ACAC SMS Training v01

TRAINING IN SAFETY
MANAGEMENT SYSTEMS
ARAB CIVIL AVIATION CONFERENCE

Amman, Jordania 19-23 July 2009
1
Welcome to Safety
Management
System Workshop
ACAC, Safety Management Systems Training
Speakers:
CHRISTER PRAHL
ATM Safety Expert

Electronic Engineer
Degree in Communication
Degree in Networking
Pilot (IFR rated)
Speakers:
MICHAEL NIELS THORSEN
ATM Safety Expert

Master of Science in Engineering
Expert International Cooperation
Expert Safety Management Implementation
Expert Organisational Structures
Round the table

Name and Position
Agenda for today:
09.00 10.30
Registration and Welcome
10.30 11.00
Break
11.00 12.30
ICAO presentation on Safety Management System

SES Regulations
12.30 14.00
Lunch
14.00 15.00
The Safety System
15.00 15.30
Break
15.30 16.30
The Safety Management System
16.30 17.00
Wrap - Up
General House-Rules
Hand-outs will be given in connection with the lesson;

CD will come at the end of the course;
Questions during the lessons;
Active participation is anticipated;
Flexible approach, programme can be changed also
on request;
Turn off cell phone;
Please stop the instructors if you dont understand
them;
Objectives of the workshop

Provide participants the knowledge of Safety
Management Concept and ICAO Standards and
Recommended Practices (SARPs) on safety management in
Annexes 6, 11 and 14 and related guidance material
AND TO
Develop participants knowledge to certify and oversee
the implementation of key components of an SMS, in
compliance with relevant ICAO SARPs.
ICAO - Safety Management System

What is Safety?
Zero Accidents?
Freedom from danger or risks?
Error avoidance?
Any suggestions?

According to ICAO Doc 9859:
Safety is the state in which the risk to harm the
persons or property damages is reduced, and
maintained at or below, an acceptable level
through a continuing process of hazard
identification and risk management.
10

A safety management system (SMS) is an organised approach to
managing safety, including the necessary organisational structures,
accountabilities, policies and procedures.
(ICAO Doc 9859 - Safety Management Manual)
The objective of a Safety Management System is to provide a

structured management approach to control safety risks in operations.
Effective safety management must take into account the organisations
specific structures and processes related to safety of operations.
11
Safety Management System

Structure and Contents
10: Phased approach
to SMS
Implementation
8: SMS planning
5: Risks
1: SMS course
introduction
9: SMS operation
6: SMS regulation
2: Basic safety
concepts
7: Introduction to
SMS
3: Introduction
to safety
management
4: Hazards
12
Safety Management Manual

Objectives
Objectives of the Safety Management Manual are to provide States:
Knowledge of safety management concepts, the ICAO Standards and
Recommended Practices (SARPs) on safety management contained in Annexes
1, 6, 8, 11, 13 and 14, and related guidance material;
Guidance on how to accept and oversee the implementation of the key
components of an SMS in compliance with the relevant ICAO SARPs;
Guidance on how to develop and implement an SSP in compliance with the
relevant ICAO SARPs.
13

Concept
SMS/SSP
Implementation
ICAO SARPS
Safety Concepts
14
Generic SMS Requirements

ICAO requirements for implementation of SMS are currently applicable to:
Air Traffic Service Providers (Annex 11)

Aerodrome Operators (Annex 14, Volume 1)
Amendment to Annex 1, 6, 11, 13 and 14 are proposed in order to harmonise

and extend provisions relating to safety management.
15
SES Regulation - Objectives

The second SES package has been put forward by the European
Commission in order to make the European sky safer and more
sustainable by:
Introducing a performance framework for European ATM with quantified
target setting;
Creating a single safety framework to enable harmonised development of
safety regulations and their effective implementation;
Opening the door to new technologies enabling the implementation of
new operational concept and increasing safety levels by a factor of ten;
Improving management of airport capacity.
16
The 1st SES legislative package

The legislative package adopted in 2004 comprises four base regulations,
which reinforce safety and foster the restructuring of European airspace
and air navigation services. The regulations provide the framework for the
creation of additional capacity and for improved efficiency and
interoperability of ATM system in Europe.
The Framework regulation (EC No 549/2004) - laying down the
framework for the creation of the single European sky;
The Service provision regulation (EC No 550/2004) - laying down
common requirements for the provision of air navigation services;
The Airspace regulation (EC No 551/2004) - on the organisation and
use of airspace in the Single European sky;
The Interoperability regulation (EC No 552/2004) - on the
interoperability of the European Air Traffic Management network.
17
(EC) No 549/2004 - Framework

The objective of the Framework regulation is to enhance current safety
standards and overall efficiency of the general air traffic in Europe,
to optimise ATM system capacity and minimise air traffic delays by
establishing a harmonised regulatory framework for air traffic
management in Europe.
The Framework regulation establishes harmonised institutional, regulatory
and consultation arrangements to enable the creation of the Single European
Sky.
In brief these are:
National Supervisory Authorities (NSA)
Single Sky Committee
Military Issues
Industry Consultation Body
Implementing Rules
Performance Review
Safeguards
18
(EC) No 550/2004 Provision of Air

Navigation Services in SES
The Service provision regulation establishes common requirements to ensure
that air navigation services are provided safely and efficiently, on a continuous and
interoperable basis, throughout the European Community. It introduces a
harmonised system of certification and lays down rules for designating service
providers.
The stipulations of this regulation apply to the provision of air navigation
services to General Air Traffic (GAT) and can be summarised as follows:
National Supervisory Authorities (NSA)

