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Introduction to Safety Management Systems Course eTextbook International Aviation Training Program 2 nd Edition

Introduction to Safety Management Systems

Course eTextbook

Introduction to Safety Management Systems Course eTextbook International Aviation Training Program 2 nd Edition

International Aviation Training Program

2nd

Edition

NOTICE

DISCLAIMER. The information contained in this publication is subject to constant review in the light of changing government requirements and regula- tions. No subscriber or other reader should act on the basis of any such information without referring to applicable laws and regulations and/or without taking appropriate professional advice. Although every effort has been made to ensure accuracy, the International Air Transport Association shall not be held responsible for any loss or damage caused by errors, omissions, misprints or misinterpretation of the contents hereof. Furthermore, the International Air Transport Association expressly disclaims any and all liability to any person or entity, whether a purchaser of this publication or not, in respect of anything done or omitted, and the consequences of anything done or omitted, by any such person or entity in reliance on the contents of this publication.

© International Air Transport Association. All Rights Reserved. No part of this publication may be reproduced, recast, reformatted or trans- mitted in any form by any means, electronic or mechanical, including photocopying, record- ing or any information storage and retrieval sys- tem, without the prior written permission from:

Director IATA Training and Development Institute International Air Transport Association 800 Place Victoria P.O. Box 113 Montreal, Quebec CANADA H4Z 1M1

Introduction to Safety Management Systems Course Textbook Material No: 400601 ISBN 978-92-9252-470-8 © 2014 International Air Transport Association. All rights reserved. Montreal—Geneva

INTRODUCTION TO SAFETY MANAGEMENT SYSTEMS (SMS) TABLE OF CONTENTS Introduction 1 Lesson 1— Introduction to

INTRODUCTION TO SAFETY MANAGEMENT SYSTEMS (SMS)

TABLE OF CONTENTS

Introduction

1

Lesson 1— Introduction to Safety Management Systems (SMS)

5

1.0 Introduction to Safety Management Systems (SMS)

7

1.1 Definition of Safety

8

1.2 What is an SMS?

8

1.3 Why SMS?

9

1.4 SMS Requirements

10

1.5 Components of an SMS

12

1.5.1 Safety Policy and Objectives

13

1.5.2 Safety Risk Management (SRM)

16

1.5.3 Safety Assurance (SA)

16

1.5.4 Safety Promotion

17

1.6 Definition of Concepts

19

1.7 Organizational and Safety Cultures

20

Lesson 2— Safety Policy and Objectives

25

2.0 Safety Policy and Objectives

27

2.1 Management Commitment and Responsibility

28

2.2 Safety Accountabilities

29

2.3 Appointment of Key Safety Personnel

30

2.3.1 Safety Review Committee (SRC)

30

2.3.2 Safety Action Group

32

2.4 Coordination of Emergency Response Planning

34

2.4.1 Airports

34

2.4.2 Airlines

34

2.4.3 Activation of ERP

35

2.5 SMS Documentation

37

Lesson 3— Safety Risk Management

43

3.0 Safety Risk Management

45

3.1 Hazard Identification

47

3.1.1 Occurrence Data Collection and Analysis

50

3.1.2 Accident and Incident Investigations

53

3.1.3 Flight Data Analysis

55

3.1.4 Safety Auditing

58

3.2 Risk Assessment and Mitigation

61

3.2.1 Risk Assessment

62

3.2.2 Risk Mitigation

63

58 3.2 Risk Assessment and Mitigation 61 3.2.1 Risk Assessment 62 3.2.2 Risk Mitigation 63 iii

iii

Lesson 4— Safety Assurance 71 4.0 Safety Assurance 73 4.1 Safety Risk Management and Safety

Lesson 4— Safety Assurance

71

4.0 Safety Assurance

73

4.1 Safety Risk Management and Safety Assurance

74

4.2 Safety Performance Monitoring and Measurement

76

4.3 Management of Change

82

4.4 Continuous Improvement of the SMS

85

Lesson 5— Safety Promotion

89

5.0 Safety Promotion

91

5.1 Safety Training and Education

92

5.2 Safety Communication

93

Lesson 6— Integrating Airline Management Systems (iAMS)

97

6.0 Integrating Airline Management Systems (iAMS)

99

6.1 Integrating Airline Management Systems (iAMS)

100

Lesson 7— The Regulatory Authority ' s Role in SMS Oversight

105

7.0 The Regulatory Authority 's Role in SMS Oversight

107

7.1 The Regulatory Authority 's Role in SMS Oversight

108

Lesson 8— SMS Implementation Requirements

115

8.0 SMS Implementation Requirements

117

8.1 Gap Analysis

118

8.2 Safety Management Plan

118

8.3 Safety

Policy

120

8.4 Provision of Resources

121

8.5 Outsourcing of Services

122

8.6 Phased Approach to SMS Implementation

123

Conclusion

127

Glossary of Abbreviations

131

References and Resources

135

Answer Key

139

Conclusion 127 Glossary of Abbreviations 131 References and Resources 135 Answer Key 139 iv

iv

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Introduction

It is widely accepted that most accidents result from human error. While it

may be easy to dismiss these human errors as acts of carelessness or incompetence, recent research and accident investigation reports demon- strate that human error is merely the last link in the chain of events that leads to an accident. Increasingly, the aviation community is coming around to the notion that most accidents are “organizational ” in nature where latent conditions combine with active failures to produce an accident.

If most accidents are indeed organizational, it follows that organizations

are best placed to control those factors that are known to lead to accidents. But the question is how? IATA believes the Safety Management System approach and effective SMS Promotion, to document and communicate safety accountabilities and authorities throughout the organization is the most effective way of dealing with this organizational phenomenon and it is

of key importance in the promotion of safety culture within organizations.

A Safety Management System ( SMS) is a more structured and standard-

ized approach to how Safety processes should be implemented and will provide overall better and more uniform standards throughout the aviation industry.

Implementing SMS will allow for an effective safety risk management process contributing to making Safety processes increasingly proactive in nature. Essentially, a SMS is an element of corporate management 's responsibility which sets out a company 's Safety policy to manage Safety as an integral part of its overall business making Safety one of the company's core values by developing a Safety culture.

SMS is a business-like approach to Safety; goals are set, levels of authority are established, etc. much the same as with Quality Management Systems (QMS) and Security Management Systems (SeMS ).

When viewed in this context it becomes obvious that the three programmes (SeMS, QMS , SMS) must be harmonised to ensure consistency and an equivalent level of attention.

The purpose of this course is to provide learners with an understanding of the basic concepts associated with Safety Management Systems.

In this course you will learn about:

The basic principles of Safety Management Systems ( SMS ) including:

its definition, why you would use an SMS, the requirements and components, and organizational and safety cultures.

Safety Policy and Objectives, including: management commitment and responsibility, safety accountabilities, appointing key safety personnel, the coordination of an ERP and SMS documentation.

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Safety Risk Management including: identifying and classifying haz- ards, Occurrence Data Analysis, accident and incident investigation, flight data analysis, safety auditing, and risk assessments and miti- gation.

Safety Assurance, including: safety risk management and safety assurance, safety performance monitoring and measurement, man- agement of change, and continuous improvement of the SMS.

Safety Promotion, including: safety training and education, and safety communication.

Integrated Airline Management Systems.

The Regulatory Authority ' s Role in SMS Oversight.

The requirements for SMS Implementation, including: safety gap analysis, safety management plan, safety policy, provision of re- sources, outsourcing of services, and phased approach.

Learning Aids

To help you successfully complete and enjoy the course in a productive fashion, each lesson includes the following learning aids:

Key Learning Points

Key Learning Points are highlighted throughout the text and are designed to emphasis particularly important issues and facts.includes the following learning aids: Key Learning Points Lesson Overview The beginning of each lesson provides

Lesson Overview

The beginning of each lesson provides you with an overview of the topics to be covered and its learning objectives.particularly important issues and facts. Lesson Overview Lesson Summary Each lesson ends with a summary of

of the topics to be covered and its learning objectives. Lesson Summary Each lesson ends with

Lesson Summary

Each lesson ends with a summary of the key points.

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Aviation Training Program Progress Checks At the end of each lesson is a short exercise composed

Progress Checks

At the end of each lesson is a short exercise composed of multiple choice, short answers, or matching questions. These are designed to provide you with the opportunity to see if you understood the material.

Glossary

This section at the back of the course textbook explains the most important abbreviations and acronyms used throughout the lessons.

Answer Key

The answers to the progress check questions can be found at the end of the course textbook.

USE OF LANGUAGE

We realise that there is an international audience for this and other IATA distance education programmes, and that many students will have English as a second language. As such, we have made every effort to keep the language in this manual at a level which every student can understand.

Note

1)

We will be using some Latin abbreviations in the text, most notably ‘i.e.’ (meaning ‘id est ’ or ‘that is ’) and ‘e.g. ’ (meaning ‘exempli gratia ’ or ‘for example ’).

2)

For practical reasons the terms ‘he’, ‘him’ and ‘his ’ have been used to refer to male and female persons.

