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Safety Management

Manual............

Version 0.1
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Revision Table

Version Date of effect Changes


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Index
Revision Table....................................................................................................................................... 2

Index........................................................................................................................................................ 3
List of abbreviations ............................................................................................................................ 5

Example: Safety policy statement ................................................................................................... 7

Safety Goals .......................................................................................................................................... 8

Organisation .......................................................................................................................................... 9

Organisational flow chart ............................................................................................................... 9

Function Descriptions ...................................................................................................................... 9

Chairman of the Board/Owner .................................................................................................. 9

Safety Manager ............................................................................................................................ 9

Instructor ..................................................................................................................................... 10

Members ...................................................................................................................................... 10

Safety Management Meetings ..................................................................................................... 10

Incident management and investigation ...................................................................................... 11

Incidents to be reported: ............................................................................................................. 11

Risk Management .............................................................................................................................. 12

Method 1 .......................................................................................................................................... 13

Method 2 .......................................................................................................................................... 13

Method 3 .......................................................................................................................................... 15

Safety Assurance ............................................................................................................................... 16

Mitigation Measures....................................................................................................................... 16

Annual Review ............................................................................................................................ 16

Achieving the goals ....................................................................................................................... 16

Safety Training ................................................................................................................................... 16

Chairman of the board, board of directors and owner .......................................................... 17

Safety Manager and other safety personnel ............................................................................ 17

Instructors and flying personnel ................................................................................................. 17

Members, students, etc. ............................................................................................................... 18

Safety Promotion ............................................................................................................................... 18

Goal ................................................................................................................................................... 18

Resources ........................................................................................................................................ 18

Appendices .......................................................................................................................................... 19

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Appendix Safety Policy Manual ....................................................................................................... 23

General ............................................................................................................................................. 23

Appendix Chapter 1 Safety Policy Statement .......................................................................... 23

Safety Policy Statement ................................................................................................................... 24

Appendix Chapter 2 Safety Goals............................................................................................... 25

Appendix Chapter 3 Organisation .............................................................................................. 25

The Safety Manager .................................................................................................................. 25

Appendix Chapter 4 Incident Management and Investigation ............................................. 26

Appendix Chapter 5 Risk Management ..................................................................................... 26

The use of the effect table ....................................................................................................... 26

Appendix Chapter 6 Safety Assurance ..................................................................................... 27

Appendix Chapter 7 Safety Training .......................................................................................... 27

Appendix Chapter 8 Safety Promotion ...................................................................................... 27

Appendix Findings Register ............................................................................................................. 29

Appendix Hazard Register ................................................................................................................ 30

Incident Register ................................................................................................................................ 32

Incident Register ................................................................................................................................ 32

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List of abbreviations

FR Findings Register

HRF Hazard Registration Form

HR Hazard Register

IR Incident Register

IRF Incident Registration Form

SM Safety Manager

SMM Safety Management Manual

SMS Safety Management System

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List of definitions

Hazard A condition or an object which can cause injury,


damage to material and objects, the destruction of
material and objects or the reduction of the usability
of material and objects.

Mitigation measures Measures taken to limit the risk of the consequences


of an identified hazard.

Risk management The identification of hazards, the quantification of


risks and the establishing of mitigation measures the
goal of which is to bring the risk back down to the
lowest possible, acceptable level.

Safety policy statement Document setting out the organisation's safety policy.
This statement is known to everyone who belongs to
this organisation and has been signed by the
chairman/owner/CEO.

Safety management system A systematic, proactive approach to managing safety,


including the necessary organisational structures,
responsibilities, procedures and policy

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Example: Safety policy statement

.......strives to ensure that our aviation activities operate as safely as possible. This
means flying with airworthy aircraft (helicopters, micro light aeroplanes, balloons, etc.),
operated by competent airmen after good flight preparation. Furthermore, we will comply
with all regulations applicable to us and to limit the risks inherent in flying as much as
possible. Our goal is therefore:
No accidents,

and that is why we encourage


increasing knowledge of safe aviation among our customers, members and staff,
an environment in which safety has top priority and is second nature.

We are deploying all necessary resources to achieve this. This includes the introduction
and application of a safety management system. This entails that we are systematically
and continually improving ourselves in the area of safety. Toward this end we have
appointed a Safety Manager who will implement and maintain the Safety Management
System.
An important part of a safety management system is having the right culture within our
organisation. We create a culture whereby learning from incidents is key and the honest
acknowledgement of mistakes is seen as a chance to learn and as an opportunity to
increase the safety or our aviation activities. When researching incidents it is therefore
the identification of the cause of the incident which is the focal point and not the
individual. This allows us to do something about that cause and prevent the same
incident from happening again. The issue of guilt is therefore not relevant, unless there
has been negligent and reckless behaviour.

We will take action against the wilful contravention of (Dutch) legislation and regulations
and against our own rules. We will not tolerate this unacceptable behaviour.

In order to learn from incidents it is necessary that you report your incidents to us. We
would also like to ask you to report identified hazards to us. This is in our joint interest.
We therefore request your explicit cooperation! We guarantee the anonymity of the
person making the report.
We publish the results of the investigations of incidents and identified hazards, plus the
measures which we take in connection with this (on the notice board, in our club
magazine, on our website, etc. ) for your perusal. Naturally we also publish the measures
taken in connection with identified hazards.
A safe environment is created by all of us together!

Thank you for your cooperation,

The Board of Directors,

Signature
Mr P. Pilot,
Chairman

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Safety Goals

As already mentioned in the safety policy statement, our goals are:

- No accidents,

- Increasing the knowledge on safe operations on the part of our customers, members
and personnel and

- Encouraging an environment whereby safety has top priority and is second nature.

In order to achieve this we are introducing a Safety Management System whereby we


systematically work to achieve the above goals and improve safety.

As these goals have a high abstraction level, we have defined practical indicators and set
objectives. These objectives must be achieved within the specified time limit.

