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54

10.5 Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54

10.5.1 Internal SMS Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54

10.5.2 External SMS Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56

Appendices10-1 Chapter References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57


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SMS Communication

Chapter TenSMS Communication


10.2 PurposeTo articulate a SMS communication strategy designed to establish regular SMS related communications at all levels of the organization.


10.4 GeneralThe GAC SMS will use a variety of tools and ways to communicate issues important to the operation and improvement of the SMS. This strategy will complement existing safety communication channels to make Gulfstream personnel aware of SMS-related safety issues and their roles and responsibilities related to those issues.

10.5 ProcedureEffective SMS Communication is an essential requirement to ensure and demonstrate closed-loop communication (lessons-learned) from the SMS as a part of the continuous improvement of the GAC SMS, including:

• Ensuring that all staff are appropriately aware of the SMS.

• Conveying safety lessons/information.

• Explaining why SMS related activities are introduced or changed.

• Conveying SMS activity updates.

• Educating personnel on procedures for hazard and near-miss reporting.

• Promotion of the company’s safety objectives, targets and culture.

The SMS communications procedure will be comprised of the following elements:

• Internal SMS Communication/Awareness.

• External SMS Communication/Awareness.

10.5.1 Internal SMS CommunicationInternal SMS Communications/Awareness may be accomplished by the use of:

• Notice boards.

• Postings to the Gulfstream intranet site.


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• Postings to the Gulfstream SMS intranet site.

• Regular meetings and/or training sessions.

• Site safety meetings.

• SMS Site Advisories.

• Written memorandum.

• Telephone conversations.

• Electronic and/or hard copy mail.

• Awareness training of facility personnel, as appropriate in line with job function.

The SMS Manager/Coordinator, with the assistance of the Site Safety Council and senior management, is responsible for site specific internal SMS communication.

SMS site communications will consist of ad hoc and regular activities designed to communicate and reinforce the SMS Policy and related elements to all affected employees, to include:

• The importance of conformance and the potential consequences of non-conformance with the SMS policy, procedures and processes.

• Individual roles and responsibilities in achieving conformance with SMS procedures.

• The risks associated with work activities revealed from SMS data.

• Relevant output from management SMS reviews.

• Local site reported Hazards/Near Misses and Incidents.

• GAC enterprise Hazards/Near Misses and Incidents of note.

• Changing SMS requirements.

• SMS performance data.

• Key results of SMS Assessments/Audits.

• Any other information needed to support successful implementation and maintenance of the SMS.

Also, each site is responsible for communicating events and safety information to other GAC sites/business units as appropriate utilizing the Significant Occurrence Summary (SOS) process (see EHS Standards Manual 1016 – SOS) or other authorized communication processes.

Each site SMS Manager/Coordinator will notify Corporate SMS of any changes to their SSC or ERT Charters or event investigator listing. This may be done through email correspondence or by submitting a SMS System Request (SSR) through Q-Pulse. See Safety Management System Manual, Chapter 11. Training, Awareness and Competence and Appendix 11-2 SMS Required Training Matrix.

The Corporate SMS Senior Manager will be the focal for all internal Corporate SMS communication and maintain the SMS intranet web site and liaise with additional GAC departments as required to:

• Respond to SMS-related inquiries from internal areas that may arise as a result of hazard reports, near-miss reports or accident/incident investigations.

SMS Communication


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• Respond to SMS-related inquiries from National Aviation Authorities (NAA’s) / Civil Aviation Authorities (CAA’s).

• Coordinate with Aviation Safety Officer for any SMS-related inquiries, as applicable, and when in the interest of airplane accident follow-up actions as conveyed in CP-14-13.

10.5.2 External SMS CommunicationGulfstream has determined that significant risks identified through the operation of the SMS will not be communicated to the general public unless required per federal, state or local regulations. Information regarding general SMS operation and specific risks identified will be communicated to the appropriate National Aviation Authorities (NAA’s) as required by regulations.

The Director of Corporate Communications or designee is responsible for media communications regarding SMS issues, in consultation with the Corporate SMS Department.