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Lesson 1 Introduction to Safety Management Systems (SMS)

Lesson 1

Introduction to Safety Management Systems (SMS)

Lesson 1 Introduction to Safety Management Systems (SMS)

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Aviation Training Program 1.0 Introduction to Safety Management Systems (SMS) Lesson L e a r n

1.0 Introduction to Safety Management Systems (SMS)

Lesson Learning

Objectives

Lesson Overview

Upon successful completion of This lesson will describe the basic concepts about an SMS and what is

this lesson, you will be able to: included in SMS methodology. Topics will include definition of safety,

explanation of an SMS, reasons for implementing an SMS , links between

Define the term “safety ”

Explain what is an SMS

Identify reasons for

implementing an SMS promoting a safety culture. On successful completion of this lesson, you

Recognize the link between will be able to obtain a basic knowledge of Safety Management Systems the ICAO Annexes and SMS

concepts, definition of organizational and safety culture, and benefits of

the ICAO Annexes and SMS requirements, definition of service provider, SMS requirements, SMS components and elements, definition of key

and explain the value of safety within the airline industry.

requirements

Define the term “service provider”

Describe the requirements of an SMS

Describe the four components and twelve elements of an SMS

Define key concepts

Define organizational and safety cultures

Identify the benefits of promoting a safety culture

○ Identify the benefits of promoting a safety culture Lesson 1: Introduction to Safety Management Systems
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1.1 Definition of Safety

Safety is the state in which the risk of harm to persons or property damage

is reduced to, and maintained at or below, an acceptable level through a

continuous process of hazard identification and risk management. This definition implies constant measurement and evaluation of an airline 's safety performance and feedback into the SMS.

airline 's safety performance and feedback into the SMS. 1.2 What is an SMS? ICAO defines

1.2 What is an SMS?

ICAO defines an SMS as a systematic approach to managing safety, including the necessary organizational structures, accountabilities, policies and procedures. Airlines are responsible for establishing an SMS while

Key Learning Point States are responsible for the acceptance and oversight of an airline 's

A fully-developed SMS is a

formalized, company-wide

system established at the corporate level, which

encompasses all of the accountabilities for operational safety established, and provision made for individual departments of the the SMS to obtain the same focus as the airline 's financial management company. system. Ultimately, the SMS becomes an integral part of the airline ' s management system and culture.

An SMS is a business-like approach to managing safety. As with any business process, goals must be set, levels of authority and clear

SMS.

A

fully-developed SMS is a formalized, company-wide system established

at

the corporate level, which encompasses all of the individual departments

of the company. Flight operations, engineering and maintenance, ground operations and all other departments whose activities contribute to the airline's safety performance will have their own processes and procedures within the context of the corporate SMS. Furthermore, the organization will develop a management system that maintains continuity throughout the organization, and provides positive control of the operation. The company should also consider extending its SMS to vendors when the activities listed above have been outsourced. Particularly in respect of Sub-contract vendors where the organization retains primary responsibility.

Internal reporting, documentation, and communication are essential to ensure that operational personnel and members of the management team have accurate information regarding the SMS. Therefore, airlines must

create and maintain a manual that provides a comprehensive description

of the scope, structure and functionality of the SMS, including documented

organizational roles and responsibilities. In addition, a system must be in place to ensure that the content of manuals, used to support and control airline operations, is clear, concise and current.

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Aviation Training Program 1.3 Why SMS? Effective safety management requires a realistic balance between safety,

1.3 Why SMS?

Effective safety management requires a realistic balance between safety, productivity, and costs. The process for achieving this balance is called system safety and is described by ICAO as balancing the needs of an

Key Learning Point organization in terms of production such as delivery of services and

The SMS is designed to increase the knowledge

System safety is a formal, yet flexible process. It does not limit itself to

errors and operational issues in reactively identify deficiencies after events or adverse events. Instead, it

order to develop effective pro-actively searches for opportunities to improve operational processes. mitigation strategies. As a result of the continuous and proactive identification of safety concerns within the operation, improvements to mitigate negative outcomes become embedded in processes throughout the organization.

understanding of employee

protection or safety.

and

The SMS is designed to increase the knowledge and understanding of employee errors and operational issues in order to develop effective mitigation strategies. Data sources, such as employee safety reports, allow the airline to analyze operational work errors and how they may contribute to a serious incident or accident. Both safety managers and line managers must understand the following:

Everyone make mistakes.

Errors are consequences rather than causes.

We analyze errors to help understand “ why,” and “ how” not “ what” or “who” .

Errors may be precursors to a more serious incident or accident.

Thorough investigation and analysis of errors will enable development of effective mitigations.

These concepts are supported by the notion of the organizational accident. This notion illustrates that an accident is an interaction between organiza- tional processes set out by senior management, workplace conditions that lead personnel to commit active failures, and latent conditions that can penetrate current defenses and have adverse effects on safety.

Safety is increasingly viewed as the outcome of operational processes which may be considered as components of an organization's manage- ment systems. These systems undergo constant change and an SMS provides the tools and processes to facilitate organizational or procedural change and maintain an acceptable level of safety.

State regulatory agencies are in a period of transition from a predominantly prescriptive or rule based regulatory framework to an integrated regulatory environment that combines prescriptive and performance-based regulatory approaches. Moreover, two activities are being conducted in parallel. On one hand, States are establishing a State Safety Program or SSP that is a management system to provide oversight of service providers licensed by

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the State. On the other hand, individual service providers, such as airlines, are implementing an SMS.

providers, such as airlines, are implementing an SMS. Key Learning Point • T h e o

Key Learning Point

The organization must

appoint a senior corporate

official as the Accountable Executive, who retains overall accountability for the SMS. The Accountable Executive must possess the authority and control of the resources necessary to finance, implement, and enforce policies and procedures within the operation.

The outsourcing of any

function that may affect safety requires the organization to ensure

effective

such functions.

safety oversight of

1.4 SMS Requirements

ICAO has introduced safety management requirements into the following annexes:

Annex 1– Personnel Licensing

Annex 6– Operation of Aircraft:

Part I –International Commercial Air Transport – Aeroplanes

Part III– International Operations – Helicopters

Annex 8– Airworthiness of Aircraft

Annex 11 –Air Traffic Services

Annex 13 –Aircraft Accident and Incident Investigation

Annex 14 –Aerodromes

Annex 19 –Safety Management Systems

As part of the ICAO requirements in these annexes, service providers must implement an SMS that is accepted by their State. ( ICAO Annex 19 Chap 4)

The term “service provider ” includes the following entities:

approved training organizations (that are exposed to safety risks during the provision of their services)

aircraft operators, maintenance organizations

air traffic services providers

certified aerodrome operators

organizations responsible for type design and/or manufacture of aircraft

As part of the requirements, an SMS should as a minimum include (Annex 19 Chap 4.2.2):

a process to identify actual and potential safety hazards and assess the associated risks.

a process to develop and implement remedial action necessary to maintain an acceptable level of safety, and

provision for continuous monitoring and regular assessment of the appropriateness and effectiveness of safety management activities.

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As part of these requirements, the organization must appoint a senior corporate official as the Accountable Executive, who retains overall accountability for the SMS. The Accountable Executive must possess the authority and control of the resources necessary to finance, implement, and enforce policies and procedures within the operation. While ultimate responsibility for the SMS remains at all times with the Accountable Executive, implementation of the SMS may be delegated to an identified responsible person within the organization (see page 7, Transport Canada Advisory Circular 107-001, Guidance on SMS Development) 1 .

The organization needs to identify and assign responsibility within SMS for ensuring compliance with regulatory requirements and established internal standards. The outsourcing of any function that may affect safety requires the organization to ensure effective safety oversight of such functions. The means by which this control is achieved needs to be identified within the SMS. Safety responsibilities will be further discussed in Lesson 2 of this course.

Section 1 of the IOSA Standards Manual or ISM, and the associated guidance material, will continue to be revised to reflect current ICAO SMS requirements and best practices. The IOSA standards will only reflect the basic SMS requirements stated in the ICAO Annexes. Some Civil Aviation Authorities or CAAs may develop additional requirements above those SMS standards reflected in the ISM .

1 http://www.tc.gc.ca/media/documents/ca-opssvs/107-001-e.pdf

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Aviation Training Program 1.5 Components of an SMS The structure of an SMS may vary according

1.5 Components of an SMS

The structure of an SMS may vary according to the size and complexity of

a service provider and its aims and objectives. ICAO and various CAA s

have produced guidance for service providers on the implementation of the

Key Learning Point four components and associated twelve elements that comprise an SMS

The primary requirement for an SMS is a general

commitment from the

highest level of management. The separate elements of an SMS are not

stand-alone and unique; the

elements inter-react and

support each other.

Four components and

twelve associated elements defined, with procedures and processes in place to detail how such policies

Quality management must be utilized to ensure that all policies are clearly

The primary requirement for an SMS is a general commitment from the highest level of management. The separate elements of an SMS are not stand-alone and unique; the elements inter-react and support each other. All components of an SMS should be reviewed on a regular basis to ensure that they remain current and relevant to the organization.

framework. IATA aligns with the ICAO SMS framework, which is presented in this lesson.

should be included in an

are to be implemented and managed.

SMS framework. The following four components and twelve associated elements, as a minimum, should be included in an SMS framework. This section presents

a high-level summary; each element will be discussed in more detail later

in this course. For a graphical representation of the components and elements of an SMS, please refer to the inside cover of this course textbook. You may use this model as a learning aid throughout this course.

I.

Safety policy and objectives

1

Management commitment and responsibility

2

Safety accountabilities

3

Appointment of key safety personnel

4

Coordination of emergency response planning

5

SMS documentation

II.

Safety risk management

1

Hazard identification

2

Safety risk assessment and mitigation

III.

Safety assurance

1

Safety performance monitoring and measurement

2

The management of change

3

Continuous improvement of the SMS

IV.

Safety promotion

1

Training and education

2

Safety communication

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1.5.1 Safety Policy and Objectives

Management commitment and responsibility: Commitment of the senior management to safety is reflected in a policy statement, which is signed by the Accountable Executive. ( ICAO Annex 6, 3.3.5; Appendix 7, 1.1) (ICAO Annex 19 App 2 - 1.1)

Safety policy and objectives:

1. Management commitment and responsibility

The service provider shall define its safety policy in accordance with international and national requirements.

The safety policy shall:

(a)

reflect organizational commitment regarding safety;

(b)

include a clear statement about the provision of the necessary resources for the implementation of the safety policy;

(c)

include safety reporting procedures;

(d)

clearly indicate which types of behaviours are unacceptable related to the service provider' s aviation activities and include the circumstances under which disciplinary action would not apply;

(e)

be signed by the accountable executive of the organization;

(f)

be communicated, with visible endorsement, throughout the organiza- tion; and

(g)

be periodically reviewed to ensure it remains relevant and appropriate to the service provider.