Indicators Objective

SMS introduction Safety personnel designated and tasks divided before month
2

SMS introduction Safety policy statement adjusted and distributed before


month 2

SMS introduction Incident management and study implemented before month


4

SMS introduction SMS manual adjusted before month 6

SMS introduction First safety management meeting held before month 6

SMS introduction Everyone trained in SMS application before month 12

SMS introduction First Safety Assurance audit executed and dealt with before
month 12

SMS introduction First risk management session executed and dealt with
before month 12

Incident management All incidents investigated within 1 month after receipt

Incident management All results of incident investigation published within 3 months


after receipt

Risk management All approved mitigation measures have been introduced


within the stipulated term

Incidents A 10 % reduction in incidents in the three most commonly


used incident categories before month 24

Hazards A considerable reduction of the risk level of the top 3 risks


before month 24

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Organisation

Following is a description of the organisation and the functions of the people who have a
role in the SMS

Organisational flow chart

Example:
Chairman

BoardofDirectors

Safety Manager

Instructors

Function Descriptions

Chairman of the Board/Owner


Is also the chairman of the three-monthly SMS meeting

Responsible for the safety of the operation

Responsible for making airworthy aircraft available

Responsible for making sufficient manpower and other resources available to bring
about an effective SMS

Responsible for limiting the risks inherent in flying

Responsible for steering the Safety Manager

Responsible for promoting the correct safety culture within the organisation

Safety Manager
Is also the Secretary of the three-monthly SMS meeting
Responsible for realising the SMS

Responsible for steering the SMS and the various components

Responsible for carrying out or instructing the carrying out of an incident


investigation

Responsible for the drawing up of mitigation measures in connection with incident


findings or risk identification

Responsible for maintaining the SMS documentation

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Responsible for the agenda and the minutes of the SMS meeting

Responsible for bringing noted risks to the attention of the chairman of the
board/owner

Responsible for giving safety advice to the board/owner

Responsible for promoting the correct safety culture within the organisation

Responsible for the communication with the organisation with regard to safety
matters

Instructor
Is also a member of the three-monthly SMS meeting
Responsible for promoting the correct safety culture within the organisation and
airmanship of the members

Responsible for the introduction of the SMS to (new) members, customers


whereby the emphasis lies on drawing attention to the obligation toward the
organisation to report incidents

Members
We expect of our members that they take note of the safety notices on the notice board
(club magazine) and that they report unsafe incidents by means of the IRF and report
hazards by means of the HRF. See also 'incident reporting and investigation' and risk
management method 3 further on in this chapter. We furthermore expect that they
comply with the legislation and regulations which apply at that time and with the
additional rules as laid down.

Safety Management Meetings


It is compulsory for the members of the meeting to attend SMS meetings. If a member
cannot attend, he/she must give the Secretary notice in due time. The meeting will take
place at least every three months. The Secretary will send the agenda of the meeting to
participants together with the minutes of the preceding meeting in due time.

The minutes of the meeting contain:


An attendance list

The topics which were discussed

Old action points which could be closed

Action points which will be taken along to the next meeting and the latest state of
affairs

New action points and the owner of the action to be taken

The agenda and the minutes will be kept for 5 years.

The agenda is comprised of at least:

Those present are asked whether they agree with the minutes of the last meeting

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The hazards which have been identified and any mitigation measures which have
been proposed

Discussion of the incidents which have taken place and the status of the
investigation

The findings in connection with the investigation

A proposal of the mitigation measures in connection with the findings which are
intended to prevent a repetition of the incident or reduce the seriousness of the
outcome of an incident

Noted negative trends and possible mitigation measures

Findings in connection with Safety Assurance sessions and possible mitigation


measures

Who participates and what is his function:

The chairman or owner of the club or school Chairman of the meeting

The SM - Secretary

Representatives of operational staff/members

Incident management and investigation

Members and customers are encouraged to report incidents. The relevant form can be
found in the appendix. The list of incidents to be reported can be found there. Should
there be incidents which are not on this list but which threaten/may affect the safety of
the activities, we ask that you report them nevertheless.

Incidents to be reported:

Bird/wildlife strike

Loss of control of the aircraft

AIRPROX

Airspace violation

In-flight technical malfunctions

In-flight incapacitation of pilot

Incidents connected with I am safe" situations

Problems during the flight execution which affect flight safety

Emergency landings and precautionary landings

Runway/taxiway incursions and excursions

Fire or smoke on board of the aircraft

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Faulty/incorrect loading (outside of envelope)

Distress calls (both PAN and Mayday calls)

Damage to aircraft and/or damage to others due to contact with aircraft

Lost

Injuries (self/third parties)

Incorrect documentation, procedures etc.

Problems with oil or fuel

Problems relating to the condition of the airfield

Incidents not mentioned here but which nevertheless have an impact on safety

All fields to be filled in on the incident registration form (IRF) which apply, are
compulsory. However, the filling in of the name of the reporting party is not compulsory.
It is possible to report incidents anonymously. Should other details (aircraft registration,
route, etc.) on the IRF lead to identification of the reporting party, these details may be
left out. Customers and members must be aware that filling in all details can
considerably help the investigation and improve the investigation outcome as the SM can
ask the reporting party for further details.

The members or customers can put completed forms in the sealed post box intended for
this purpose. The SM will empty this post box on a regular basis. It is also possible to
send the electronically completed form by e-mail to the SM. The IRFs will then be entered
in the register and the form will be placed in a binder and stored for 5 years. The
investigation will be started after this. The investigation is geared to the causes of the
incident and the underlying hazards. The role of the organisation, the procedures,
environmental factors and the individual will be included. The issue here is not
determining guilt, but identifying the underlying hazards. On the basis of the
investigation the SM will determine the findings. These are objective and ensue from the
investigation. The investigation report will be drawn up by the SM.

On the basis of the report the SM will establish the mitigation measures. There can be
one or more mitigation measures for every finding and every identified hazard. The SM
will present the mitigation measures to the SMS meeting for approval or will immediately
introduce them when they are urgently necessary, with the consent of the chairman or
owner. When the mitigation measures have been approved they can be introduced. The
chapter 'Safety Assurance ' sets out how the effectiveness of the mitigation measures is
reviewed. This will be done immediately after the introduction and thereafter with every
Safety Audit.