Licensing of Controllers
Common Requirements
Certification of Air Navigation Service Providers (ANSPs)
Designation of Air Traffic Service Providers
Relations between Service Providers
Transparency of Accounts
Access to and Protection of Data
Charging Schemes
19
(EC) No 551/2004 Organisation

and use of Airspace in SES
The objective of the Airspace regulation is to put an end to the fragmentation of European
Union (EU) airspace and to create an efficient and safe airspace without frontiers. The
organisation and management of airspace should be improved by merging all the national
flight information regions (FIRs) into a single portion of airspace within which ATS will be
provided according to the same rules and procedures.
The Airspace regulation forms part of the first package of legislation on air traffic management
designed to create a SES. This objective will make for improved safety, optimum use of
European
airspace, reduced air traffic delays and sustainable air transport growth.
The following is summarising this regulation:
Establishment of European Upper Flight Information Region (EUIR)
Reconfiguration of Upper Airspace
Optimised Route and Sector Design in the Upper Airspace
Flexible Use of Airspace
Safeguards
20
(EC) No 552/2004 Interoperability

of the European ATM Network
The aim of the Interoperability regulation is two-fold:
To achieve interoperability between the different systems, constituents and
associated procedures in the European ATM network by establishing a
harmonised system for certification of components and systems;
To ensure the introduction of new agreed and validated concepts of operations
and technology in air traffic management.
The following topics summarise the Interoperability regulation:
Essential Requirements
Implementing Rules for Interoperability
Community Specifications
EC Declaration of Conformity of Suitability for Use of Components
Safeguards
Transitional Arrangements
21
The SES Implementation

Implementing the provision of the SES regulations would bring a number of
significant benefits:
Improved level of safety of air navigation services;

A more effective and integrated air traffic management architecture;
Demand driven air navigation service provision;
Enhanced cross-boarder co-ordination;
Improved decision-making and enhanced enforcement in ATM.
22
Regulations, Directive and

Implementing Rules
Regulations: Mandatory to the letter

Directives: Mandatory with National exemptions
Implementing Rules: Guidelines
23
The 1st SES legislative package

The First Report on the implementation of the Single Sky Legislation
was published in December 2007.
It
presents:
the achievements,
identifies new challenges
proposes the way forward.
Based on the report findings, the Commission came forward with

proposals for a 2nd Single Sky package, including extension of EASA
competencies to ATM and adoption of the European ATM Master Plan.
24
The 2nd SES legislative package

To tackle issues such as traffic increase, financial burden and
environmental awareness, the Commission has come up with 2nd SES
legislative package aimed to:
Create a single safety framework to enable harmonised development
of safety regulations and their effective implementation;
Improve the performance of the ATM system through setting of
targets;
Open the door to new technologies enabling the implementation of
new operational concept and increasing safety levels by a factor of
ten;
Improve management of airport capacity
25
(EC) No 2096/2005 Common Requirements

for the Provision of Air Navigation Services
The objective of this Regulation is to establish common requirements for the safe and
efficient provision of air navigation services in the European Community and to set uniform
and high safety standards for ANSPs.
The common requirements cover the following areas:
Technical and operational competence and capability

Organisational structure and management
Safety and quality management
Security
Human resources
Financial strength
Liability and insurance cover
Quality of services
Reporting requirements
The common requirements do not cover military operations and training and do not apply to
activities or resources allocated to activities outside the provision of air navigation services.
26

The Regulation identifies and adopts the mandatory provisions of the following
EUROCONTROL Safety Regulatory Requirements (ESARRs) which are relevant for the
certification of air navigation service providers:
ESARR3 - on the use of safety management systems by air traffic management

(ATM) service providers;
ESARR4 - on risk assessment and mitigation in ATM;
ESARR5 - on ATM services' personnel, in particular the requirements for engineering
and technical personnel undertaking operational safety related tasks.
The detailed requirements relating to safety of services are contained in Annex II to
the Regulation.
27

Subjects summarising (EC) No 2096/2005 are as follows:
Certification of ANSPs
Derogations
Demonstration of Compliance
Compliance Monitoring
Peer Review of NSAs
28
Similarities and Differences between

ICAO and SES
t c an
Wha ng?
ro
go w
ICAO Methodology
Step 7:
Documentation
Step 6:
Risk Mitigation
Step 5:
System Description
Step 4:
Likelihood Assessment
Step 3:
Severity Assessment
Step 2:
Hazard Identification
Step 0:
Planning
Step 1:
System Description
we
n
a
?
c
at out it
h
W ab
do
EUROCONTROL Methodology (ESARR)

Functional
Hazard Assessment
(FHA)
Preliminary
System Safety
Assessment
(PSSA)
System Safety
Assessment
(SSA)
29
ICAO Safety Regulation

ICAO Annex 11 Paragraph- 2.26 ATS Safety Management
includes relevant requirements related to ATS
Para 2.26.1 requires the States to implements systematic and
appropriate Safety Management Programmes, further detailed in
Para 2.26.4
Para 2.26.2, requires States to establish the acceptable level of
safety and safety objectives applicable to the provision of ATS
within their airspace and at their aerodromes with acceptable level
of safety further detailed in 2.26.3
30
ICAO Provisions
Para 2.26.5 requires that any significant safety-related change to
the ATC system shall only be implemented after a safety
assessment has demonstrated that an acceptable level of safety will
be maintained.
Para 2.26.5 also requires that the responsible authorities shall
provide for post-implementation monitoring to verify that the
defined levels of safety continues to be met
31
ICAO Provisions
PANS-ATM doc.4444 includes in Chapter 2 requirements for:
ATS maintaining acceptable level of safety (section 2.1)

Implementation of systematic Safety Management Programmes (section 2.1)
ATS Safety Management Activities (section 2.3)
Monitoring of Safety Levels (section 2.4)
Safety Reviews (section 2.5)
Safety Assessments (section 2.6)
Safety-enhancing measures (section 2.7)
32
ICAO Provisions
PANS-ATM Doc 4444 clarifies a significant safety-related change as

(examples):
A new operating procedure, including departure and arrival procedures, to
be applied within an airspace or at an aerodrome;
A reorganization of the ATS route structure;
A resectorisation of an airspace;
Physical changes to the layout of runways and /or taxiways at an
aerodrome; and
Implementation of new communications, surveillance or other safetysignificant systems and equipment, including those providing new
functionality and or capabilities.
33