Safety accountabilities: A statement of accountabilities clearly defines safety responsibilities of managers and employees at different levels in the organization, with effective deputation of responsibilities established for operationally critical areas when principal office holders are absent. ( ICAO Annex 6, 3.3.5; Appendix 7, 1.2) ( ICAO Annex 19 App 2 - 1.2)

2. Safety accountabilities

The service provider shall:

(a)

identify the accountable executive who, irrespective of other functions, has ultimate responsibility and accountability, on behalf of the organ- ization, for the implementation and maintenance of the SMS;

(b)

clearly define lines of safety accountability throughout the organization, including a direct accountability for safety on the part of senior management;

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(c)

identify the accountabilities of all members of management, irrespec- tive of other functions, as well as of employees, with respect to the safety performance of the SMS;

(d)

document and communicate safety responsibilities, accountabilities and authorities throughout the organization; and

(e)

define the levels of management with authority to make decisions regarding safety risk tolerability.

3.

Appointment of key safety personnel:

The Safety Manager, in most organizations, will be the person to whom the Accountable Executive has assigned the daily oversight functions of the SMS. ( ICAO Annex 6, 3.3.5; Appendix 7, 1.3) ( ICAO Annex 19 App 2 - 1.3)

4. Coordination of emergency response planning:

Service providers implement an Emergency Response Program or ERP that includes contingency plans to ensure proper response throughout the organization when an emergency situation arises. This may not necessarily involve an actual aircraft accident, but should include a business continuity contingency plan. (ICAO Annex 6, 3.3.5; Appendix 7, 1.4)

The service provider shall ensure that an emergency response plan is properly coordinated with the emergency response plans of those organ- izations it must interface with during the provision of its products and services. (ICAO Annex 19 App 2 - 1.4)

5. SMS documentation:

Safety management activities must be documented appropriately and be available to all employees. (ICAO Annex 6, 3.3.5; Appendix 7, 1.5)

SMS documentation ( ICAO Annex 19 App 2 - 1.5)

The service provider shall develop an SMS implementation plan, formally endorsed by the organization, that defines the organization's approach to the management of safety in a manner that meets the organization's safety objectives.

The service provider shall develop and maintain SMS documentation that describes its:

(a)

safety policy and objectives;

(b)

SMS requirements;

(c)

SMS processes and procedures;

(d)

accountabilities, responsibilities and authorities for SMS processes and procedures; and

(e)

SMS outputs.

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The service provider shall develop and maintain an SMS manual as part of its SMS documentation.

The SMS documentation covers all elements and processes of the SMS and normally includes:

1. A consolidated description of the SMS components and elements such as:

(a)

document and records management;

(b)

regulatory SMS requirements;

(c)

framework, scope and integration;

(d)

safety policy and safety objectives;

(e)

safety accountabilities and key personnel;

(f)

voluntary hazard reporting system;

(g)

incident reporting and investigation procedures;

(h)

hazard identification and risk assessment processes;

(i)

safety performance indicators;

(j)

safety training and communication;

(k)

continuous improvement and SMS audit;

(l)

management of change; and

(m)

emergency or operations contingency planning.

2. A compilation of current SMS related records and documents such as:

(a)

hazards report register and samples of actual reports;

(b)

safety performance indicators and related charts;

(c)

record of completed or in-progress safety assessments;

(d)

SMS internal review or audit records;

(e)

safety promotion records;

(f)

personnel SMS/safety training records;

(g)

SMS/Safety committee meeting minutes;

(h)

SMS implementation plan (during implementation process); etc.

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1.5.2 Safety Risk Management (SRM)

Hazard identification: The airline must maintain processes that ensure that operational hazards are identified for all operational activities. Hazard identification is typically based on a combination of reactive, proactive, and predictive safety management methods. (ICAO Annex 6, 3.3.5; Appendix 7, 2.1)

Risk assessment and mitigation: Individual hazards are analyzed; their consequences are assessed and communicated throughout the organiza- tion. Mitigation actions must be developed for those hazards presenting unacceptable operational risk. ( ICAO Annex 6, 3.3.5; Appendix 7, 2.2)

Hazard Identification

The service provider shall develop and maintain a process that ensures that hazards associated with its aviation products or services are identified.

Hazard identification shall be based on a combination of reactive, proactive and predictive methods of safety data collection.

Safety Risk Assessment and Mitigation

The service provider shall develop and maintain a process that ensures analysis, assessment and control of the safety risks associated with identified hazards. ( ICAO Annex 19 App 2 - 2.1)

with identified hazards. ( ICAO Annex 19 App 2 - 2.1) 1.5.3 Safety Assurance (SA) Safety

1.5.3 Safety Assurance (SA)

Safety performance monitoring and measurement: SA activities focus on assessing the health of the organization, with an emphasis on safety. Specific goals for improvements in all areas should be set for all senior Key Learning Point operational managers. SA should include monitoring of external sources of

SA activities focus on safety information and include participation in regional safety groups or

assessing the health of the

organization, with an

emphasis on safety.

safety performance of the organization and to validate the effectiveness of safety risk controls.

may introduce new hazards

to operational activities. The service provider's safety performance shall be verified in reference to the safety performance indicators and safety performance targets of the SMS. ( ICAO Annex 19 App 2 - 3.1)

safety data sharing organizations. ( ICAO Annex 6, 3.3.5; Appendix 7, 3.1)

The service provider shall develop and maintain the means to verify the

External or internal

changes

Management of change: External or internal changes may introduce new hazards to operational activities. Processes must exist to manage organ- izational responses to regulatory changes, major changes in operational procedures, or new activities such as new airport destinations. Safety

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reporting systems should have processes established to identify new risks and actively monitor performance in new areas of the operation. ( ICAO Annex 6, 3.3.5; Appendix 7, 3.2)

The service provider shall develop and maintain a process to identify changes which may affect the level of safety risk associated with its aviation products or services and to identify and manage the safety risks that may arise from those changes. ( ICAO Annex 19 App 2 - 3.2)

Continuous improvement of the SMS: SA utilizes quality tools such as internal evaluations or independent audits to assess organizational health from a safety perspective. Onsite assessments of operational management systems on a recurring basis provide opportunities for continuous improve- ment of processes and procedures for each functional area of the airline. (ICAO Annex 6, 3.3.5; Appendix 7, 3.3)

The service provider shall monitor and assess the effectiveness of its SMS processes to enable continuous improvement of the overall performance of the SMS. ( ICAO Annex 19 App 2 - 3.3)

overall performance of the SMS. ( ICAO Annex 19 App 2 - 3.3) 1.5.4 Safety Promotion

1.5.4 Safety Promotion

Training and education: The airline must identify safety training require- ments for each level of management and for each employee group. Safety training for operational personnel should address safety responsibilities, Key Learning Point including complying with all operating and safety procedures, recognizing

The airline must identify and reporting hazards, and ultimately ensuring that employees have the

safety training requirements knowledge and skills to safely complete work activities. ( ICAO Annex 6, for each level of

management and for each employee group. The service provider shall develop and maintain a safety training pro-

Communication of

gramme that ensures that personnel are trained and competent to perform their SMS duties.

3.3.5; Appendix 7, 4.1)

safety

information is a key responsibility for the Safety Manager.

The scope of the safety training programme shall be appropriate to each individual's involvement in the SMS . ( ICAO Annex 19 App 2 - 4.1)

Safety communication: Communication of safety information is a key responsibility for the Safety Manager. Continuous improvement and learning is accomplished through the sharing of lessons learned from investigations, hazard report analysis, and operational safety assess- ments. Feedback to operational personnel, such as examples of pro- cedural improvements as a result of safety reports, is an essential feature of safety communications. (ICAO Annex 6, 3.3.5; Appendix 7, 4.2)

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The service provider shall develop and maintain a formal means for safety communication that:

(a)

ensures personnel are aware of the SMS to a degree commensurate with their positions;

(b)

conveys safety-critical information;

(c)

explains why particular safety actions are taken; and

(d)

explains why safety procedures are introduced or changed. (ICAO Annex 19 App 2 - 4.1)

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1.6 Definition of Concepts

As part of the SMS requirements, several concepts have been introduced (ICAO SMM 6.4.6):

Level of safety: the degree of safety within a system expressed through safety indicators.

Safety indicators: the parameters that characterize and/or typify the level of safety of a system.

Safety targets: the concrete objectives of the level of safety.

Acceptable Level of Safety or ALoS : the minimum degree of safety that must be assured by a system in actual practice.

Safety indicator value: the quantification of a safety indicator.

Safety target value: the quantification of a safety target.

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Aviation Training Program 1.7 Organizational and Safety Cultures ICAO (SMM 2.8.4) defines organizational culture as

1.7 Organizational and Safety Cultures

ICAO (SMM 2.8.4) defines organizational culture as follows: Organizational culture differentiates the characteristics and value systems of particular organizations; the behavior of members of one company vs. that of another Key Learning Point company, or government vs. private sector behavior. Organizations

A safety culture is generated provide a shell for national and professional cultures. For example, in an within an organizational airline, pilots may come from different professional backgrounds such as

military vs. civilian experience, or light aircraft or commuter operations vs. development within a large carrier. They may also come from different organizational cultures due to corporate mergers or lay-offs.

culture by an open and honest reporting system where employees can feel free to report safety issues without the threat of punitive measures being taken.

The culture of an organization sets informal boundaries of behavior and provides a framework for decision making, threat or hazard identification,

and willingness to take personal and organizational risks.

both the attitudes of the employees and the A safety culture is generated within an organizational culture by an open

structural organization. and honest reporting system where employees can feel free to report

safety issues without the threat of punitive measures being taken. An

mechanical adherence to effective, proactive safety reporting culture has been achieved when the

procedures. majority of employee safety reports relate to identified or perceived threats,

Safety culture is based on

Safety culture goes beyond

A safe and just culture is necessary for the organization to learn from

widest

the

instead of errors or incidents.