Risk Management

The organisation has several methods for identifying risks.

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Method 1
This method has been previously discussed under Incident Management and
Investigation.
If an individual is involved in an incident, he/she must complete an IRF. During the
investigation the SM will primarily concentrate on the question what the underlying
hazard of this incident was. In order to limit the risk of this hazard from resulting in an
incident again, the mitigation measures in connection with this incident will concentrate
on reducing the risk that this will happen again and/or on reducing the effect of the
hazard.

Method 2
The second method entails that a number of operational experts identify the hazards on
the basis of their experience. Toward this end, on the initiative of the SM, every year
before the start of the annual flying season the organisation will hold a meeting with a
number (approx. 4) of the most experienced members and/or instructors (experts).
During this meeting the top 3 hazards will be identified during a brainstorming session.
This will take place as follows:
1. The experts will each write down their individual top 3 possible hazards

2. They will, again each individually, set out the most serious, and most likely
consequences of these hazards, in detail

3. All hazards with consequences will be gathered and corresponding hazards will be
combined

4. The experts will then decide together whether the consequences which have been
written down are indeed the most serious, likely consequences and they will then
study all possible consequences

5. It will then be reviewed for each consequence how big the chance of this event is
and how big the effect is. This is again done by each of the experts separately.
Questions which can be used to determine the effect: How many deaths could
there be, taking account of personnel, passengers, bystanders, etc.? What will the
financial impact be? Could there be damage to the environment? Will there be a
big political impact or negative media attention?

6. The following tables will be used in this respect:

Occurrence Meaning Value


Frequent Several times per season certainty 5
Occasional A couple of times per season/ likely 4

Remote One time per season or per two seasons/ possible 3


Improbable Not known to have happened earlier, one time in five 2
years/ slight
Extremely Almost inconceivable that it will ever occur / unlikely 1
Improbable
Severity of Meaning Value
Occurrence
Catastrophic Material destroyed, fatality/fatalities A
Hazardous Safety margins have been seriously affected, serious B
injuries, substantial damage to material
Major Safety margins have been affected, serious incidents, C

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injuries, damage to material


Minor Emergency procedures are used, aircraft limits have been D
exceeded, incident, causes minor inconveniences in the
programme
Negligible Few consequences E

7. The values of the consequences under 'Occurrence' and 'Severity of Occurrence'


are multiplied and the outcome (the risk) will be reviewed as to whether they
correspond. Through a discussion between the experts it will be reviewed whether
agreement can be reached on the various risk numbers. If this agreement is
reached the following table will be used:

Risk Risk severity


probability
Catastrophic Hazardous Major Minor Negligible
A B C D E
Frequent 5A 5B 5C 5D 5E
Occasional 4A 4B 4C 4D 4E
Remote 3A 3B 3C 3D 3E
Improbable 2A 2B 2C 2D 2E
Extremely 1A 1B 1C 1D 1E
Improbable

8. The outcome of the above table will be used as input for the following table and it
will be reviewed whether measures are necessary to limit the risk:

Outcome of the Criteria


multiplication
5A, 5B, 5C, 4A, 4B, 3A Intolerable risk under the
current circumstances,
mitigation measures are
necessary to lower the
risk
2A, 2B, 2C, 3B, 3C, 3D, Tolerable risk, the board
4C, 4D, 4E, 5D, 5E can demand that (extra)
mitigation measures may
still be necessary. Risk
will be monitored for risk
growth
1A, 1B, 1C, 1D, 1E, 2D, Acceptable risk. Risk will
2E, 3E be monitored for risk
growth

9. All hazards with their consequences and risks are then entered in the hazard risk,
see appendix. The hazards with the highest risk total are at the top.

10. Mitigation measures will now be conceived for the top three hazards with the
highest totals.

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Method 3
During the daily operation it is possible that club members note hazardous situations.
These hazardous situations need not have caused an incident yet. These hazardous
situations will be reported to the SM by means of the hazard registration form (HRF). The
hazards are evaluated by the Safety Manager. He will establish whether the reported
hazards have been properly worded and will adjust this if necessary, he will then go
through steps 2 through 9 for this reported hazard. When this is ready, it will be
discussed in the Safety Management Meeting. It will be reviewed here whether all
members agree with the risk level and the mitigation measures. It will also be discussed
what the sequence of introduction will be for the mitigation measures and the time line
for the introduction

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Safety Assurance

Mitigation Measures

Safety Assurance will answer the question whether the implemented mitigation measures
work. These are the measures which are taken in connection with an incident or in
connection with a hazard identification session. The question which must be answered in
this respect is whether these measures have reduced the previously established risk
level.

This question will first be asked, and answered, shortly after introduction of the measure.
Thereafter this question will be asked on an annually recurring basis by the SM. During
these safety assurance sessions it will be reviewed whether the mitigation measure
works. This can be done in various ways and fully depends on the nature of the
mitigation measure. For example, the SM can hold interviews, study (learning) material,
review the operation, etc.

With major changes the measures will be reviewed again by the SM to review whether
the changes have an influence on the measures (and concomitantly on the risk level of
the previously identified hazards) and what influence this is.

Annual Review

All previously introduced measures will be reviewed in this respect. The questions which
will be answered, are:
- Do the measures work the way they are supposed to?

- Do they still have the intended effect on the hazard?

- Is the risk that these measures limit still at the same level?

- Have the measures ended up introducing new hazards?

If these questions cannot be answered with Yes, a finding will be entered.

The SM will offer this finding to the board/the owner, who will resolve it within a pre-
discussed and fixed time period by means of establishing mitigation measures which will
also be recorded in the findings register. The SM monitors the stipulated timeline for
closing the finding (This is including the introduction of the mitigation measures).

Achieving the goals

The second way in which Safety Assurance is applied lies in the continual monitoring of
the achieving of the goals which the organisation has set for itself. The SM monitors
whether the goals which have been set are achieved. Should this not be the case, or
should this threaten to occur, the SM will intervene via the board or owner and a finding
will be entered in the findings register by the SM. After that mitigation measures will be
introduced, in conjunction with the person responsible for achieving the goal, to ensure
that the goal is in fact achieved. These mitigation measures are then noted in the
findings register along with the finding.