The new Manual on Safety Management for Aerodromes and Air
Traffic Services (Doc 9859)
Provides detailed guidance on implementation of the provisions of Annexes
6, 11, 14 and the PANS-ATM
First Draft was endorsed by 11th Air Navigation Conference (Montreal, Sep/Oct 2003)
Current version in ICAO NET web
Based on the same approach to safety as recommended by the ATM Operational Concept
(Doc 9854)
34
The Concept of Safety Management

Safety
Culture
Safety
Monitoring
Philosophy
Of Safety
Management
Safety
Policy
Safety
Assessment
Safety
Auditing
Maintenance of
Improvement of
Safety Performance
Safety
Promotion
Supporting
Organisational
Requirement
Safety Management
35
Legal and Regulatory Foundation

for Safety Management
Implementation of safety management programs refers to the day
to day keep safety oversight management by the service providers
States shall establish systemic and suitable ATS safety management

programs with defined levels and objectives (PANS-ATM, in force since
November 2003)
The acceptable level of safety shall be established by the States. As
appropriate, the target levels of safety (TLS) will be established through
regional air navigation agreements.
Prior to any significant change to the safety-related ATC system, a safety
assessment will be carried out, proving that an acceptable safety level may
be obtained
SMS includes the establishment of runway safety programs.
36
The Safety System
Global Safety System
Organizational structure - Staffing, documentation, resources and leadership commitment

must be sufficient to support the desired process.
Planning - Strategic planning and development of appropriate activities must be based on
systematic and comprehensive assessment of risks.
Management personnel standards - Safety must be integrated into line and operating
management responsibilities, and their roles must be clearly defined in written standards of
performance.
Training for operations and emergencies
Procedures - The organization must develop written procedures for design, operations and
maintenance activities to control routine work and probable emergencies.
Management of change
Mechanical integrity - The organization must establish systematic and comprehensive
means to assess the integrity of process equipment.
Management of contractors - Safety must be a prominent consideration in the selection of
contractors, and appropriate means to monitor the work of contractors must be in place
and working.
Involvement of the work force
Accident/incident reporting, investigation and follow-up - Monitoring and auditing methods
must be in place to monitor the on-going, day-to-day performance of the safety system, as
well as to audit thoroughly compliance to all requirements on a periodic basis.
37

Documentation:
AD Technical
Implementing Rules
Guidance Material
Acceptance Means of Compliance
Notices of proposal amendments
ICAO
EASA
EUROCONTROL
EC
States
Ministries
CAA
Service Providers
Guidelines
Regulations
Requirements, EU OPS
Recommendations
Legislation
National Legislation
NSA
Aviation Law
Airport Law
Regulations
Standards
Manuals
Working Procedures
Documentation
38

Organisation:
The world global Safety System consist of all

the existing safety management systems on
all levels in all the areas of aviation like the
service providers, the airspace users, the
maintenance organisations etc.
39

Supporting Issues:
Auditing
Inspections
40

Security:
Improved security of ATM systems and

information
Provides assistance and information
In Flight Emergency Response
ICAO Annex 17
41

Security:
Until the events of 11 September 2001, the ICAO model was regarded as adequate and
sufficient to ensure the safety of passengers, aircraft and goods. However, in December
2001 the ICAO adopted an Amendment 10 to Annex 17, which set out a number of
additional safety and security requirements. These include the following:
1. Aircraft security check
2. Background check
3. Screening
4. Application of Security
5. Security Restricted Areas
6. Objectives
7. International cooperation
8. National Organization and appropriate authority
9. Airport Operations
10. Quality Control Programme
11. In-flight aircraft security measures
42

Security:
ICAO Security Concept:

National Civil Aviation Security Program
National Aviation Security Committee
Airport
Security
Program
Operator
Security
Programs
Quality
Control
Program
National
Training
Program
Authority
Contingency
Plan
Airport Security
Committee
Airport
Emergency
Plan
43

Quality Definitions:
Quality the totality of features and characteristics of a product or service that bear on
its ability to satisfy a given need.
Quality Policy the overall quality intentions and direction of an organisation as regards
quality, as formally expressed by top management.
Quality Management that aspect of the overall management function that determines
and implements the quality policy.
Quality System the organisational structure, responsibilities, procedures, processes and

resources for implementing quality management.
Total Quality Management a management approach of an organisation centred on
quality, based on the participation of all its members and aimed at long term success
through customer satisfaction and benefits to the members of the organisation and society.
Quality Assurance the activities an organisation carries out to provide to external and
internal parties confidence that the organisation will consistently meet the requirements for
quality.
44

Quality:
Airport Quality Process:
Evaluation of user needs and expectations

Design and implementation of service
Operation and achievement of service
Measurement of quality of service
Evaluation and Corrective action
45

Quality Definitions:
Airport Quality Elements:

Safety
Security
Efficiency
Service
Capacity
Environment
Health
46

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

product quality assurance and control processes. These processes drew on
the following existing resources:
day-to-day consistency checking systems for both data and products,
forecast verification system developed in 2000 which gave for each
forecast a score relative to the ICAO desirable accuracy for each of the
weather elements.
The QMS also included on-going review processes for continual
improvement and for the provision of adequate resources to sustain the
QMS.
Further, as important components of the QMS, customer needs

assessment and satisfaction survey became an institutionalized part of the
system.
47

Safety:
As stated before:
The world global Safety System consist of all
the existing safety management systems on
all levels in all the areas of aviation like the
service providers, the airspace users, the
maintenance organisations etc.
48
Safety Versus Quality and Security:

It is accurate to say that SMS and QMS share many commonalities. They both:
a) have to be planned and managed;
b) depend upon measurement and monitoring;
c) involve every function, process and person in the organization; and
d) strive for continuous improvement.
SMS differs from QMS in the following way:
a) SMS focuses on the safety, human and organizational aspects of an organization
(i.e. safety satisfaction);
while
b) QMS focuses on the products and services of an organization (i.e. customer
satisfaction).
49
Safety Management System

Safety 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 continuing process
of hazard identification and risk management.
Management Allocation of resources.
System Organized set of processes and procedures.
SMS An organised set of processes and procedures,
based upon a principled allocation of resources, that allows
the control of safety risks to an acceptable level
50