Safety culture is based on both the attitudes of the employees and the structural organization. It includes the requirement to actively identify safety issues and to respond with appropriate action.

errors, including the

distribution of the lessons

learned throughout

airline to take remedial action where necessary,

and to ensure that carried out correctly, with alertness, sound judgment, and a proper sense

processes and procedures of accountability by competent persons throughout all levels of an

are improved to prevent

recurrence of the errors. basic foundation of a successful SMS.

organization. The adoption and promotion of such a safety culture is the

Safety culture goes beyond mechanical adherence to procedures. It requires that all duties that can have an impact on operational safety be

The term “just culture ” is also commonly used when discussing safety culture. It encompasses the notion that within an organization, honest human errors are accepted as part of human nature. However, deliberate violations of rules and established procedures are condemned and should result in disciplinary action.

The promotion of the safety or just culture within airlines has been proven

to be beneficial as it has increased the flow of safety reports and enriched

the safety data available. Within the mindset of a just culture, errors are considered inevitable. They are dealt with fairly and result in some real corrective action; aside from a reminder not to err again. This type of

culture is necessary for the organization to learn from errors, including the widest distribution of the lessons learned throughout the airline to take remedial action where necessary, and to ensure that processes and procedures are improved to prevent recurrence of the errors. Establishing

a just culture is clearly the responsibility of senior management

Aviation Training Program

Aviation Training Program

who creates the work environment throughout the organization (Just Culture— Balancing Safety and Accountability, Sidney Dekker, 2007).

Balancing Safety and Accountability, Sidney Dekker, 2007). Lesson Summary This lesson described the basic concepts

Lesson Summary

This lesson described the basic concepts around an SMS and what is included in SMS methodology. Topics included definition of safety, explanation of an SMS, reasons for implementing an SMS , links between the ICAO Annexes and SMS requirements, definition of service provider, SMS requirements, SMS components and elements, definition of key concepts, definition of organizational and safety culture, and benefits of promoting a safety culture. If you need to review any of the material further, please feel free to navigate through the course again.

please feel free to navigate through the course again. Progress Check 1. Complete this sentence: Safety

Progress Check

1. Complete this sentence: Safety is the state in which the risk of harm to persons or property damage is reduced to, and maintained at or below, an acceptable level through a continuous process of

.

(a)

Security implementation and safety management.

(b)

Hazard identification and risk management.

(c)

Crisis identification and risk management.

(d)

Hazard identification and safety management.

2. A fully-developed SMS is a formalized, company-wide system estab- lished at what level of the company?

(a)

Corporate

(b)

Flight Operations

(c)

Engineering and Maintenance

(d)

Ground Operations

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Aviation Training Program

3. Which concept listed below is supported by the notion of the organizational accident?

(a)

Only junior personnel make mistakes.

(b)

Errors are causes rather than consequences.

(c)

We analyze errors to help understand “ what” not “why ”.

(d)

Errors are precursors to a more serious incident or accident.

4. What do the ICAO requirements in Annexes 1, 6, 8, 11, 13, and 14 state?

(a)

Airlines must implement an SMS that is accepted by their State.

(b)

Airlines have the option to implement an SMS that is accepted by their State.

(c)

Service providers must implement an SMS that is accepted by their State.

(d)

Service providers have the option to implement an SMS that is accepted by their State.

5. Select true or false: An SMS must provide for continuous monitoring and regular assessment of the safety performance.

(a)

(b)

True

False

6. Complete this sentence. The separate elements of an SMS

(a)

Are stand-alone.

(b)

Are unique.

(c)

Are exclusive.

(d)

Support each other.

.

7. Read this definition and identify which term it defines. The parameters that characterize and/or typify the level of safety of a system.

(a)

Level of safety

(b)

Safety indicators

(c)

Acceptable level of safety

(d)

Safety indicator value

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Aviation Training Program

8. Select true or false: The term “ just culture” is also commonly used when discussing safety culture. It encompasses the notion that within an organization, honest human errors should result in disciplinary action.

(a)

(b)

True

False

9. Who is responsible for establishing a just culture?

(a)

Safety Manager

(b)

Quality Manager

(c)

Senior Management

(d)

Safety Review Board

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Aviation Training Program

Lesson 2 Safety Policy and Objectives

Lesson 2

Safety Policy and Objectives

Lesson 2 Safety Policy and Objectives

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Aviation Training Program
Aviation Training Program 2.0 Safety Policy and Objectives Lesson Overview Lesson Learning O b j e

2.0 Safety Policy and Objectives

Lesson Overview

Lesson Learning Objectives

This lesson will describe the importance of roles in an effective SMS

Upon successful completion of environment. Topics will include management commitment and responsi-

this lesson, you will be able to:

State the minimum components of a safety

policy completion of this lesson, you will be able to explain the value of roles to

review board and action group, coordination of emergency response planning, activation of ERPs and SMS documentation. On successful

bilities, safety accountabilities, appointment of key safety personnel, safety

Explain safety responsibilities throughout an organization

Explain the role of safety services in the safety department

Describe the roles of key safety personnel

Describe the nature of the Safety Review Board

Describe the duties of the Safety Review Board

List the necessary input to the management review process

Explain the role of a Safety Action Group (Safety Committee)

Explain the importance of having an Emergency Response Plan

Describe the details of ICAO Annex 14

Explain an airport 's responsibilities regarding the ERPs of other airports

Describe how an ERP is activated

Explain the role of the Emergency Management Center in the event of an accident

List the basic components of an SMS manual

the SMS process.

of an accident • List the basic components of an SMS manual the SMS process. Lesson
Aviation Training Program

Aviation Training Program

Aviation Training Program 2.1 Management Commitment and Responsibility The safety policy of an organization should define

2.1 Management Commitment and Responsibility

The safety policy of an organization should define senior management' s fundamental approach towards safety, to be adopted by employees and contractors. The policy should be based on a clear and genuine board- Key Learning Point level commitment, which clearly states that the management of aviation

The safety policy of an safety is paramount. A commitment to compliance with aviation regulations

organization should be based on

a clear and genuine board-level commitment, which clearly

states that the management aviation safety is paramount.

and the adoption of industry best practices should be included.

The safety policy should, as a minimum:

Contain a senior management commitment to safety as a fundamental priority throughout the organization, signed by the Accountable Execu- tive.

Commit the organization to continuous improvement of its manage- ment system and safety Culture.

Contain a clear statement of the organization 's safety objectives and measures necessary to conform to safety regulations.

Include imperatives for operational safety in the description of duties and responsibilities of senior management.

Promote a just culture that includes non-punitive reporting procedures and encourages the reporting of any inadvertent human error.

Enforce safety as a primary responsibility of all managers.

Include communications processes that permit a free flow of infor- mation throughout the Organization.

Identify clearly that the safety principles outlined in the SMS policy statement apply to employees and contracted parties.

Cover procedures for reporting and coordinating events and activities performed by other organizations that are subject to their own safety management systems, between the relevant systems.

Include a requirement for continual senior management review and improvement.

of

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Aviation Training Program
Aviation Training Program 2.2 Safety Accountabilities Successful handling of safety matters is a line management 's

2.2 Safety Accountabilities

Successful handling of safety matters is a line management 's responsi- bility, requiring the active participation of all levels of management and supervision. This should be reflected in the structure of the company and in Key Learning Point published safety accountabilities. While ultimate responsibility for the SMS

Top-level accountabilities remains with the Accountable Executive at all times, responsibility for SMS may not be delegated, but implementation may be delegated to other identified individuals within the

organization. Top-level accountabilities may not be delegated, but re-

the sponsibilities should be cascaded throughout the organization so that all

aspects of aviation safety are covered. A company responsibility structure could be similar to this diagram, which you can examine in further detail by

responsibilities should be

cascaded throughout

organization so that all aspects of aviation safety are covered.

The safety department 's purpose is to provide a service to the organization, that is, the management of safety is considered a core business process.

The individual and collective responsibilities affecting safety performance should be stressed to all employees.

mouse-clicking on the Helpful Visual Aids button.

employees. mouse-clicking on the Helpful Visual Aids button. Figure 2.2 — Example of an organizational responsibility

Figure 2.2 — Example of an organizational responsibility structure

The notion that ownership of the safety process was exclusive to the safety office has evolved in the SMS environment to a concept of safety services. This reflects the idea that the safety department 's purpose is to provide a service to the organization, that is, the management of safety is considered a core business process. Functionally, the safety department is a safety data collection and analysis unit that uses a number of predictive, proactive, and reactive methods to provide reliable information to the entire management team. However, the responsibility for managing safety within each responsible division such as Flight Operations, Engineering and Maintenance, Ground Operations, resides within that division.

The functional responsibilities of managers and employees at different levels in the organization should be clearly defined, documented and communicated, with the aid of organizational diagrams where appropriate. The individual and collective responsibilities affecting safety performance should be stressed to all employees. Effective deputation of responsibilities

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Aviation Training Program

should be established for operationally critical areas of the operation to cover the absence, or change, of principal office holders.

cover the absence, or change, of principal office holders. 2.3 Appointment of Key Safety Personnel The

2.3 Appointment of Key Safety Personnel

The Safety Manager, in most organizations, will be the person whom the Accountable Executive has assigned the daily management of SMS functions and oversight of the safety department that is, implementation of

Key Learning Point the SMS for the organization. The size of the staff will vary depending upon

In small organizations, the

the size of the airline. For example, in small organizations, the Safety

Safety Manager may be Manager may be assigned a number of different responsibilities to include

assigned a number of different responsibilities to include flight safety, ground safety, quality, and perhaps security.

flight safety, ground safety, quality, and perhaps security. In contrast, larger organizations will have Directors leading specialized departments. These Directors develop and manage processes to ensure neutral and unbiased support of organizational managers; collection of data, identifi-

In large organizations will have Directors leading

cation of hazards, risk analysis, and assessment of mitigation strategies in relation to agreed safety performance metrics of the organization.

specialized departments. In large organizations, the Safety and Quality Managers will work together as a team to jointly identify operational safety hazards, assess operational risks and ensure mitigation strategies are appropriate for the identified hazard. They ensure compliance with State regulatory requirements and conformance with organizational processes and procedures. They identify opportunities for continuous improvement.