Safety Training

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Before people become active within the organisation they must first follow safety
training. What safety training they follow depends on their function within the
organisation. In addition, a record will be kept of who has received training and what
training each person has received.

Everyone has responsibilities within the SMS but the type of training differs per group.

The various groups can be distinguished as follows:

- Chairman of the board, board of directors and owner

- Safety Manager and other safety personnel

- Instructors and flying personnel

- Members, students, etc.

Chairman of the board, board of directors and owner

They will receive a briefing on the following topics:


The SMS framework

The various components of the organisation's SMS

The organisation's Safety Policy Manual

Their share and responsibilities within the SMS, the Safety Management Meeting
and the safety culture of the organisation

The SM gives this briefing at the beginning of the annual flying season.

Safety Manager and other safety personnel

They receive training in the following topics:


The SMS framework

The various components of an SMS

The Safety Policy Manual

The role of the Safety Manager

Risk Management

Hazard identification

Incident investigation

Safety culture

(An external course will be followed to gather the necessary knowledge.)

Instructors and flying personnel

They receive training in the following topics:


The SMS framework

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The various components of the organisation's SMS


The Safety Policy Manual of the organisation
Risk management
Hazard identification
Safety culture

The SM will give this training course at the beginning of the annual flying season.

Members, students, etc.

They will receive a briefing on


The SMS framework
The various components of the organisation's SMS
The organisation's Safety Policy Manual
Hazard identification
Safety culture
Incidents and hazards to be reported and the forms to be used

This briefing will be given at the beginning of the annual flying season by the instructors
or other flying (professional) personnel for existing members. New members are given
this briefing when they become a member and before they fly.

Safety Promotion

Goal

The goal of safety promotion is:


- to ensure that everyone is aware of the SMS
Safety training is only one aspect of this. All changes in the structure of the SMS
and important decisions which are made in the safety management meetings will
be communicated to members, students and instructors.
- to ensure that everyone is aware of information which is of influence on safety
- to ensure that everyone knows why certain measures have been taken
If people know that measures are taken due to their reporting, they are more
likely to report incidents.
- to ensure that everyone knows why certain safety procedures have been
introduced or have been changed.
When people know the reason for certain safety procedures they will be more
likely to comply with these measures.
- the transfer of interesting safety information

This ensures that people are aware of safety information which they might not have
found on their own. This results in an increase in safety awareness within the
organisation.

Resources

The organisation uses the safety page of the website/the safety notice board in the
common room for publishing safety information. The organisation distinguishes two types
of safety information: critical safety information which must be known before the next
flight or as soon as possible and information whereby the time factor is less critical.

Members and customers are expected to check the notice board or website before every
flight/flying day!

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Critical safety information which must be known before the next flight or as soon as
possible will be printed on red paper and will be hung up on the safety notice board for
one month. After this month the information will be placed in the red binder. It is
compulsory for anyone who has been away for longer than three weeks to go through
this binder before the flight in order to become familiar with new critical safety
information. Critical safety information which is no longer relevant will be removed from
the binder by the SM. In the front of the binder is a list with all topics of the critical
safety information so that it is clear whether the binder is complete.

Information whereby the time factor is less critical can also be found on the safety notice
board. Examples of safety information whereby the time factor is less critical are:

- Results of incident investigation, mitigation measures, lessons learned

- Results of hazard reports, mitigation measures

- Results of hazard identification sessions

- Changes in (Safety) procedures (not time-critical)

- Safety policy statement

- Safety goals

- Interesting articles from newspapers and magazines

- Interesting safety developments at other airfields

Appendices

- Incident registration form

- Hazard registration form

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Appendices

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Appendix Safety Policy Manual

General

Although a Safety Management System (SMS) is not required for small, non-commercial
aviation, the Dutch Transport and Water Management Inspectorate (IVW) believes the
introduction of an SMS to in fact be a valuable step for this diverse group toward
improving safety. Toward this end the IVW has created the SMS Light. The
implementation of SMS Light is on an entirely voluntary basis.
The Safety Policy Manual is an important pillar of the SMS Light. This describes all
components of the SMS Light as well as the processes which form part of the SMS Light
and the function descriptions of the relevant persons. This gives all members, customers
and personnel access to this information.
It is the intention that where (..) appears in the manual, the organisation's own name
will be entered. Where it says school/club the term which does not apply must be
crossed out.
In addition, the manual is written on the basis of ICAO document 9859 Safety
Management Manual and addresses all components of an SMS. Furthermore, the Safety
Policy Manual takes account of EASA CRD 2008-22C, the Requirements for small
organizations.
The SMS Light deviates from the EASA CRD in the following areas:

- The manual does not contain an Emergency Response Plan. There is already a
Emergency Checklist for light aviation. The related AIC-Bs are attached and
serve as a further guideline for the development of an individual emergency
response plan or checklist. The link:
http://www.civ.zweefportaal.nl/docs/checklist_calamiteiten_civ_vs_1_aug06.pdf
- EASA CRD 22C does not provide a Safety Manager description for small
organisations. Nevertheless, in line with ICAO, a choice has been made to
designate someone who is specifically engaged in the facilitation of the SMS Light.
- EASA CRD 22C does not describe a safety management meeting for small
organisations. IVW, in line with ICAO, has opted to describe this process to
promote the systematic consultation on safety matters.
- EASA CRD 22C does not describe any Management of change for small
organisations. This has therefore not been incorporated in this system..
- EASA CRD 22C classifies the quality control system (Compliance Monitoring)
under the Safety Management System. The SMS Light has only been developed
for managing safety and not quality. Many organisations already have a properly
working quality control system. However, Safety Assurance is described in
accordance with ICAO and forms part of the SMS. Safety Assurance does not form
part of CRD 22C for small organisations.
- Hazards ensuing from the outsourcing of work to third parties, e.g. maintenance,
will not be discussed separately but are a factor which have to be included when
going through the risk management for the entire organisation.