The Director of EHS or designee:

• During accidents or incidents provides liaison with appropriate regulatory agencies, after determining need and preparing the notification contents. Communication may include reports of chemical spills and releases to the environment in accordance with applicable regulatory Requirements.

• Responds to complaints regarding SMS-related matters.

• Reports audit findings and inspections that result in a finding or penalty from a U.S. or foreign aviation authority.

• Responsible for General Dynamics reporting.

SMS Communication


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SMS Communication

Appendix



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Training, Awareness and Competence

11. Training, Awareness and Competence

11.1 Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59

11.2 Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59


11. 4 General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59

11.5 General Scope of SMS Training. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59

11.5.1 Training/Awareness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59

11.6 Competence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60


11-2 SMS Required Training Matrix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .62


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Chapter ElevenTraining, Awareness and Competence


11.2 PurposeTo establish a corporate-level approach that ensures that all employees have the appropriate level of knowledge about the GAC SMS and how the policies and processes affect how they perform their duties. This aspect of the SMS is a requirement for both initial and on-going competence-building, and as a way to demonstrate that the SMS is contributing to the right safety culture development.


11. 4 GeneralGulfstream will appropriately train employees at each relevant function and level so they are aware of:

• The SMS Safety Policy.

• The SMS Safety Culture Policy.

• The SMS Manual and website.

• The importance of conformance with the requirements of the SMS.

• Individual roles and responsibilities specific to the SMS (Safety Accountabilities).

• General hazard reporting requirements of the SMS.

• General risk assessment procedures of the SMS.

• General accident/incident reporting and investigation requirements.

• General responsibilities with respect to the SMS emergency preparedness and response plan.

11.5 General Scope of SMS Training11.5.1 Training/AwarenessGulfstream’s SMS training takes into account differing levels of responsibility, ability, literacy, and risk to ensure that there is an appropriate awareness among employees and managers as to what their responsibilities are. In accordance with the above policy objectives, GAC will provide SMS training as follows:

• Senior Leaders/Accountable Manager/Senior Managers: Awareness of SMS roles and responsibilities, safety policy, safety culture policy, SMS requirements, related National Aviation Authority (NAA) regulations, management commitment and responsibilities, safety performance monitoring responsibilities.

• Managers & Supervisors: SMS policy, SMS processes management commitment and responsibilities, hazard identification and risk management, safety performance monitoring responsibilities.

• Frontline Personnel: SMS overview, safety policy, safety culture policy, safety reporting, hazard definition,


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hazard identification and risk assessment procedures, accident/incident investigation procedures.

• All Gulfstream Employees: An overview of SMS, provided in Safety Management System Orientation (HF009) training, is required for all new Gulfstream employees within 180 days of their employment initiation.

See Appendix 11-2 SMS Required Training Matrix for specific requirements.

11.6 CompetenceFrontline employee and Management competence within the SMS operations will be assured through continuous communication and involvement in the SMS as follows:

Employees shall be:• Involved in the review of hazard and risk assessments, accident/incident investigation findings and

department or process-specific SMS standard operating procedures development where appropriate.

• Consulted where there are workplace changes that occur as a result of SMS-related activities.

• Be represented in SMS matters at their site.

• Informed as to who their Site Safety Council representative(s) are.

• Informed of significant issues arising from the operation of the SMS at their site; including lessons-learned from hazards, near-miss reports and Accident/Incident Investigation findings.

Employee involvement shall be accomplished by:• Submission of hazard reports.

• Involvement in risk assessment results and post-event investigation findings implementation.

• Participation in site safety performance monitoring.

• Participation in site SMS Assessments.

• Involvement in Site Safety Councils.

Managers shall:• Be involved in the review of hazard and risk assessments, accident/incident investigation findings and

department or process-specific SMS standard operating procedures development where appropriate.

• Coordinate workplace changes that need to occur as a result of SMS-related activities.

• Lead resolution of SMS matters at their site.

• Direct their Site Safety Council representative(s) in ad hoc and regular safety performance reviews.