2.3.1 Safety Review Committee (SRC)

Safety Review Committee (SRC). The SRC provides the platform to achieve the objectives of resource allocation and to assess the effective- ness and efficiency of risk mitigation strategies. The SRC is a very high- level committee, chaired by the Accountable Executive and composed of senior managers, including line managers responsible for functional areas as well as those from relevant administrative departments. The safety manager participates in the SRC in an advisory capacity only.

The SRC may meet infrequently, unless exceptional circumstances dictate otherwise.

Consider that twice yearly meetings maybe be considered appropriate with quarterly reviews for oversight and status update, (meetings may be less frequent in small organisations.)

Aviation Training Program

Aviation Training Program

The SRC:

(a)

monitors the effectiveness of the SMS;

(b)

monitors that any necessary corrective action is taken in a timely manner;

(c)

monitors safety performance against the organization's safety policy and objectives;

(d)

monitors the effectiveness of the organization's safety management processes which support the declared corporate priority of safety management as another core business process;

(e)

monitors the effectiveness of the safety supervision of subcontracted operations;

(f)

ensures that appropriate resources are allocated to achieve safety performance beyond that required by regulatory compliance; and

The SRC is strategic and deals with high-level issues related to policies, resource allocation and organizational performance monitoring. Once a strategic direction has been developed by the SRC, implementation of safety strategies must be coordinated throughout the organization. This can be accomplished by creating a Safety Action Group (SAG).

SAGs are composed of line managers and front-line personnel. SAGs are normally chaired by a designated line manager. SAGs are tactical entities that deal with specific implementation issues per the direction of the SRC. The SAG:

(a)

oversees operational safety performance within the functional areas of the organization and ensures that appropriate safety risk management activities are carried out with staff involvement as necessary to build up safety awareness;

(b)

coordinates the resolution of mitigation strategies for the identified consequences of hazards and ensures that satisfactory arrangements exist for safety data capture and employee feedback;

(c)

assesses the safety impact related to the introduction of operational changes or new technologies;

(d)

coordinates the implementation of corrective action plans and ensures that corrective action is taken in a timely manner;

(e)

reviews the effectiveness of previous safety recommendations; and

(f)

oversees safety promotion activities as necessary to increase aware- ness of safety issues among relevant employees, to ensure that employees are provided appropriate opportunities to participate in safety management activities.

Aviation Training Program

Aviation Training Program

Aviation Training Program Figure 2.3.1 — SMS Continuous Feedback Loop 2.3.2 Safety Action Group A safety

Figure 2.3.1 — SMS Continuous Feedback Loop

Program Figure 2.3.1 — SMS Continuous Feedback Loop 2.3.2 Safety Action Group A safety action group

2.3.2 Safety Action Group

A safety action group may be established as a standing group or as an ad-hoc group to assist or act on behalf of the safety review committee.

More than one safety action group may be established depending on the scope of the task and specific expertise required.

Key Learning Point

Composition of the Safety

Committee should include line A Safety Action Group also called Safety Committee should be formed to

managers as well as representatives from each of the

Safety Committee should meet on a quarterly basis to determine whether operational areas. SMS objectives have been met in order to adequately address safety concerns. Composition of the Safety Committee should include line managers as well as representatives from each of the operational areas including, but not limited to:

provide internal reviews of SMS performance at an operational level. The

Flight Operations

Engineering and Maintenance

In-flight Services

Ground Handling and

Cargo

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Aviation Training Program

The safety action group should:

monitor operational safety;

resolve identified risks;

assess the impact on safety of operational changes; and

ensure that safety actions are implemented within agreed timescales.

The safety action group should review the effectiveness of previous safety recommendations and safety promotion.

Depending on the type and size of the operation, the Safety Committee 's role should include the following:

Identification and mitigation of operational hazards

Review of safety audit results and Corrective Action Plans

Review of internal reporting systems

Review of industry accident investigation reports

Implementation of previous safety recommendations

Risk assessment of new routes, equipment or procedures

Developing a Safety Expert Group as a Sub Group to the Safety Action Group.

To consider the merit of using a small group of representatives from each business area will receive dedicated training in support of hazard identifi- cation, analysis and development of mitigations proposals.

Note— The organisational goal is to encourage everyone to report no matter how small a perceived Hazard, we can not place the entire organization on specialist training to Identify Hazards, however in realty we do not need to, rather we need to directly encourage them to report anything which they see as an impediment, whether it be related to tooling, personnel, competences, documentation or manpower.

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Aviation Training Program

Aviation Training Program 2.4 Coordination of Emergency Response Planning Since commercial airline transport operations

2.4 Coordination of Emergency Response Planning

Since commercial airline transport operations are based almost entirely on public confidence, any accident has a significant impact. A major accident resulting in a hull loss, human suffering and loss of life will not only

Key Learning Point undermine public confidence in the industry as a whole, but particularly the

An operator to have an company involved. It is therefore essential for an operator to have an Emergency Response Plan Emergency Response Plan or ERP, also known as a Business Continuity

Plan, as an integral part of its SMS. The widely differing operating styles as and corporate structures of different operators preclude presenting an emergency management plan in detail. The principles, which follow, are

Senior representatives of

or ERP, also known as a Business Continuity Plan, an integral part of its SMS.

therefore only an initial guide to airlines.

the airline will be required to coordinate the airline's emergency response with the authorities at the accident location, and must

therefore have a readily ICAO Annex 14 specifies the actions that must be undertaken by an available, tested,

emergency response plan in place.

2.4.1 Airports

aerodrome operator to deal with an accident occurring on, or in the vicinity of, its airport. This plan, in addition to specifying the aerodrome operator 's role, must also show the details of local authorities and organizations that could assist in such an event. The aerodrome operator will generally establish an Emergency Coordination Center or ECC through which all post-accident activities are organized and controlled.

2.4.2 Airlines

It is the airline's responsibility to maintain familiarity with emergency plans at all airports into which it operates. Senior representatives of the airline will be required to coordinate the airline's emergency response with the authorities at the accident location, and must therefore have a readily available, tested, emergency response plan in place.

To fulfill its responsibilities, the airline must establish and equip:

A Emergency Management Center or EMC at its headquarters

A Local Incident Control Center or LICC at the accident location to coordinate activities with company headquarters and the local authority EMC

A mobile support and investigation team to assist local investigators and victim support Services

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Aviation Training Program

2.4.3 Activation of ERP

In the event of an accident or serious incident, Operations Control will probably receive the first notification of the event, and will be the department to initiate the ERP, beginning with members of the EMC. When the EMC assumes control of the event, it is essential for business continuity, that Operations Control resumes control of continuing oper- ations, leaving event control to the EMC.

continuing oper- ations, leaving event control to the EMC. In the event of an accident or

In the event of an accident or serious incident, the airline will basically have three areas of response:

Headquarters – activation of the company EMC

Key Learning Point

Local– activation of the LICC at or near the event location

The airline will have three Mobile – activation and dispatch of the Company Incident Support areas of response: Team or Go Team headquarters, local, mobile.

The EMC must be maintained in a constant state of preparedness. It

adopted will depend on the size of the airline, its

corporate structure, route

network, type of operation

and the requirements of prevailing legislation not

only in the operator's State, cedures manual that is distributed selectively throughout the network. but also in the country in Individuals who have responsibilities following a major accident or incident, which an event occurs. or who are likely to become involved in the aftermath, are obliged to keep themselves apprised of its contents and their role.

All procedures, including local airport emergency plans at route stations, must be promulgated through a dedicated Company Emergency Pro-

The exact procedures to

should also be borne in mind that the EMC will require 24-hour manning for an unspecified period after an incident, and the previously stated require- ment for alternative members to be nominated fulfills a dual purpose.

be

The airline ERP should include network-wide exercises at least annually. Furthermore, as individuals and contact details change, communications and appointment lists should be updated at frequent intervals.

The exact procedures to be adopted will depend on the size of the airline, its corporate structure, route network, type of operation and the require- ments of prevailing legislation not only in the operator's State, but also in the country in which an event occurs. It is prudent to ensure a minimum of two, or preferably three, persons are identified for each nominated ERP position to allow for absences.

8 Point Emergency Response Plan Implementation Plan

The following is provided as guidance regarding the steps which may be taken to implement or develop further your Emergency Response Plan.

Analysis –Where is the ERP currently?

Perform Gap Analysis

Who is Managing?

When did we last have an Exercise

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Aviation Training Program

Planning–Developing our ERP further!

Project definition

Who is managing?

Team members structure

Implementation Timescales?

Training–Who requires Training?

Team Member Role Definition

Perform Training needs Analysis

Who is coordinating the Training?

Training delivery

Implementation Timescales?

Systems –Who is Managing the Documentation Process? (Manual)

Core Processes for ERP

Airports Interface Process –Communications

Crises Management Process

Regulatory Compliance and Oversight — Management Function

Implementation Timescales

Competence–How will we measure Competence?

Team Member Competence Assessment — Training Needs Analysis

Managing Competence on going process — who is coordinating

Implementation Timescales

Simulation–How to develop our simulation models?

One Big Exercise or

Segmenting the Exercise Process to optimise the processes and procedures

Leading to Full Exercises

Managing Test Scenarios

Exercising–How to develop Relevant Exercising?