Appendix Chapter 1 Safety Policy Statement

The Safety Policy Statement

The board of directors or the owner will set out the safety policy. The safety policy
statement presents this policy to the customers, the members and the personnel. The
complete safety policy will be described in the Safety Policy Manual.

The enclosed document provides a blueprint for the safety policy statement.

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In any event, items can be added to this document which specifically relate to your club
or company. For example, the operation of the winch could be added to the document at
a gliding club and at a ballooning club, the safety of bystanders when the balloon goes
up. However, these additions may not affect the statements of the blueprint.

The safety policy statement will be communicated to everyone in the organisation


(members, customers, guests and personnel). This is possible by, e.g., displaying the
document in a common area. The statement has also been included in the Safety
Management Manual.

In addition the safety policy statement must be reviewed every two years so that the
information remains valid and up-to-date.

Example:

Safety Policy Statement

.......strives to ensure that our aviation activities operate as safely as possible. This
means flying with airworthy aircraft (helicopters, micro light aeroplanes, balloons, etc),
operated by competent airmen after good flight preparation. Furthermore, we will comply
with all regulations applicable to us and limit the risks inherent in flying as much as
possible. Our goal is therefore:
No accidents,

and that is why we encourage


increasing knowledge about safe flight execution among our customers, members
and employees,
an environment whereby safety is top priority and second nature.

We are deploying all necessary resources to achieve this. This includes the introduction
and application of a safety management system. This entails that we are systematically
and continually improving ourselves in the area of safety. Toward this end we have
appointed a Safety Manager who implements and maintains the Safety Management
System.
An important part of a safety management system is having the right culture within our
organisation. We create a culture whereby learning from incidents is key and the honest
acknowledgement of mistakes is seen as a chance to learn and as an opportunity to
increase the safety or our aviation activities. When researching incidents it is therefore
the identification of the cause of the incident which is the focal point and not the
individual. This allows us to do something about that cause and prevent the same
incident from happening again. The issue of guilt is therefore not relevant, unless there
has been negligent and reckless behaviour

We will take action against the wilful contravention of (Dutch) legislation and regulations
and against our own rules. We will not tolerate this unacceptable behaviour.

In order to learn from incidents it is necessary that you report your incidents to us. We
would also like to ask you to report identified hazards to us. This is in our joint interest.
We therefore request your explicit cooperation! We guarantee the anonymity of the
person making the report.
We publish the results of the studies into incidents and identified hazards, plus the
measures which we take in connection with this (on the notice board, in our club
magazine, on our website, etc. ) for your perusal. Naturally we also publish the measures
taken in connection with identified hazards.
A safe environment is created by all of us together!

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Thank you for your cooperation,

The Board of Directors,

Signature
Mr P. Pilot,
Chairman

Appendix Chapter 2 Safety Goals

The safety indicators and goals which are mentioned here are possible indicators and
goals and can be adjusted to the organisation. This can mean, e.g., other time limits but
it is also possible to divide the specified indicators into various lower level indicators or
indicators in another area.
When defining indicators always bear in mind that indicators have to be SMART, i.e.
Specific, Measurable, Acceptable, Reasonable, Timely.
In addition, the goals will have to have the approval of the individual responsible for
achieving the goals. He or she must stand behind the indicator and the time span.

The goals and indicators will change as the SMS Light develops further and will
consequently be continually adjusted to the latest state of affairs. This ensures that we
make continual improvements in the area of safety.
Furthermore, the indicators will always be comprised of, on the one part, indicators which
relate to the working of the SMS Light and on the other of indicators which relate to
topics/trends which we manage by means of the SMS Light.
In order to ensure that the goals which have been set are in fact achieved, it is necessary
to designate a person who is responsible for achieving the goal. This is not the Safety
Manager but can be someone of the board of directors or the owner. This person will
always make an interim report on the state of affairs in the Safety Management Meeting.
This will ensure that the tactics can be adjusted in the interim should this be necessary to
achieve the goal. The SM will monitor the process and monitor that the goals are
achieved. See Appendix Chapter 6 Safety Assurance

Appendix Chapter 3 Organisation

The presented organisational flow chart is an example. It is the intention that it is


adjusted to the individual organisation. If different types of boxes and lines are used in
the organisational flow chart, the meaning thereof must be explained.
It is also possible in this chapter to refer to another place where the function descriptions
and the organisation are laid down, as long as the safety tasks are adequately described.
The function descriptions in the manual contain the minimum tasks to be performed.
Naturally there is the option to add other safety tasks.
The safety management meetings which are discussed here set out the minimum
contents of these meetings. These meetings are primarily intended to facilitate the
decision making on safety matters. In small clubs/schools this can of course be realised
in a less formal manner. It is advised in this respect to keep notes on the decision
making, as this can serve as a reference in the future.

The Safety Manager


The Safety Manager is the person in the organisation who facilitates and is responsible
for the Safety Management System. In order to be able to do this effectively it is not only
important that this person can put in enough time on this function, but a number of
personal characteristics are also important.
The SM must preferably:

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have sufficient authority within the organisation


be approachable
have sufficient knowledge about the operations of the organisation
have affinity with Safety Management Systems

These characteristics are necessary to ensure that the SMS is properly rooted in the
organisation. In many organisations this will require a culture shift. This is only possible if
the SM has the support of the board of directors and the members. Furthermore, the SM
will have to have sufficient knowledge to execute the tasks related to the SMS. For
details see the chapter Safety Training in the SMM.

Appendix Chapter 4 Incident Management and Investigation

No further comments.

Appendix Chapter 5 Risk Management

Aviation has many hazards. Risk management provides a structured method for reducing
potential hazards to an acceptable, documented risk level. It is the intention that this risk
level is reduced to the lowest possible level, naturally account will be taken in this
respect of the costs of implementing a mitigation measure and the effect that this has on
the risk level. However, before we can manage the risk level, caused by a specific
hazard, to an acceptable level, we will first have to know the potential hazards. When
identifying hazards a number of difficulties may be encountered:
1. The level of the identified hazard is too low and a hazard at a higher level is
consequently overlooked.
2. The level of the identified hazard is too high and consequently the mitigation
measures are very difficult to implement. This can be overwhelming and
consequently nothing is done with the measures.
3. The hazard is defined as the lack of a measure.