• Coordinate resolution of significant issues arising from the operation of the SMS at their site including lessons-learned from hazards, near-miss reports and implementation of Accident/Incident Investigation findings.

• Lead monthly site safety performance monitoring activities.


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Appendix



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Appendix

11-2 SMS Required Training Matrix

SMS Function Required TrainingSMS Manager/Coordinator Initial Training:

HF001 - Maintenance Human Factors HF007 - SMS for Senior Management* HF009 - Safety Management Systems Orientation HF010 - Event InvestigatorHF017 - Q-Pulse for InvestigatorsERT/SSC Charter Session Recurrent Training: WBCHF008 - Recurrent Human Factors Training

*HF007 equivalent with HF009

SMS Investigator Initial Training: HF001 - Maintenance Human Factors HF009 - Safety Management Systems Orientation HF010 - Event InvestigatorHF017 - Q-Pulse for Investigators Recurrent Training: WBCHF008 - Recurrent Human Factors Training

ERT or SSC Member Initial Training: HF001 - Maintenance Human Factors HF009 - Safety Management Systems Orientation ERT/SSC Charter Session Recurrent Training: WBCHF008 - Recurrent Human Factors Training

Site Personnel HF009 - Safety Management Systems OrientationHF001 - Maintenance Human Factors**

**Refer to Site Repair Station Manual for specific requirements


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All Human Factors (HF) related training classes, with the exception of HF007, HF010 and HF017, are coordinated through Gulfstream University. HF007, HF010 and HF017 are co-coordinated through both the Corporate SMS Department and Gulfstream University.

Initial ERT/SSC Charter Sessions are coordinated through and conducted by the GAC Corporate SMS Department. Additional chartering may be completed using the ERT/SSC Training “Disc” provided by Corporate SMS.

Also, it is recommended that members of the ERT or SSC also attend Event Investigator Training (HF010).


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SMS Information Management

12. SMS Information Management

12.1 Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65

12.2 Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65


12.4 General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65

12.5 Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65

12.6 Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66



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Chapter TwelveSMS Information Management


12.2 PurposeTo establish the information management processes for the Gulfstream Safety Management System (SMS). In addition, GAC follows the General Dynamics Corporate Policy 03-102 for Records Management as a guideline for identifying critical SMS records and requirements for maintaining and disposing of these records.

For operation of the SMS, GAC has set out this procedure to respond to the requirement for information management to assist with the establishment and verification of the effectiveness of the SMS. The SMS information management requirements in this section primarily apply to:

• Oversight of the Gulfstream intranet site(s) sections relating to the operation of the SMS.

• Oversight/updates of the Gulfstream SMS intranet site.

• Oversight/updates of the GAC enterprise SMS data system (Q-Pulse).

• Oversight/updates to the GAC SMS Manual.

• Oversight of the SMS information generated through routine monitoring of the SMS operations.

Operating an SMS generates significant amounts of data, documents and reports. Proper management and record keeping of such data is crucial for sustaining an effective SMS. Effective safety analysis is totally dependent upon the availability and competent use of the safety data. Cross-functional safety data integration is one of the cornerstones of SMS achievement.


12.4 GeneralAll SMS-related records are maintained such that they are:

• Legible, identifiable, and traceable to the activity, product or service involved.

• Protected against damage, deterioration, and loss.

• Readily retrievable when required for internal review and/or audits from external organizations e.g. suppliers, business partners, NTSB, CAA’s, and NAA’s.

12.5 ProcedureCommunications relating the operation of the SMS are accomplished through a wide variety of tools and methodologies and generate records of the SMS performance. See Safety Management System Manual, Chapter 10. SMS Communication. Examples of such records include:


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• Hazard Identification and Risk Assessment reports.

• Accident/Incident reports (GA3558).

• ASR/GSR

• Periodic analyses of safety trends/indicators.

• Lessons-learned (e.g. SOS).

• Minutes of Site Safety Reviews or Site Safety Council meetings.

It is necessary that GAC maintains a systematic record of this information to demonstrate evidence of ongoing SMS operations including hazard identification, risk mitigation and safety performance monitoring. These records should be appropriately centralized and maintained in sufficient detail to ensure traceability of all safety-related decisions.