Consider the difference between Simulation and Exercising

Managing Training & Exercising on going — who is coordinating

Implementation Timescales

Aviation Training Program

Aviation Training Program
Aviation Training Program 2.5 SMS Documentation Although documentation techniques may vary between organizations each

2.5 SMS Documentation

Although documentation techniques may vary between organizations each feature of the SMS must be documented and readily available to those managers and employees who need access to the information. In smaller Key Learning Point airlines, the Accountable Executive may prefer that the SMS documen- The SMS must be documented tation be centralized in an SMS manual. Larger airlines will likely capture

and readily available to those SMS information, as appropriate, in corporate, division, and functional level

managers and employees who

manuals. This technique ensures that SMS principles are cascaded

need access to the information. throughout the organization and detailed SMS information is readily available to line personnel.

An SMS manual should cover the following subjects:

Scope of the SMS

Safety policy and objectives

Safety accountabilities

Key safety personnel

SMS documentation and procedures

Coordination of emergency response planning

Hazard identification and risk management schemes

Safety assurance

Safety performance monitoring and measurement

Safety auditing

Management of change

Continuous improvement

Safety promotion; training education and communication

Contracted services

Aviation Training Program

Aviation Training Program

Aviation Training Program Lesson Summary This lesson described the importance of roles in an effective SMS

Lesson Summary

This lesson described the importance of roles in an effective SMS environment. Topics included management commitment and responsi- bilities, safety accountabilities, appointment of key safety personnel, safety review board and action group, coordination of emergency response planning, activation of ERPs and SMS documentation. If you need to review any of the material further, please feel free to navigate through the course again.

please feel free to navigate through the course again. Progress Check 1. Which of the following

Progress Check

1. Which of the following is a minimum requirement for a safety policy?

(a)

Plans for continual editing of the document

(b)

Enforcement cost-cutting principles

(c)

A clear statement of the organization' s safety objectives

(d)

Approval from local authorities

2. Which of the following statements correctly describes safety responsi- bilities?

(a)

Successful handling of safety matters is a line management's responsibility.

(b)

Responsibility for SMS implementation must be partly delegated to an external organization.

(c)

Top-level accountabilities may be delegated.

(d)

Responsibilities should not be distributed throughout the organiza- tion.

3. Select true or false: The safety department 's purpose is to provide reliable safety information to the management team based on predic- tive, proactive, and reactive methods.

(a)

(b)

True

False

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Aviation Training Program

4. What is the role of the Safety Manager?

(a)

Hire the accountable executive

(b)

Delegate corrective actions to the senior staff

(c)

Supervise the quality manager

(d)

Implement the SMS for the organization

5. Which of the following statements correctly describe the Safety Review Board?

(a)

An ad-hoc group that meets annually to discuss recent trends in statistic analysis.

(b)

A strategic body that addresses high-level issues relating to policies, resource allocation and organizational performance moni- toring.

(c)

A secondary concern for SMS planning and implementation, but should be considered once an organization is running smoothly.

(d)

A group comprised of safety managers from major aviation organizations who communicate directly with the media.

6. Which of the following statements correctly describes the duties of the Safety Review Board?

(a)

Meeting schedules, agendas and minutes are confidential and therefore must not be recorded in any manner.

(b)

The results of Safety Review Board Meetings should include action plans for changes to be implemented within the organization.

(c)

An informal management review must take place every five years.

(d)

All members are strictly prohibited from other boards, due to inherent conflict of interest.

7. Select true or false: Input to the management review process should include, but not be limited to the following?

Results of safety risk assessments

Safety performance results

Operational feedback

Regulatory violations

(a)

True

(b)

False

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Aviation Training Program

8. Depending on the type and size of the operation, the Safety Com- mittee's role should include which of the following?

(a)

Review of industry accident investigation reports

(b)

Supervision of the Quality Committee

(c)

Analysis of previous safety recommendations

(d)

Risk assessment of new hires

9. Select true or false: Commercial airline transport operations have been proven to succeed despite any apparent loss of public confidence. A major accident resulting in a hull loss, human suffering and loss of life, therefore, will undermine public confidence in the industry, but should not interfere with the continuity of its business. For this reason, an operator's Emergency Response Plan is not expected to play a role in such issues.

(a)

(b)

True

False

10. ICAO Annex 14 specifies the actions that must be undertaken by an aerodrome operator to deal with an accident occurring on, or in the vicinity of, its airport. The plan includes which of the following details?

(a)

Color-coded threat levels, which detail responses from green to red

(b)

A detailed analysis of risks compiled from industry leaders

(c)

Outline of job-specific instances of post-accident media responses

(d)

Shows the details of local authorities and organizations that could assist in such an event

11. It is the airline's responsibility to maintain familiarity with emergency plans at all airports into which it operates. To fulfill its responsibilities, the airline must establish and equip which of the following?

(a)

An Emergency Management Center or EMC at its headquarters

(b)

A Local Insurance Control Center or LICC at the accident location to coordinate activities to address insurance issues

(c)

An investigation team to provide the media with unclassified details of the incident

(d)

An exchange program that allows employees from one organiza- tion to visit another on a semi-annual basis

Aviation Training Program

Aviation Training Program

12. Select true or false: In the event of an accident or serious incident, EMC will probably receive the first notification of the event, and will be the department to initiate the ERP. When the Operations Control assumes control of the event, it is essential for business continuity, that EMC resumes control of continuing operations, leaving event control to the Operations Control.

(a)

(b)

True

False

13. Complete the following statement with the correct response.

The Emergency Management Center ( EMC) must be maintained in

state of preparedness. It should also be noted that the EMC will require 24-hour manning for a(n) period after an incident,

and the previously stated requirement for alternative members to be

nominated fulfills a dual purpose.

a

(a)

50%; one-week

(b)

constant; unspecified

(c)

nightly; indefinite

(d)

80%; one-month

14. An SMS manual should cover which of the following subjects:

(a)

Safety journal subscriptions

(b)

Key customer service personnel

(c)

Continuous improvement

(d)

Long-term parking plans

Aviation Training Program

Aviation Training Program

Lesson 3 Safety Risk Management

Lesson 3

Safety Risk Management

Lesson 3 Safety Risk Management

Aviation Training Program

Aviation Training Program
Aviation Training Program 3.0 Safety Risk Management Lesson Learning Lesson Overview O b j e c

3.0 Safety Risk Management

Lesson Learning

Lesson Overview

Objectives This lesson will describe areas of risk, the potential impact and what to do

Upon successful completion of in order to determine risk and provide mitigation. Topics will include hazard this lesson, you will be able to: identification, occurrence data collection and analysis, accident and

Define hazard

List the programs that provide detailed data on hazards

Explain the three categories of data sources

Describe the three levels of hazard identification within most organizations

List the external sources of hazard identification

Explain why it is recommended that airlines use electronic data storage systems

List the recommended electronic data storage systems

Describe the stages of the internal feedback loop

List the additional levels of occurrence data analysis

incident investigations, flight data analysis, auditing and risk assessment

and mitigation. On successful completion of this lesson, you will be able to explain key areas of risk and how to mitigate them.

able to explain key areas of risk and how to mitigate them. • Describe the essential

Describe the essential components of an effective accident or incident investigation program

Describe the process of flight data analysis

Explain the purpose of safety audits

Explain why the identification of hazards in audit summaries must be shared with the safety staff

Define ALARP and state the objective of Safety Risk Management (cont' d)

Aviation Training Program

Aviation Training Program

Aviation Training Program Lesson Learning Objectives (cont ' d) • Define risk assessment • Explain the

Lesson Learning Objectives (cont ' d)

Define risk assessment

Explain the purpose of a Corrective Action Request (CAR )

Distinguish short-term from long-term corrective actions

Describe the benefits of the SRM processes to hazard identification

Aviation Training Program

Aviation Training Program

3.1 Hazard Identification

A hazard is defined as a condition, object or activity with the potential of causing death, injuries to personnel, damage to equipment or structures, loss of material, or reduction of ability to perform a prescribed function (ICAO SMM 1.12.1).

Safety management begins through an organization's ability to identify actual and potential hazards.

Hazard identification is the first step in a formal process of collecting, recording, acting on, and generating feedback to all managers and employees in terms of safety risks ( ICAO SMM 4.3.6). There are multiple sources of hazard identification. For example, front line employees are a rich source of hazard identification since they must deal with system, procedural, and training deficiencies to accomplish their daily tasks. Flight data analysis and on-site audits of activities provide additional insight into the hazards that exist in any aviation-related activity. An airline 's safety department should ensure that data collection activities are structured in a manner that allows for the understanding of hazards that must be effectively managed to ensure safe operations.

Hazard Identification and Prioritization (ICAO SMM 1.12.2)

Hazards exist at all levels in the organization and are detectable through use of reporting systems, inspections or audits. Mishaps may occur when hazards interact with certain triggering factors. As a result, hazards should be identified before they lead to accidents, incidents or other safety related occurrences. An important mechanism for proactive hazard identification is a voluntary hazard/incident reporting system.

Hazards can also be identified or extracted from review of investigation reports, especially those which are deemed to be indirect contributing factors and which may not have been adequately addressed by corrective actions resulting from the investigation process. Thus, a systematic procedure to review accident/incident investigation reports for outstanding hazards is a good mechanism to enhance an organization 's hazard identification system. This is particularly relevant where an organization 's safety culture may not have sufficiently matured to support an effective voluntary hazard reporting system yet.

Hazards may be categorized according to their source, or location.

Given the importance of data quality, organizations must assess the data used to support safety risk management and safety assurance processes using the following criteria: ( ICAO SMM 1.11.1)

(a)

Validity: data collected is acceptable as per established criteria for its intended use.

(b)

Completeness: no relevant data are missing

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Aviation Training Program

(c)

Consistency: the extent to which measurement of a given parameter is consistent, can be reproduced and avoids error.

(d)

Accessibility: data are readily available for analysis

(e)

Timeliness: data are relevant to the time period of interest and available promptly.