Re 1 and 2: In connection with a brainstorming session, for example, the following


hazard is named: A hole in front of the hangar door. A mitigation measure could be to
repair this hole. Suppose Club x ensures that this happens. The next time there is
another hole or another small defect, it is reported, and soon the register will be
comprised of hundreds of hazards with as the result that one is always putting out little
fires and the work pressure for the SM becomes very high. If one had gone one level
higher and had classified the hazard as follows: The poor condition of the (own) site,
then one would have specified other (better) mitigation measures which probably would
have addressed other holes and perhaps bumps or poor drainage of the site, resulting in
better management of the field. This is thus the better option.
An example of an abstraction level which is too high is if the hazard had been the
condition of airfields. The abstraction level here is so high that it is not known which
measures should be defined and when this has been done, the task of applying the
measures can be overwhelming.

Re 3 An example: The hazard is the lack of a barrier to the airfield. This is thus
incorrect. The correct definition of the hazard is: The hazard that unauthorised persons
can simply walk onto the airfield. A barrier can be a mitigation measure.

The use of the effect table


A single component of the definition set out in the effect table provides an adequate
indication for the effect level.

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E.g. if the consequence of a known hazard entails the complete loss of the aircraft
without any fatalities or injuries, it is still a very big (A) effect.

Appendix Chapter 6 Safety Assurance

Safety Assurance answers the question whether the activities which are developed within
the SMS Light do in fact increase the safety of the operation. We distinguish two methods
in this respect. With the first method we check whether the mitigation measures we
introduced are working. With the second method we check whether the safety goals we
have set for ourselves are achieved. When we can answer both positively we can say that
our SMS Light is working.

Appendix Chapter 7 Safety Training

Safety training is necessary to ensure that everyone knows his or her responsibilities
within the SMS. This is furthermore an important method for promoting the right safety
culture.

Appendix Chapter 8 Safety Promotion

Safety promotion is an important method for sharing knowledge which has been
gathered inside and outside of the organisation.
This also promotes the right safety culture. Members/students will report incidents
and/or hazards earlier if they know that in connection with their report action will be
taken by the organisation.

There are several methods for promoting safety in an effective manner.


A distinction must be drawn between time-critical safety information which must be
known before the next flight or as soon as possible and information whereby the time
factor is less critical.
This difference must be immediately clear to the relevant parties of the club/school,
either through a difference in the communication channel, or through a clear difference in
lay-out.

The methods which can be used are:


- Safety promotion board or website for general safety information whereby the time
factor is less critical such as results of investigations, the transfer of interesting
information, etc.
- Safety promotion board or e-mail for critical information

When use is made of a safety promotion board or place in a briefing room or a room
where everyone comes before each flight, it is compulsory that before a flying day the
information on this board is checked.
Re safety board: All other information relating to the safety will be displayed on the
safety board, possibly with a different lay-out each time (e.g. paper colour) when a
different type of information is concerned. This lay-out will be described in this manual. A
safety magazine could also be created for this information, instead of making use of a
safety promotion board.

Instead of a safety promotion board use can also be made of e-mail. Aside from the
method for distributing the critical safety information which is used, use must always be
made of the above-described binder.

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If the club makes use of a website it can also be used for time-critical safety information.
The publication management is important in this respect; information which is not (or no
longer) relevant must be removed as soon as possible, or must be provided with a
validity date. The website can therefore be viewed in the club building or use can be
made of a binder.

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Appendix Findings Register

The Findings Register (FR) will be kept up to date by the SM and has been developed to
facilitate the management of findings and the ensuing mitigation measures.
The FR will be kept for 5 years.
This document contains the explanation on how the various columns are filled in.

Explanation on filling in the columns:

Column A: Sequential number: The sequential number is the internal number given to
the finding. The method of compiling this number is free-form. The finding is kept for 5
years.

Column B: Date of incident: Fill in the date of the incident, in accordance with the format
dd-mm-yyyy.

Column C: Finding: In this column describe the finding as completely as possible in 1 or


2 sentences. The finding will set out what mitigation measure is not (or no longer)
working or which goal is not being achieved. Only facts are mentioned here, not opinions.
Try to be as complete as possible.

Column D: Mitigation measure: Use a separate rule for each mitigation measure. Try to
be as thorough as possible.

Column E: Owner: This is the person who is going to introduce the mitigation measures
and who is responsible for the topic to which the finding applies. This is therefore not the
SM.

Column F: Earlier risk: The risk number in the hazard register that still assumes that the
mitigation measure has been applied successfully. This number will be taken over from
the hazard register.

Column G: Risk now?: What is the risk number now that it has turned out that the
measure has not been applied or has not had the desired effect?

Column H: Finding status: There are three options: Open, In progress and Closed. The
status Open is used when no action has yet been taken to address the finding. In
progress is used when work is being carried out on addressing the finding. Closed is
used when the finding has been addressed and mitigation measures have been
introduced.

Column I: Completion date: The latest date on which the mitigation measure must be
introduced and working. This date will be determined in advance. This usually involves a
period of between 1 to 3 months.

Column J: Realised completion date: The date on which the mitigation measure has been
introduced and it has been established that it works.

Column K: Risk after closing the finding?: This number can be the same number as in
column F but due to changing circumstances can also turn out lower or higher.

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Appendix Hazard Register

The Hazard Register (HR) will be kept up to date by the SM and has been developed to
facilitate the management of hazards and the ensuing mitigation measures.
The HR will be kept for 5 years.
This document will explain how to fill in the various columns.

Explanation on the columns to be filled in:

Column A: Sequential number: The sequential number is the internal number which is
allocated to the hazard. The method for compiling this number is free-form. The hazard
will be kept for 5 years.

Column B: Date of hazard: Enter the date of the identification of the hazard in
accordance with the format dd-mm-yyyy.

Column C: Hazard: In this column describe the hazard as completely as possible in 1


sentence. Only facts are mentioned here, not opinions. Try to be as thorough as possible.

Column D: Consequences: Describe the most serious, likely consequences, using a


separate line for each one. Try to be as thorough as possible.