What is SMS?
A system for managing safety as part of the overall
management objective and policy;
Why SMS?
To regulate airport operations and improve safety levels,
especially in areas not covered by applicable ICAO or
applicable national standards and regulations;
How?
Existence of comprehensive technical
Standards/specifications, a safety management policy, their
implementation and maintenance at all times.
51

SMS Tool-box:
The scope of SMS encompasses most of the activities
of the organization.
SMS must start from senior management, and safety
must be considered at all levels of the organization.
SMS aims to make continuous improvement to the
overall level of safety.
All aviation stakeholders have a role to play in SMS.
52

The components of SMS:
1) Safety policy and objectives
2) Safety risk management
3) Safety assurance
4) Safety promotion
53

SMS at glance:
Safety
Safety Policy and
Objectives
Safety Assurance
Effectiveness
Management
Commitment
Safety Risk
Management
Safety Promotion
Efficiency
Aviation Community Stakeholders

54

The Elements of SMS:
Safety policy and objectives

Management commitment and responsibility
Safety accountabilities of managers
Appointment of key safety personnel
SMS implementation plan
Coordination of emergency response planning
Documentation
55

The Elements of SMS:
Safety risk management
Hazard identification processes
Risk assessment and mitigation processes
Safety assurance
Safety performance monitoring and measurement
The management of change
Continuous improvement of the SMS
Safety Promotion:
Training and Education

Safety Communication
56
Safety Risk Management

What is Risk Management?
The identification, analysis and elimination, and/or

mitigation to an acceptable level of risks that threaten the
capabilities of an organization.
What is the objective of Risk Management?
Aims at a balanced allocation of resources to address all

risks and viable risk control and mitigation.
Why is Risk Management important?
A key component of safety management systems.

Data-driven approach to safety resources allocation, thus
defensible and easier to explain.
57

Four steps for hazard identification process:
1. Reporting hazards, events or safety concerns.
2. Collecting and storing the data.
3. Analyzing reports.
4. Distributing the information distilled from the analysis.
58
Risk Assessment and Mitigation Process
Risk Assessment:
Regularly
Commitments
Documentation
Mitigation:
Measures to address the potential hazard or to
reduce the risk probability or severity.
Risk mitigation = Risk control
59
Risk Management System

Risk Management at glance:
Equipment, Procedures, Organisation, etc
Risk Analysis
Probability
Analyse the likelihood of the consequence

occurring
Risk Analysis
Severity
Evaluate the seriousness of the consequence

if it occurred
Risk Assessment and

Tolerability
Risk
Control/Mitigation
Is the risk assessed acceptable and within

the organisational safety performance criteria
Yes, Accept the risk

No, take action in order to reduce the risk to
an acceptable level
60

Risk Mitigation at glance:
Hazard identification and
Risk Assessment
Each Consequence
Assessment of the
defences within the
safety system
Control and
Mitigation of the risks
Intolerable
Region
Technology
Training
Regulations
Tolerable
Region
Acceptable
Region
Accepting the mitigations

of the risk(s)
Does it address
the risk(s)?
Is it effective?
Is it appropriate?
Is additional mitigation
warranted?
Do the mitigations
Strategies generate
additional risks?
Etc
Each Risk
Feedback safety assurance

61
Risk Management Assessment
There is no such thing as absolute safety In aviation it is not possible to

eliminate all risks.
Risks can be managed to a level as low as reasonably practicable

(ALARP)
Risk mitigation must be balanced against:

Time
Cost
Difficulty of taking measures to reduce or eliminate the risk (i.e. managed).
Effective risk management seeks to maximize the benefits of accepting a

risk
(a reduction in time and cost) while minimizing the risk itself.
Communicate the rationale for risk decisions to gain acceptance by stakeholders

affected by them.
62
Safety Assurance
Safety Assurance is built upon the following:
63
Safety Assurance
The process by which the safety performance of the
organization is verified in comparison to the approved safety
policies and objectives.
Safety reporting
Safety studies
Safety reviews
Audits
Surveys
Internal safety investigations
64
Safety Assurance
Safety Audits are used to ensure that the structure of the SMS is sound in terms of:
Levels of staff;
Compliance with approved procedures and instructions;
Level of competency and training to:
Operate equipment and facilities; and
Maintain their levels of performance.
Safety surveys examine particular elements or processes of a specific operation.

Problem areas or bottlenecks in daily operations.
Perceptions and opinions of operational personnel.
Areas of dissent or confusion.
Check list
Questionnaires
Informal confidential interviews
65
Safety Assurance
Internal safety investigations include occurrences or events
that are not required to be investigated or reported to State.
In-flight turbulence (flight operations)
Frequency congestion (ATC)
Material failure (maintenance)
Ramp vehicle operations (aerodrome)
66
Safety Information Sources

The protection of safety information from inappropriate use is essential
to ensure its continued availability in future, since the use of safety
information for other than safety-related purposes may reduce the
availability of such information, with an undesirable effect on safety.
During the 35th Assembly of ICAO, it was noted that existing national
laws and regulations in many States may not address adequately the
protection of safety information from inappropriate use.
Following the Assembly, ICAO has produced a legal guidance for the
protection of information from SDCPS and it is included in Attachment E
to Annex 13.
67
Annex 13
General Principles
The sole purpose of protecting safety information from inappropriate use is to ensure its continued
availability so that proper and timely preventive actions can be taken and aviation safety improved.
It is not the purpose of protecting safety information to interfere with the proper administration of justice
in States.
National laws and regulations protecting safety information should ensure that a balance is struck
between the need for the protection of safety information in order to improve aviation safety, and the
need for the proper administration of justice.
National laws and regulations protecting safety information should prevent its inappropriate use.
Providing protection to qualified safety information under specified conditions is part of a States safety
responsibilities.
Principles of Protection
Safety information should qualify for protection from inappropriate use according to specified conditions
that should include, but not necessarily be limited to: the collection of information was for explicit safety
purposes and the disclosure of the information would inhibit its continued availability.
The protection should be specific for each SDCPS, based upon the nature of the safety information it
contains.
A formal procedure should be established to provide protection to qualified safety information, in