(f)

Security: data are protected from inadvertent or malicious alteration

(g)

Accuracy: data are error free.

By considering these seven criteria for data quality, safety data analyses

will generate the most accurate information possible to be used in support

of strategic decision making.

A number of programs exist to gain detailed data on hazards. These

include the following:

Employee safety reports, potentially including vendor reports when applicable

Ground handling reports

Pilot, dispatch, and cabin crew reports

Aircraft engineering and maintenance reports

Accident and incident investigations

Flight Data Analysis

Process analysis

Job Task Analysis or JTA

On-site safety audits

Maintenance reliability and Continuous Analysis and Surveillance System or CASS reports

External sources such as CAA s, investigative bodies, safety organiza- tions and manufacturers

Hazard identification methods can be classified under three wide catego- ries of data sources: reactive, proactive and predictive.

Reactive data sources: Data emerges from processes that need to be triggered by a serious event, which may often involve material damage and/or injuries. These processes are activated once a system failure has occurred. Reactive data sources include accident or incident investigations.

Proactive data sources: Data is drawn from processes that are triggered by occurrences that are less serious or where there are minimal or no damaging consequences. These processes are based

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Aviation Training Program

on the notion that identifying safety risks within a system prior to any system failures, and taken action, can minimize the negative out- comes. Data sources include safety audits, mandatory or voluntary reporting systems, and safety surveys.

Predictive data sources: Processes are in place to captured routine operational data, in real time. The airline monitors its operation with these processes to discover potential safety concerns. A Flight Data Analysis or FDA program and Line Operations Safety Audit or LOSA observations are examples of proactive data sources.

There are three levels of hazard identification within most organizations:

Organizational or corporate level: Data analysis is typically conducted by the management team. Hazards to the organization may be identified by different departments as they review employee reports, audit results, or flight data. The SMS will have processes in place to assess and assign risk, develop corrective action plans, and to conduct follow-ups to ensure sustainable mitigations.

Functional level: Daily hazard identification is a fundamental responsi- bility of the line manager supervising the work activity. The line manager is responsible to ensure that operational procedures and activities are planned, trained, and executed in a manner to meet operational goals. Ensuring both an efficient and safe operation is a management responsibility, particularly at the level where the work is taking place.

Individual level: Each employee is required to deal with a workplace that contains several hazards. The Threat and Error Management or TEM concept is effective in all workplaces to identify the operational threats to safety and how to manage or mitigate them effectively. For example, ramp personnel have to deal with the hazard such as hot and cold weather extremes, windy conditions, fatigue, and pressures to complete the work quickly. Each employee group must be trained to deal effectively with the potential hazards they are likely to encounter in their “unique” workplace; for example, the cabin, maintenance hangar, flight deck, or ramp.

External sources of hazard identification include:

Accident investigation data;

Mandatory incident investigation data;

Voluntary reporting data;

Continuing airworthiness reporting data;

Operational performance monitoring data;

Safety risk assessment data;

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Aviation Training Program

Data from audit findings/reports;

Data from safety studies/reviews;

regional and international safety organizations;

internet industry news and incident reporting sources;

regulatory advisory bulletins;

directives and new regulations;

aircraft and parts manufacturers;

feedback from vendors and;

industry safety data sharing organizations.

The ability to benchmark internal performance against industry safety standards allows airlines to determine areas where their own operation could be improved.

3.1.1 Occurrence Data Collection and Analysis

The collection and retention of data on its own serves no useful purpose. All data that is collected must be used for review and analysis of the operation for the purpose of identifying hazards, system weaknesses, process breakdowns, regulatory violations and other trends or conditions that could potentially lead to a negative safety outcome. The data must be used for review and acquisition and analysis process must include a method of risk analysis and prioritization to enable the development and implementation of effective corrective action. This topic is further discussed in Lesson 3.2 of this course.

Management of Safety Information: ( ICAO SMM 1.11.3)

Effective safety management is –data driven. Sound management of the organization's databases is fundamental to ensure effective and reliable safety analysis of consolidated sources of data.

The establishment and maintenance of a safety database provide an essential tool for personnel monitoring system safety issues. A wide range of relatively inexpensive electronic databases, capable of supporting the organization's data management requirements, are commercially avail- able.

Depending on the size and complexity of the organization, system requirements may include a range of capabilities to effectively manage safety data. In general, the system should:

(a) include a user friendly interface for data entry and query;

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Aviation Training Program

(b)

have the capability of transforming large amounts of safety data into useful information that supports decision making;

(c)

reduce workload for managers and safety personnel; and

(d)

operate at a relatively low cost.

Basic features should enable the user to perform such tasks as:

(a)

log safety events under various categories;

(b)

link events to related documents (e.g. reports and photographs);

(c)

monitor trends;

(d)

compile analyses, charts and reports;

(e)

check historical records;

(f)

share safety data with other organizations;

(g)

monitor event investigations; and

(h)

monitor the implementation of corrective actions.

Given the potential for misuse of safety data that have been compiled strictly for the purpose of advancing aviation safety, database management must include the protection of the data.

Database managers must balance the need for data protection with that of making data accessible to those who can advance aviation safety. Protection considerations include:

(a)

adequacy of–access to information regulations vis- à -vis safety man- agement requirements;

(b)

organizational policies and procedures on the protection of safety data that limit access to those with a –need to know;

(c)

de-identification, by removing all details that might lead a third party to infer the identity of individuals (for example, flight numbers, dates/times, locations and aircraft type);

(d)

security of information systems, data storage and communication networks;

(e)

prohibitions on unauthorized use of data.

There are many methods of storing data, from the traditional paper files to highly sophisticated electronic data storage systems. Airlines are strongly recommended to use an electronic system, as this will facilitate analysis and reporting. Examples of electronic safety data systems available for storage and analysis of crew reports are:

Mercator Sentinel formerly BASIS

AvSoft or AVSiS

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Aviation Training Program

Aviation Events Reports Organizer or AERO

Superstructure Aviation Quality Database or AQD

The use of sophisticated analytical tools and methods gives a safety department the ability to analyze the data from their occurrence reporting system, and a means of understanding the possible causes of hazards and monitor trends in safety data.

A typical airline safety data reporting system, such as those mentioned above, will have lessons for a broad spectrum of activities relevant to operational safety and accident prevention.

After collecting safety data through various sources, organizations should then perform the necessary analysis to identify hazards and control their potential consequences. Among other purposes, the analysis may be used to: (ICAO SMM 1.11.3)

(a)

assist in deciding what additional facts are needed;

(b)

ascertain latent factors underlying safety deficiencies; and

(c)

assist in reaching valid conclusions;

(d)

monitor and measure safety trends or performance.

Safety analysis is often iterative, requiring multiple cycles. It may be quantitative or qualitative. The absence of quantitative baseline data may force a reliance on more qualitative analysis methods.

Human judgement may be subject to some level of bias based on past experiences, which may influence the interpretation of analysis results or testing of hypotheses. One of the most frequent forms of judgement error is known as– confirmation bias. This is the tendency to seek and retain information that confirms what one already believes to be true.

The first stage includes the gathering and entering of reports from personnel such as flight crew, dispatchers, cabin crew, maintenance personnel and ground handling personnel into the database. The database will have a system of keywords and descriptors that can be used to classify the particular occurrence in a clear and logical manner. An important part of the classification system is that personnel who are making the classifications must be trained to treat all occurrences in the same manner. This will ensure a consistency within classification.

Investigation of occurrences must be carried out meticulously, using the applicable specialists where necessary. The safety department must have the unimpeded authority to request assistance in the investigation of these occurrences.

The database will contain internal tools to assist in the identification of trends. While an individual occurrence may stand out, it is necessary to

Aviation Training Program

Aviation Training Program

conduct regular analyses of the data to detect any emerging trends, and take action at an early stage.

The database can also be used to produce follow-up information for the individuals who have submitted the occurrences reports, and to dissemi- nate the information widely throughout the airline. An important function of the safety department is to acknowledge receipt of every incident report directly to the person or persons submitting it, and to record when the occurrence file is closed.

The communication of safety issues and action taken, can take many forms. Newsletters, safety magazines, journals, flyers and websites are some of the methods regularly used. A Confidential Reporting System or CRS is also a valuable tool to confidentially publish potential safety or organizational issues that do not fit the normal safety reporting chain.

The final stage in the internal feedback loop is the management review, discussed in more detail in lesson 4.4.1 of this course. It is an essential and regular review of hazards, risks and remedial action, including their follow- up and effectiveness. If the corrective action taken is found to have been ineffective, the safety issue needs to be studied in further detail.

Additional levels of occurrence data analysis include participation in industry or regional safety data sharing events, safety committees, or data sharing programs. These programs often provide an ability to benchmark internal performance against industry performance, or to perform individu- alized queries against industry wide databases. Examples include:

IATA Global Safety Information Centre or GSIC

IATA Safety Trend Evaluation and Analysis and Data Exchange System or STEADES

NASA Aviation Safety Reporting System or ASRS and

FAA Aviation Safety Information Analysis System or ASIAS

FAA Aviation Safety Information Analysis System or ASIAS 3.1.2 Accident and Incident Investigations Accidents and

3.1.2 Accident and Incident Investigations

Accidents and incidents that occur in all areas of operations are reflective of a system failure at some level in the organization. The purpose of a thorough investigation is to understand what happened and how to prevent Key Learning Point the event from reoccurring. Many airlines follow the same steps and The purpose of a thorough processes that have been proven so effective by State accident investi- investigation is to understand gation organizations. As a minimum, an effective accident or incident what happened and how to prevent the event from reoccurring.

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Aviation Training Program

investigation program is managed at the corporate level by the safety department and should contain the following essentials:

Fact finding and data collection including:

Employee interviews

Flight data from the digital flight data recorder or cockpit voice recorder

Failed hardware such as aircraft parts, etc.