Column E: Occurrence: Enter an occurrence number between 1 and 5 in accordance with


the SMM occurrence table.

Column F: Severity of Occurrence: Enter a severity number between 1 and 5 in


accordance with the occurrence table in the SMM.

Column G: Risk: This is column E times column F. The outcome is a number.

Column H: Outcome of the multiplication: This is the outcome of the multiplication


according to the table in the SMM. The choice is made between: Intolerable risk,
tolerable risk, acceptable risk on the basis of the outcome in column G.

Column I: Mitigation measures: The mitigation measures which are proposed to limit the
risk. Use a new line for each measure.

Column J: Each mitigation measure requires the approval of the safety management
meeting. This column is used to keep track of which measures have been approved and
which have not (yet) been approved. It is possible that measures which have not been
approved for introduction at this time will be approved at a later time.

Column K: Category of mitigation measures: A choice can be made in this respect


between the categories within which the mitigation measure falls. This can be
Technology, Training or Procedures, regulations. Technology not only includes the aircraft
but also, e.g., improving the condition of the runway.

Column L: Owner: This is the owner of the hazard, the person within whose operational
area the hazard falls. This is also the person who is going to introduce the measures. The
SM will later check whether this has been done properly. It is therefore not the intention
that the SM introduce these measures himself.

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Column M: Completion date: Date as of when the mitigation measure must have been
introduced by the owner. The SM will monitor this date.

Column N: Realised completion date: This is the date on which the mitigation measure
has in fact been introduced and the owner has reported this to the SM.

Column O: Closed: This is the date of the closing of the process. The process will only be
closed if the SM has checked that the mitigation measure really does work. If this is not
the case the process will not be closed.

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Incident Register

Incident Register

The Incident Register (IR) will be kept up to date by the SM and is intended to register all
incident reports and to make an analysis possible. Toward this end a system of
classification codes has been applied. A distinction is made between cause (3 columns)
and consequence (2 columns).
- Per incident several lines with classification codes can be entered. Bear this in
mind when a new incident is registered and there are empty lines.
- It can also occur that several reports are made in connection with one incident
because, e.g., several aircraft of your organisation are involved. The second or
following report will have the same sequential number as the first report with
addition of one letter: 10-2010, 10-2010A, 10-2010B, etc.
- Maintain the text of the report! This means that if something is not in the report,
it must not be classified. Example: When the report reports that there was a
serious injury during an emergency landing, this is INJ (injured) and SI (serious
injury). It is perhaps logical that an ambulance will have been called out to
transport the person but if the Safety Manager does not know this for certain
he/she may not assume this and enter it regardless!
Furthermore the incident register can annually be sent to the Royal Netherlands
Aeronautical Association (RNAA). This organisation will then draw up an analysis report
which makes use of the received incident registers.
The intention of the classification system is that all incidents can be classified with the
codes which have been made available.
It is very important for the uniformity between the various clubs and schools that no
personal classification codes are added. This would destroy the possibility of a joint
analysis. Should an extra code turn out to be necessary, contact IVW and in consultation
an extra code will be added. A new version of the incident register will then be made
available on the website www.ivw.nl .

Explanation on filling in the columns:

Column A: Sequential number: The sequential number is the internal number which is
allocated to the report. The compiling of this number is free-form. The number will then
be taken over on the original report and the original report will be kept for 5 years.

Column B: Date of incident: Enter the date of the incident in accordance with the format
dd-mm-yyyy.

Column C: Type of aircraft: Enter the type of aircraft in which the party reporting the
incident was flying at the time of the incident. A choice can be made from the following
list:

Aeroplane SE/ME
TMG
MLA
Unanchored balloon
Helicopter
Gyroplane
Hang glider
Glider

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Paraglider
Parasailer
Airship

Column D: Title of incident: The format of the title is free-form. The title briefly sets out
what has happened. It is furthermore recommended to describe similar incidents in the
same manner. This promotes clarity which will benefit subsequent analysis.

Column E: Time of the flight: A choice will be made from the following list:
Parked
Taxi
Take off
Climb
Cruise
Descent
Approach
Landing

Column F: Incident location: An airport or a geographical location indicator is used (e.g.


10 km west of Deventer). If it is not known where the incident occurred, do not fill in this
column.

Column G: Departure location: this is the departure airport, using the ICAO taxonomy if
available (e.g. EHGG)

Column H: Precautionary landing/Emergency landing: this column will only be filled in if


there is a de facto emergency landing or precautionary landing. This can be an airport or
a geographical location indicator

Column I: Arrival location: this is the airport of arrival, using the ICAO taxonomy if
available (e.g. EHGG)

Column J, K, L: Classification of the cause of the incident: the cause of the incident is
filled in here. Several causes can be selected per incident. See the following list:

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AIRPROX
Technical - Engine (ENG)
malfunction - Propeller/Rotor (PR)
(TEC) - Undercarriage (UC)
- Electrics (EL)
- Ailerons / Tail rotor
(AIL/TR)
- Radio (RA)
- Emergency parachute
(EP)
- Wing (WI)
- Screen (SC)
- Equipment (EQUIP)
- Frame (FR)
- Burner (BR)
- Balloon/envelope (BA)
- Instrumentation (IN)

Airmanship - Flight preparation - Load (lo)


(AMS) (FPrep) - Weather (we)
- Fuel calculation
(fc)
----------------------------- - Navigation (na)
- Flight execution - NOTAMS (no)
(FExe) - Pre-flight check
(ch)
-------------------------
- Navigation (na)
- Procedures (pr)
- Speed (spd)
Extreme weather - Lightening strike (LS)
(EXT) - Hail (HA)
- Wind gusts (WI)
- Icing conditions (IC)
Winch use (WIN) - Premature stop (PS)
- Cable rupture (CabRup)
- Cable off-course
(CabOC)
- Engine malfunction
(ENGMal)
Condition of - Birds/wildlife
airfield (BIRD/WILD)
(CON) - Condition of taxiway
(ConTx)
- Condition of runway
(ConRw)
Use of towline - Towline off-course
(TOW) (TOWOC)
- Tower too low (Low)
Launch assistance - Wing runner (WIRU)
(LAsst) - Signaller (SIG)
- On-duty instructor
(ODI)

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The classification Pre-flight check (ch) is used in the broadest sense of the word, it
includes the walk-around and all checks and checklists before the start.