accordance with specified conditions.
Safety information should not be used in a way different from the purposes for which it was collected.
The use of safety information in disciplinary, civil, administrative and criminal proceedings should be
carried out only under suitable safeguards provided by national law.
68
Annex 13
Principles of Exception
Exceptions to the protection of safety information should only be granted by national laws and
regulations when:
There is evidence that the occurrence was caused by an act considered, in accordance with the
law, to be conduct with intent to cause damage, or conduct with knowledge that damage would
probably result, equivalent to reckless conduct, gross negligence or wilful misconduct;
An appropriate authority considers that circumstances reasonably indicate that the occurrence
may have been caused by conduct with intent to cause damage, or conduct with knowledge that
damage would probably result, equivalent to reckless conduct, gross negligence or wilful
misconduct;
A review by an appropriate authority determines that the release of the safety information is
necessary for the proper administration of justice, and that its release outweighs the adverse
domestic and international impact such release may have on the future availability of safety
information.
Public Disclosure
Subject to the principles of protection and exception outlined above, any person seeking
disclosure of safety information should justify its release.
Formal criteria for disclosure of safety information should be established and should include, but
not necessarily be limited to, the following:
Disclosure of the safety information is necessary to correct conditions that compromise safety
and/or to change policies and regulations;
Disclosure of the safety information does not inhibit its future availability in order to improve
safety;
Disclosure of relevant personal information included in the safety information complies with
applicable privacy laws;
Disclosure of the safety information is made in a de-identified, summarized or aggregate form. 69
Annex 13
Responsibility of the Custodian of Safety Information
Each SDCPS should have a designated custodian. It is the responsibility of the custodian of safety
information to apply all possible protection regarding the disclosure of the information, unless:
The custodian of the safety information has the consent of the originator of the information for
disclosure; or
The custodian of the safety information is satisfied that the release of the safety information is in
accordance with the principles of exception.
Protection of Recorded Information
Considering that ambient workplace recordings required by legislation, such as cockpit voice
recorders (CVRs), may be perceived as constituting an invasion of privacy for operational
personnel that other professions are not exposed to:
Subject to the principles of protection and exception above, national laws and regulations should
consider ambient workplace recordings required by legislation as privileged protected information,
i.e. information deserving enhanced protection; and
National laws and regulations should provide specific measures of protection to such recordings
as to their confidentiality and access by the public. Such specific measures of protection of
workplace recordings required by legislation may include the issuance of orders of non-public
disclosure.
70
Change Management Process

Aviation organizations experience permanent change due
to expansion, introduction of new equipment or procedures.
Changes can have the following output:

Introduce new hazards.
Impact the appropriateness of risk mitigation.
Impact the effectiveness of risk mitigation
71

Mentioned Changes can be:
External changes
Change of regulatory requirements.
Security.
Reorganization of air traffic control
Internal changes
Management changes
New equipment.
New procedures
72

A formal management of change process should:
identify changes within the organization which may
affect established processes and services.
prior to implementing changes describe the
arrangements to ensure safety performance.
73
Improvement Process
Continuing improvement aims at:
Determining the immediate causes of below standard
performance and their implications in the operation of
the SMS.
Rectifying situations involving below standard
performance identified through safety assurance
activities
74
Improvement Process
The mentioned improvements are achieved through:
Proactive evaluation of facilities, equipment,
documentation and procedures through audits and
surveys.
Proactive evaluation of the individuals performance, to
verify the fulfilment of their safety responsibilities.
Reactive evaluations in order to verify the effectiveness
of the system for control and mitigation of risks, for
example: accidents, incidents and major events
investigations
75
Safety Promotion
Who?
Operational personnel
Managers and supervisors
Senior managers
Accountable executive
Why?
To ensure that personnel are trained and competent

to perform the SMS duties.
How much?
Appropriate to the individuals involvement in the

SMS.
76
Safety Promotion
A building block approach:
Operational personnel
Organization safety policy
SMS fundamentals and overview
Managers and supervisors

The safety process
Hazard identification and risk management
Senior managers
Organizational safety standards and national regulations
Safety assurance
77
Safety Promotion
Safety communication aims to:

Ensure that all staff are fully aware of the SMS.
Convey safety critical information.
Explain why particular actions are taken.
Explain why safety procedures are introduced or changed.
Convey nice-to-know information.
78
Safety Promotion
The means to communicate may include:
Safety policies and procedures

News letters
Bulletins
Website
Safety communication is an essential foundation for the

development and maintenance of a positive culture.
79
Maintenance
Internal Evaluation Process
Management commitment
Just culture
Established processes
80
Maintenance
Internal Audit Process

An annual audit program should include:
Definition of the audits, in terms of;
criteria,
scope,
frequency, and
methods;
Description of the processes used to select the auditors;
The requirement that individuals shall not audit their own work;
Documented procedures for assignment of responsibilities, planning
and conduct of audits, reporting results and maintaining records;
Audits of contractors and vendors.
81
Maintenance
External Audit Process

Surveillance and compliance
the authority needs to ensure that international, national and local

standards are complied with prior to issuing any licence or approval and
continue to be complied with afterwards;
Areas and degree of risk
the audit should assess how risks are identified and how any necessary
changes are made to ensure that all safety standards are met;
Competence
the audited organisation should have adequately trained staff for all
safety related positions
Safety management
ensure that the organisations SMS is based on sound principles and

procedures, and that the organisation is meeting its safety performance
targets.
82
Maintenance
Proactive and Reactive Evaluations
Proactive before something has happened

Taking actions
Mitigate
Training
Reactive after something has happened

Investigate why it is as it is
Make improvements
83
Organisation
Cultural Levels of the organisation

The characteristics of a good company safety culture include:
Informed - Managers know what is really going on and workforce is
willing to report their own errors and near misses
Wary - ready for the unexpected
Just - a no blame culture, with a clear line between the acceptable
and unacceptable
Flexible - operates according to need
Learning - willing to adapt and implement necessary reforms
84
Organisation
The values of an Organisation:

The safety management organisation is defining
responsibilities, competence, commitment and communication of
the involved organisations or persons.
The culture is expressed by all parts of the organisation
Flight deck
Cabin crew
Maintenance
Ground staff
The cabin staff and check-in personnel provide the main indication
of the culture to the paying public
85
Organisation
Top-down
Managers
Managers influencing and motivating all

actors to take responsibility for their
work and taking into account the
safety.
Flight Crew
Engineers
(Maintenance)
Ground Staff
(Luggage Personnel)
86
Procedures
Safety Programme
Safety Programme is an integrated set of regulations and activities
aimed at improving safety.
States are responsible for establishing a safety programme,
encompassing the following responsibilities:
Safety regulation
Safety oversight
Accident/incident investigation
Mandatory/voluntary reporting systems
Safety data analysis and
exchange
Safety assurance
Safety promotion
87
State Safety Programme - SSP

Service Providers
State
States shall establish a State safety
programme (SSP), in order to achieve an
acceptable level of safety (ALoS) in
civil aviation.
Acceptable level of safety (ALoS) to be
achieved shall be established by the
State.
States shall require as part of their

State Safety Programme (SSP) that a
Service Providers implement Safety
Management System acceptable to the
State that as minimum:
identifies safety hazards;
ensures the implementation of
remedial action necessary to
maintain agreed safety
performance.
provides for continuing monitoring
and regular assessment of
the safety performance; and
aims at a continuous improvement
of the overall performance of the SMS.
88
Procedures
States safety programme
Develop the States safety programme around the

following four components:
1.
States safety policy and objectives
2.
States safety risk management
3.
States safety assurance
4.
States safety promotion
89
Procedures
Differences between State and Service Providers

Legal considerations States
Operators and service providers
Establishing acceptable level(s) of

safety does not replace legal,
regulatory, or other already
established requirements, but it
must support compliance with them.

safety for their safety programme
leaves unaffected the obligations of
States, and does not relieve States
from compliance with SARPs

safety for their safety management
system leaves unaffected the
obligations of operators or services
providers and other related parties,
and it does not relieve the operator,
services providers and other related
parties from compliance with SARPs
and/or national regulations, as
applicable.
90
Procedures
States safety programme + Service providers SMS =

Integrated safety system
Objective:
Public Safety
State Safety
Programme
Acceptance
Ov
ers
ig h
t
Oversight
Objective:
Objective:
Manage and
control
safety risks
Organisations
Production
Processes
Organisations Safety
Management
System (SMS)
Risk Management
Safety Assurance
Achieve
commercial
goals and
customer
saftisfaction
91
Safety Policy
Safety Policy - A statement of the organisations fundamental
approach to achieve acceptable or tolerable safety.
A written document that describes the generic principles upon which the
SMS is build and operated upon.
A typical safety policy document would consist of a policy statement that is
further expanded by a number of basic safety management principles to be
followed:
commitment to safety,
safety priority,
safety responsibility,
planning for safety,
safety management,
safety standards,
safety achievement,
safety assurance and
safety promotion
92
Risk Management
Risk management - The identification, analysis and
elimination (and/or mitigation to an acceptable or tolerable level) of those

hazards, as well as the subsequent risks, that threaten the viability of an
organisation.
Risk Management consists of the following three elements:

Hazard identification
Risk assessment
Risk mitigation
93

Risk Management at glance:
Equipment, Procedures, Organisation, etc
Risk Analysis
Probability
Analyse the likelihood of the consequence

occurring
Risk Analysis
Severity
Evaluate the seriousness of the consequence

if it occurred
Risk Assessment and

Tolerability
Risk
Control/Mitigation
Is the risk assessed acceptable and within

the organisational safety performance criteria
Yes, Accept the risk

No, take action in order to reduce the risk to
an acceptable level
94
Safety Assurance
Safety assurance
all planned and systematic actions necessary to

afford adequate confidence that a product, a service, an organisation or a
functional system achieves acceptable or tolerable safety
The objectives of Safety Assurance is to implement dedicated surveillance and

documenting procedures and processes in order to ensure that risk are
being properly managed.
According to ICAO State Letter SA include the following activities:
Management of change
95
Safety Assurance
Safety Assurance components:
Safety Surveys
Safety Monitoring
Safety Records
Regulators should continuously evaluate the implemented safety
management arrangements and processes by aviation service
providers by means of external regulatory safety auditing and other
safety oversight methodologies.
96
Safety Promotion
Just culture
Key Performance Indicators
Processes
97
Thank You for you

attention today
Any Questions?
See You tomorrow
98
Agenda for today:
09.00 10.30
Managing Safety
10.30 11.00
Break
11.00 12.30
WS on Safety Culture
12.30 14.00
Lunch
14.00 15.00
The Safety Components
15.00 15.30
Break
15.30 16.30
Joint session/discussions
16.30 17.00
Wrap up
Evaluation
Hand over of Diploma
99
Managing Safety
Safety Responsibility and accountability

Safety responsibility: the obligation to carry forward an assigned
safety related task to its successful conclusion. With responsibility
goes authority to direct and take the necessary action to ensure
success.
Safety accountability: the obligation to demonstrate the task
achievement and take responsibility for the safety performance in
accordance with agreed expectations. Accountability is the
obligation to answer for an action.
Clear and correctly allocated safety accountabilities and responsibilities
are prerequisite for achieving the organisations safety objectives
and for implementing an effective safety management and safety
improvement process
100
Safety Manager (SM)

An individual, responsible for the development, operation and
continuous improvement of the safety management system deployed
by an operator/service provider.
He acts as a focal point for safety management issues in the
organisation.
The approach to the assignment of Safety managers responsibilities
may differ depending on the type, size of the organisation, its
mission, complexity of operations and operating environment.
101
Safety Managers
Responsibilities
The appointment of the Safety manager (SM) is an essential step in the establishment of
the SMS organisational structure and a prerequisite for an efficient safety planning
process. Irrespectively of any other duties that may be allocated to them, safety
managers have the responsibility to:
Promote safety awareness within the organisation;