Document and procedural review

Technical expert interviews, internal and external

Manufacturer participation

Ground handling or ramp video

Data analysis including:

Subject Matter Experts or SME s to evaluate the facts

Consensus on the facts, sequence of events, and system deficiencies

Conclusions including:

A summary of factual information and analysis

Recommendations including:

Identifying and assigning specific corrective actions to prevent reoccurrence

Senior Management Review including:

Providing senior management with a thorough review of the facts and corrective action plan

Assigning and tracking implementation of corrective actions through a tailored corrective action record or request

Conducting periodic follow-up assessments to ensure the effec- tiveness and sustainability of the corrective actions

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Aviation Training Program
Aviation Training Program 3.1.3 Flight Data Analysis One of the most powerful tools to aid safety

3.1.3 Flight Data Analysis

One of the most powerful tools to aid safety management is the use of aircraft digital flight data for routine analysis of aircraft performance and operational parameters. This type of program is also known as Flight Data

Key Learning Point Analysis or FDA , Flight Data Monitoring or FDM or Flight Operations A flight data analyst analyzes Quality Assurance or FOQA.

the reports to determine

FDA data often collects many times the number of parameters that are

emerging that require action. stored in a Digital Flight Data Recorder or DFDR, which is best known as

the crash recorder, or black box. The same data can be stored on, and downloaded easily from, subsidiary recorders generically known as Quick Access Recorders or QAR. They are generally more easily accessible than the DFDR and they are not crash proof.

there are any undesirable trends

whether

Operational flight data is routinely downloaded from the aircraft QAR by means of disk exchange, direct download onto a transfer device, and more recently by automatic downloads via a wireless network directly from the aircraft recorder. The data is then fed through analysis software to check for abnormalities using parameters that have been agreed between the airline and manufacturer. The reports from this program are produced

automatically, including a negative report if no exceedances are present on

a particular flight.

A flight data analyst then analyzes the reports to determine whether there

are any undesirable trends emerging that require action; for example, an increasing rate of unstable approaches at a particular airport. Following the hazard analysis, there will usually be a review by a working group, not less than monthly, that looks for both specific exceedances and emerging unsafe trends.

The FDA can highlight deviations from Standards Operating Procedures or SOPs , which may be indicative of inappropriate procedures or confirm the effectiveness of training methods. As in any closed-loop process, follow-up monitoring is required to assess the effectiveness of any corrective actions taken. For example, FDA might help answer the following questions:

Are the desired results being achieved? Sufficiently? Soon enough?

Have the problems really been corrected, or just relocated to another part of the system?

Have new problems been introduced?

The collection, storage and analysis of FDA data require a dedicated

department with a high degree of specialization and logistical support. It must be recognized as an FDA program that is founded on a bond of trust between the airline, its crews and the regulatory authority. Crew cooper- ation is fundamental to its success, and the program must actively demonstrate a non-punitive policy. The main object of an FDA program is

to improve safety by identifying trends, not individual acts.

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Aviation Training Program

Participation in regional or international FDA data sharing programs provides an ability to analyze performance on a broader scale and to use these programs to resolve issues at a national or regional level.

Case Study

FLIGHT DATA MONITORING ( FDM) PROGRAMME – (EASA AMC1

ORO.AOC.130)

(a)

The safety manager, should be responsible for the identification and assessment of issues and their transmission to the manager(s) responsible for the process(es) concerned. The latter should be responsible for taking appropriate and practicable safety action within a reasonable period of time that reflects the severity of the issue.

(b)

An FDM programme should allow an operator to:

1. identify areas of operational risk and quantify current safety margins;

2. identify and quantify operational risks by highlighting occurrences of non-standard, unusual or unsafe circumstances;

3. use the FDM information on the frequency of such occurrences, combined with an estimation of the level of severity, to assess the safety risks and to determine which may become unacceptable if the discovered trend continues;

4. put in place appropriate procedures for remedial action once an unacceptable risk, either actually present or predicted by trending, has been identified; and

5. confirm the effectiveness of any remedial action by continued monitoring.

(c)

FDM analysis techniques should comprise the following:

1. Exceedance detection: searching for deviations from aircraft flight manual limits and standard operating procedures. A set of core events should be selected to cover the main areas of interest to the operator. The event detection limits should be continuously reviewed to reflect the operator's current operating procedures.

2. All flights measurement: a system defining what is normal practice. This may be accomplished by retaining various snapshots of information from each flight.

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Aviation Training Program

3. Statistics – a series of data collected to support the analysis process: this technique should include the number of flights flown per aircraft and sector details sufficient to generate rate and trend information.

(d)

FDM analysis, assessment and process control tools: the effective assessment of information obtained from digital flight data should be dependent on the provision of appropriate information technology tool sets.

(e)

Education and publication: sharing safety information should be a fundamental principle of aviation safety in helping to reduce accident rates. The operator should pass on the lessons learnt to all relevant personnel and, where appropriate, industry.

(f)

Accident and incident data requirements specified in CAT.GEN.MPA.195 take precedence over the requirements of an FDM programme. In these cases the FDR data should be retained as part of the investigation data and may fall outside the de-identification agreements.

(g)

Every crew member should be responsible to report events. Significant risk-bearing incidents detected by FDM should therefore normally be the subject of mandatory occurrence reporting by the crew. If this is not the case then they should submit a retrospective report that should be included under the normal process for reporting and analysing hazards, incidents and accidents.

(h)

The data recovery strategy should ensure a sufficiently representative capture of flight information to maintain an overview of operations. Data analysis should be performed sufficiently frequently to enable action to be taken on significant safety issues.

(i)

The data retention strategy should aim to provide the greatest safety benefits practicable from the available data. A full dataset should be retained until the action and review processes are complete; there- after, a reduced dataset relating to closed issues should be maintained for longer-term trend analysis. Programme managers may wish to retain samples of de-identified full-flight data for various safety purposes (detailed analysis, training, benchmarking etc.).

(j)

The data access and security policy should restrict information access to authorised persons. When data access is required for airworthiness and maintenance purposes, a procedure should be in place to prevent disclosure of crew identity.

(k)

The procedure to prevent disclosure of crew identity should be written in a document, which should be signed by all parties (airline manage- ment, flight crew member representatives nominated either by the

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Aviation Training Program

union or the flight crew themselves). This procedure should, as a minimum, define:

1. the aim of the FDM programme;

2. a data access and security policy that should restrict access to information to specifically authorised persons identified by their position;

3. the method to obtain de-identified crew feedback on those occasions that require specific flight follow-up for contextual information; where such crew contact is required the authorised person(s) need not necessarily be the programme manager or safety manager, but could be a third party (broker) mutually acceptable to unions or staff and management;

4. the data retention policy and accountability including the measures taken to ensure the security of the data;

5. the conditions under which advisory briefing or remedial training should take place; this should always be carried out in a constructive and non-punitive manner;

6. the conditions under which the confidentiality may be withdrawn for reasons of gross negligence or significant continuing safety concern;

7. the participation of flight crew member representative(s) in the assessment of the data, the action and review process and the consideration of recommendations; and

8. the policy for publishing the findings resulting from FDM.

(l) Airborne systems and equipment used to obtain FDM data should range from an already installed full quick access recorder (QAR), in a modern aircraft with digital systems, to a basic crash-protected recorder in an older or less sophisticated aircraft. The analysis potential of the reduced data set available in the latter case may reduce the safety benefits obtainable. The operator should ensure that FDM use does not adversely affect the serviceability of equipment required for accident investigation.

3.1.4 Safety Auditing

Safety audits are used primarily as a means to verify the safety performance of the airline and to validate the effectiveness of safety risk controls. On-site audit activities, conducted by an independent entity, routinely identify a number of safety hazards, non-compliance with regulatory requirements, non-adherence to established procedures, latent system deficiencies and opportunities for improvement.

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Aviation Training Program

We should understand the difference between Quality Auditing and Safety Auditing.

Essentially Quality Auditing is looking at compliance both with the regulations and with the Organisations own specific requirements, Whereas Safety Auditing is looking at exposure to risk.

Quality Auditing may in fact focus on either historic event (an engine change which has already taken place), or the current situation (an aircraft arrival and departure).

When we examine the areas to which we can employ our Safety Auditing Techniques we find that we have 3 key areas.

(a)

People Related

(b)

Documentation and Process Related

(c)

Environment, Facilities, Tooling and Equipment Related

People Related – remember we are looking at Risk not compliance

Typical questions which are asked include but are not limited to the following:

What could happen that could cause harm to the individual

For each potential possibility consider the various mitigations?

Are the mitigations perceived to be effective (subjective)?

What harm can the individual do to the business

For each potential possibility consider the various mitigations?

Are the mitigations perceived to be effective (subjective)?

Example –Does the individual have all necessary competencies in the workplace (typically health safety and general awareness of the various threats to well being).

How is this evidenced? for example– communicated for new starters (or contract workers) for example.

Who is responsible for sharing this Knowledge (or process or procedure)– management and ownership.

Are the mitigation processes tested for effectiveness? – How?

Does the individual have all the necessary competencies to ensure that he or she is not a threat to the job?

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Aviation Training Program

Remember that we start with the premise that no one deliberately harms the business, but it happens for reasons associated with the following organizational issues:

Lack of Effective Process and Procedures

Lack of Training

Lack of Competency

(Possibly this may be compounded by lack of management oversight) Also in respect of issues associated with People, do we have enough correctly trained people now and for the future period of growth.

Who is assessing the manpower status? (which should take place on a continuous basis)–using what tools? How is the data managed, recorded and evaluated?

Documentation and Process Related

Typical questions which are asked include but are not limited to the following:

Where are the weaknesses in the Documentation or Business process which possibly promotes potential risk. (again subjective)

For each potential possibility consider the various mitigations?

Are the mitigations perceived to be effective (subjective)?

What harm if any can perceived weaknesses do to the business