Column M, N: Classification of the consequence of the incident. See the following list:

Injured on board (INJ) - Serious Injury (SI)


- Minor Injury (MI)
- Fatality (FA)
Injured on the ground - Serious Injury (SI)
(INJGrnd) - Minor Injury (MI)
- Fatality (FA)
Damage to aircraft (DAC) - ENG (ENG)
- Propeller/Rotor (PR)
- Undercarriage (UC)
- Electrics (EL)
- Ailerons /Tail rotor (AIL/TR)
- Radio (RA)
- Emergency parachute (EP)
- Wing (WI)
- Screen (SC)
- Equipment (EQUIP)
- Frame (FR)
- Burner (BR)
- Balloon/envelope (BA)
- Instrumentation (IN)
- Aircraft total loss (TL)

Damage on the ground - Other aircraft (OthAir)


(DAMGrnd) - Building (BUI)
- Vehicles (VEH)
- Nature (NA)
- Other (Oth)
Emergency services - Fire Department (FD)
deployed? (EMSER) - Police (PO)
- Ambulance (AM)
Emergency landing (EL)
Precautionary landing (PL)
Lost (LST)
Airspace Violation (AV)
Loss of control (LOC) - Crashed (Cr)
- Ground looping (GL)
- Overshoot (OV)
- Undershoot (UN)
- Hard landing (HL)
- Stall (ST)
- Other (Oth)

Emergency parachute
deployed (EPD)
Bird/wildlife strike - Bird (BIRD)
(BIRD/WILD) - Other wildlife (WILD)

The definition of serious injury is the ICAO definition: Serious injury is injury which

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- necessitates a hospital admission of more than 48 hours, within 7 days after the
occurrence of the injury or
- results in a bone fracture (except for simple bone fractures, like finger, nose, toe)
- lacerations have occurred which cause serious haemorrhage or damage to nerves,
muscles or tendons
- internal organs have been damaged
- second- or third-degree burns have been suffered or the victim has suffered burns
covering more than 5 percent of the body
- it has been verified that there has been exposure to contaminated substances or
harmful radiation

Column O: Has the incident been investigated?: There are three options:

Yes
No
In progress

Column P: Have mitigation measures been defined and introduced: The answer is either
Yes or No.

Column Q: Incident closed? The answer is either Yes or No.

Furthermore there is a relationship between Column O, P and Q.


The following table sets out all possible combinations between O, P and Q with an
explanation:

Column O Column Column Explanation


P Q
Yes Yes Yes incident has been investigated, mitigation
measures have been defined and introduced, the
incident has been closed
Yes Yes incident has been investigated, no mitigation
measures, incident has been closed
Yes No No incident has been investigated, mitigation
measures have been defined but not yet
introduced, incident has not yet been closed
Yes No No incident has been investigated, mitigation
measures have not yet been defined (nor
introduced yet), incident has not yet been closed
Yes No Yes incident has been investigated, mitigation
measures have not been defined, was not found
necessary (the incident has been recorded for
analysis), incident has been closed
No Yes a choice has been made not to investigate the
incident but the incident has been closed
(incident has been recorded for analysis)
In No No investigation is ongoing, mitigation measures
progress have not (yet) been defined and introduced,
incident has not been closed

All new incidents therefore start with the status: In progress, No, No, when they have
just been introduced and will then change in status.

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CONFIDENTIAL
(WHEN FILLED IN)
Incident Registration Form
All underlined fields must
always be filled in

TITLE OF INCIDENT
Date:

Version number

Aircraft information
Sequential no. IRF (By Type of aircraft Registration Owner/Operator Date and time of the incident (UTC)
SM) DD MM yyyy
_ _/_ _/_ _
UTC:_ _:_
Incident Flight number Departure Arrival location Alternate airport Logbook no. (only for Transponder code
location/coordinates location technical incident)

Passengers /crew Flight rules Airspace Height / Flight Speed (kts) Takeoff weight Runway in use

VFR / IFR classification level


/
A /B/ C/ D/ E/ F/ G

CHECK MORE THAN ONE IF NEEDED

PARKED TAXI TAKE-OFF CLIMB EN ROUTE DESCENT APPROACH LANDING


FLIGHT
PHASE

Weather and Conditions IMC / VMC


WIND CLOUD PRECIPITATION TYPE VISIBILI ICING TURBULENCE OAT (C) RUNWAY
AND QUANTITY TY CONDITION

DIREC SPEED TYPE HEIGHT


TION (kts) (ft)

QNH (hPa) BIRD STRIKE NO. SEEN: NO. HIT: TYPE OF BIRD

Description of incident (Report cause, consequence and factors which were of influence)
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DETAILS OF THE REPORTING PARTY (NOT COMPULSORY!)


NAME AND SIGNATURE: TELEPHONE NUMBER / E-MAIL: DATE REPORTED:

INTHEEVENTOFDOUBT,ALWAYSREPORT!

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SAFETY FIRST!

CONFIDENTIAL
(WHEN FILLED IN)
Hazard Registration Form
All underlined fields must
always be filled in

SEQUENTIAL NUMBER IRF (BY


Date: SM):
Version number

Date of identified Time Location


hazard
dd/mm/yyyy Local time:
UTC:

Brief description of the identified hazard


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TO YOUR KNOWLEDGE HAS THIS HAZARD PREVIOUSLY CAUSED AN INCIDENT? NO YES, EXPLANATION:

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INTHEEVENTOFDOUBT,ALWAYSREPORT!
SAFETY FIRST!

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Possible consequences when nothing is done about this


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Your proposal for measures which could be taken


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DETAILS OF THE REPORTING PARTY (NOT COMPULSORY!)


NAME AND SIGNATURE: TELEPHONE NUMBER / E-MAIL: DATE OF REPORT:

INTHEEVENTOFDOUBT,ALWAYSREPORT!
SAFETY FIRST!

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