Ensure that safety management has the same or higher priority level throughout
organisation as any other management and operational processes;
Manage all aspects of the organisations SMS, including:
Monitoring the effectiveness of SMS;
Initiating corrective actions when necessary;
Providing safety reports on SMS performance on periodic basis;
Providing safety advice to top management and proposing corrective actions on
safety related-issues as needed;
Ensuring that safety-related documentation and records are available and up-todate.
102
Safety Levels and Targets

The term "acceptable risk" describes an event with a probability of occurrence
and consequences acceptable to the society, i.e. the society is willing to take or
be subjected to the risk that the event might bring.
It is the role of the safety regulatory authorities to translate the society
expectations and perceptions into a qualitative or quantitative target level of
safety.
Definition:
The acceptable level of safety expresses the safety goals of an oversight
authority, an operator, or a services provider.
From the perspective of the relationship between oversight authorities and
operators/services providers, it provides the minimum safety objective(s)
acceptable to the oversight authority to be achieved by the operators/services
providers while conducting their core business functions.
103
Safety Performance Targets

Safety performance targets define the required level of safety performance of a
system. A safety performance target comprises one or more safety
performance indicators, together with desired outcomes expressed in terms of
those indicators.
Safety Targets can be presented in either:
Absolute (i.e. less than 1 fatal accident per 1 000 000 operating hours)
Relative Terms
104
Safety Indicators
Definition on Safety Performance Indicators: A measure (or metric) used to

express the level of safety performance achieved in a system.
Enable the organisation to measure and demonstrate the achievement of

the set target levels.
Safety indicators differ among the various sectors of the aviation industry
such as;
air navigation services provision,
airline operations and
aerodrome operations
105
Safety Levels
The relationship between acceptable level of safety, safety
performance targets and safety performance indicators, and
safety requirements is as follows:
acceptable level of safety is the overarching concept;
safety performance targets are the quantified objectives
pertinent to the acceptable level of safety;
safety performance indicators are the measures/metrics used to
determine if the acceptable level of safety has been achieved
106
Key Performance Indicators
Easy judgments
Confirmed values
Committed results
107
Promotion and Awareness
Newsletters internal
Posters
Videos
Intranet
Presentations???
108
Safety Culture
A construct
An outcome, not a process
The introduction of safety management concepts lays the
foundation upon which to build a safety culture
Safety culture cannot be mandated or designed, it
evolves.
It is generated top-down
109
Safety Culture
How to create a Safety Culture?

Depends on where you are starting from - you dont get to the
end in one step, unfortunately, all the steps have to be traversed
Becoming a Safety Culture involves acquiring and then
maintaining a set of skills
The two major factors are information and trust, so these have
to be developed
Be systematic (SMS are a start) and then learn to operate with
the unknown as well
Have the program run right from the top
Appoint a senior champion who is dedicated and willing to stick it
out, even when it gets hard
The champion reports direct to the board
Recognise that it will be uncomfortable, safety cultures are
different, not just an add-on
110
Safety Culture
A Way Forward developing a Safety Culture:
Agree on ways to analyse incidents to reveal individual and system issues

Develop reporting systems that are easy to use (compact, open-ended,
impersonal)
Encourage the workforce (air and ground) to realise that all incidents are worth
reporting
Experiment with changes when new information comes in, dont be afraid to
admit failure first time round
Practice management in wanting to know from near misses before they become
accidents
111
Source: David Marx
Positive culture
Informed culture
People are knowledgeable about the human,
technical, organizational and environmental factors
that determine the safety of the system as a whole.
Reporting culture
People are prepared to
report their errors and
experiences
Positive
culture
Just culture
People are encouraged (even rewarded) for providing
essential safety-related information. However, there is a clear
line that differentiates between acceptable and unacceptable
behaviour.
Flexible culture
People can adapt
organizational processes when
facing high temporary
operations or certain kinds of
danger, shifting from the
conventional hierarchical
mode to a flatter mode.
Learning culture
People have the willingness
and the competence to draw
conclusions from safety
information systems and the
will to implement major
reforms.
112
Just Culture
Get rid of the idea that blame is a useful concept (this is hard to do)
Define clear lines between the acceptable and the unacceptable
Have those involved draw up the guidelines, do not impose from above if
you want them to be accepted
Have clear procedures about what to do with other forms of noncompliance
113
Just Culture
Confidentiality
People are reluctant to draw attention to errors made by themselves or their

colleagues, due to personal embarrassment. They must be confident that their
identity, or the identity of any person implicated in the report will not be
disclosed without their permission or unless this is required by law. An
assurance should also be given that any subsequent safety action taken will, as
far as possible, ensure the anonymity of the persons involved.
Punitive Action
A person who breaks the law or breaches a regulation or company procedure

through a deliberate act or gross negligence cannot expect immunity from
prosecution. However, if the offence was unpremeditated and unintentional, and
would not have come to light except for the report, he/she should be protected
from punishment or prosecution.
Loss of Licence
The circumstances of a report may indicate that the performance of an

individual is below the acceptable level. This may indicate the need for further
training, or even cancellation of an individual's licence. Such action must never
be punitive.
114
Workshop
Safety Culture
Just Culture
Promotion
Safety Awareness
115
The Safety Components

Organizational cultural transformation is not for the faint of heart. In fact, many
attempts at transforming an organization fail, for a variety of reasons:
"Playing at it" or "dabbling" with it until it's no longer fun

Not applying the kind of leadership that would best meet the needs of the
situation
Intervening in the wrong places or at the wrong time
Not taking this work seriously enough
Not giving it enough time or attention
Senior leaders "delegating" this work (rather than committing and investing
their own time and energies)
Knowing what needs to be done but being unwilling to do it...to go all the way
Not having the people and tools available internally to get the job done
Inability to engage all the right people in the process
Underestimating how big an undertaking this really is
116
Monitoring
Continuous
Documented
Committed
117
Awareness
Training
Pamphlets
News letters
Seminars
118
Reporting
Safety Records
The documents collected by ATM providers to demonstrate to
all stakeholders that the operations have been and continue
to be undertaken in a safe manner.
Safety Records are all documents developed under the
umbrella of Quality and Safety Management System.
119
Examples of Safety Records