The site management teams and the Corporate SMS Program Manager will be the focal for all internal SMS information management and will liaise with additional GAC departments as required to:

• Maintain records of SMS-significant activity (see examples above).

• Respond to SMS-related information requests from internal departments that may arise as a result of hazard reports, near-miss reports or accident/incident investigations.

• Respond to SMS-related information requests/audit requests from suppliers, business partners, and National Aviation Authorities (NAA’s) as required.

• Respond to SMS-related requests that may arise out of routine or non-routine safety performance monitoring reviews.

• Be responsible for General Dynamics record-keeping requirements (Refer to GD CP 03-102).

Site SMS performance-related information will be maintained in a manner that satisfies the record-keeping requirements stated in this policy, including (but not limited to):

• Hard-copy records.

• Electronically on site (local) shared drives.

• Electronically via the Gulfstream intranet sites.

• Electronically via the Q-Pulse SMS database.

12.6 ReviewInformation management procedures relating to the SMS operations should be reviewed annually or after the occurrence of events that may call into question the existing information management practices.


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Appendix



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SMS Assessment

13. SMS Assessment

13.1 Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69

13.2 Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69


13.4 General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69

13.5 Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69

13.6 Record Retention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69



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SMS Assessment

Chapter ThirteenSMS Assessment


13.2 PurposeTo establish SMS Assessment policy.


13.4 GeneralThis section provides the guidelines for evaluating the implementation, performance monitoring and continuous improvement of the Gulfstream Aerospace Corporation Safety Management System (SMS).

Assessments focus on the integrity of the organization’s SMS, and periodically assesses the overall level of safety and the effectiveness of the safety performance monitoring functions of the SMS. SMS assessments are intended to measure effectiveness of the site/organization’s safety management functions and activities and will ensure that the structure of the SMS is sound regarding oversight, procedural compliance, hazard identification and risk assessment, level of competency and training etc. Specifically, the SMS Assessment process will examine:

• Overall effective SMS integration.

• Assignment of Roles & Responsibilities for SMS: Safety Management System Manual, Chapter, 2.0 Safety Responsibilities.

• Staff performance and accountability for safety (create/foster a safety culture).

• Management Commitment & Employee Involvement.

• Compliance with SMS hazard/risk assessment procedures.

• Effectiveness of safety performance targets and indicators.

• Evidence of SMS continuous improvement.

• Adequacy of employee training for SMS roles.

• Human and organizational factors are addressed.

13.5 ProcedureReference manual SMS-APVI-PM-001 for detailed procedures regarding assessment of a repair stations SMS.

13.6 Record RetentionCopies of all assessment records are maintained within the Q-Pulse SMS Database and at the Corporate SMS office for a minimum period of 24 months.


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SMS Assessment

Appendix



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Aircraft Accident Emergency Response Plan

14. Aircraft Accident Emergency Response Plan

14.1 Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72

14.2 Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72


14.4 General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72

14.5 Procedures for Aircraft Accident Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72

14.6 Plan Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72

14.6.1 Response/Drill Critique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72



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Chapter FourteenAircraft Accident Emergency Reponse Plan


14.2 PurposeTo establish a plan for responding to an airplane accident and to supplement the requirements of the Airplane Accident Response Plan, Policy No.CP-14-13.


14.4 GeneralThe GAC Safety Management System (SMS) requires proactive response to aircraft-related incidents and accidents on the part of all Gulfstream employees.

14.5 Procedures for Aircraft Accident ReportingRefer to Corporate Policy, CP14-13 and associated Airplane Accident Response Plan.

14.6 Plan ReviewEmergency response procedures should be reviewed annually and after the occurrence of accidents or significant events. Certain practice drills are carried out on an annual basis for emergency scenarios and others are performed when appropriate and practicable.

NOTE: Procedures for reporting inadvertent or accidental damage to products/air-craft under direct GAC control or on GAC property are located in Safety Management System Manual, Chapter 7. Incident Reporting.


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Appendix




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Safety Management System Manual

Documents

Transcript of Safety Management System Manual