Safety Assessment Report Safety Assessments
Incident Report
Accidents
Training Records
Safety Performance Monitoring
Records
Safety Occurrence Report
Safety Survey Report
Other Examples??
Safety Monitoring
SAFETY
RECORDS
Training
Policies, Strategies,
Procedures
120
Manual
Basic Safety Concept

Introduction to Safety Management
Hazards
Safety Risks
ICAO Safety Management
requirements
Introduction to Safety Management
System (SMS)
SMS Planning
SMS Operation
Phased approach to SMS
implementation
State Safety Programme (SSP)
121
Joint Session / Discussion
122
Wrap - up
Today were following topics covered and
discussed:
ICAO Safety Management System

SES Regulations
The Safety System
123
Any Questions?
See You Tomorrow
124

Use of SMS can be generally interpreted as applying a quality management
approach to control safety risks. Similar to other management functions, safety
management requires planning, organising, communicating and providing direction.
The SMS development is built after the following structure:
1.
2.
3.
4.
Setting the Organisational Safety Policy

Safety Planning and Implementation of Safety Management Procedures
Risk and Quality Management methods
Safety Culture
125
Main SMS Components

In line with the guidance outlined in ICAO Doc 9859 - Safety Management Manual,
the SMS components may be assigned to the following broad domains:
Safety Planning
SMS Organisational Structure
Safety Achievement
Safety Assurance
Safety Promotion
A successful implementation and operation of an SMS is highly dependent on

organisational aspects such as individual and group attitudes, values, competencies and
patterns of behaviour which are frequently referred to as elements of the safety
culture.
A positive safety culture is characterised by a shared awareness of organisations
personnel of the importance of safety in their operational tasks.
126
Organisational foundation for

Safety Management
Organisational Processes
Workplace
Conditions
Active
Failures
Policy Making
Planning
Communication
Allocation of resources
Latent
Conditions
Defences
Supervision
Activities over which any organisation has a reasonable degree

of direct control
127

Safety Management
Deficiencies in
equipment design
Incomplete/incorrect standard
operating procedures
training deficiencies
Workplace
Conditions
Active
Failures
Inadequate hazard
identification and risk
management
Normalization of deviance
Latent
Conditions
Defences
Conditions present in the system before the accident, made

evident by triggering factors.
128

Safety Management
Workplace
Conditions
Latent
Conditions
Technology
Active
Failures
Defences
Training
Regulations
Resources to protect against risks that organisations involved in the

production activities generate and must control.
129

Safety Management
Workplace
Conditions
Workforce Stability
Qualifications and experience
Latent
Conditions
Morale
Active
Failures
Credibility
Ergonomics
Defences
Factors that directly influence the efficiency of people in

aviation workplaces
130

Safety Management
Workplace
Conditions
Latent
Conditions
Errors
Active
Failures
Violations
Defences
Actions or inaction of people (pilots, ATCOs, maintenance engineers,

Aerodrome staff, etc.) that have an immediate adverse effect
131

Safety Management
Improve
Identify
Workplace
Conditions
Monitor
Latent
Conditions
Contain
Reinforce
Active
Failures
Defences
Accident / Incident
132
SMS and QMS

SMS results in the design and implementation of organizational
processes and procedures to identify safety hazards and
control/mitigate safety risks in aviation operation.
QMS provides a structured approach to monitor that processes and
procedures to identify safety hazards and control/mitigate safety
risks in aviation operations function as intended and, when they do
not, to improve them.
133

ACAC SMS Training v01

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

ACAC SMS Training v01

Uploaded by

Copyright:

Available Formats

TRAINING IN SAFETY

ARAB CIVIL AVIATION CONFERENCE

ATM Safety Expert

ACAC, Safety Management Systems Training

ATM Safety Expert

ACAC, Safety Management Systems Training

Round the table

ACAC, Safety Management Systems Training

Agenda for today:

Registration and Welcome

ICAO presentation on Safety Management System

The Safety System

The Safety Management System

ACAC, Safety Management Systems Training

Hand-outs will be given in connection with the lesson;

Objectives of the workshop

ICAO - Safety Management System

ACAC, Safety Management Systems Training

ICAO - Safety Management System

ACAC, Safety Management Systems Training

ICAO - Safety Management System

The objective of a Safety Management System is to provide a

ACAC, Safety Management Systems Training

Safety Management System

ACAC, Safety Management Systems Training

Safety Management Manual

ACAC, Safety Management Systems Training

Safety Management Manual

ACAC, Safety Management Systems Training

Generic SMS Requirements

Air Traffic Service Providers (Annex 11)

Amendment to Annex 1, 6, 11, 13 and 14 are proposed in order to harmonise

ACAC, Safety Management Systems Training

SES Regulation - Objectives

ACAC, Safety Management Systems Training

The 1st SES legislative package

ACAC, Safety Management Systems Training

(EC) No 549/2004 - Framework

(EC) No 550/2004 Provision of Air

National Supervisory Authorities (NSA)

(EC) No 551/2004 Organisation

(EC) No 552/2004 Interoperability

The following topics summarise the Interoperability regulation:

The SES Implementation

Improved level of safety of air navigation services;

Improved decision-making and enhanced enforcement in ATM.

ACAC, Safety Management Systems Training

Regulations, Directive and

Regulations: Mandatory to the letter

ACAC, Safety Management Systems Training

The 1st SES legislative package

Based on the report findings, the Commission came forward with

The 2nd SES legislative package

ACAC, Safety Management Systems Training

(EC) No 2096/2005 Common Requirements

Technical and operational competence and capability

(EC) No 2096/2005 Common Requirements

ESARR3 - on the use of safety management systems by air traffic management

ACAC, Safety Management Systems Training

(EC) No 2096/2005 Common Requirements

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

ACAC, Safety Management Systems Training

Similarities and Differences between

EUROCONTROL Methodology (ESARR)