Failed Dissertation

KHONDOKAR YEAMIN | 15046575
Module Title: Individual Project

Module Code: NG3D413
Project Title: Introducing a Safety Management System (SMS) into a Part 145 (MRO).
Supervisor: Paul Constable & Emily Simba
Student ID: 15046575
BSc (Hons) Aircraft Maintenance Engineering
University of South Wales
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Acknowledgement:
I would like to thank Mr. Paul Constable & Mrs. Emily Simba for their tireless efforts in guiding
my learning process and giving me the opportunity to work with them. Their vision and
dedication have helped broaden my experience to other countries and cultures. I am grateful
for the guidance and generous work done by them, and for their collaborative efforts and
support which helped me finish this research work in time. I highly appreciate their flawless
effort planning and managing all the processes which helped me to complete the dissertation
in time with ease.
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Contents:
Abstract: ................................................................................................................................................. 4
Introduction: ........................................................................................................................................... 5
Aim: ......................................................................................................................................................... 6
Objective: ................................................................................................................................................ 7
Literature review: ................................................................................................................................... 7
Fundamentals of Safety Management System (SMS): ..................................................................... 8
Concept of safety: ........................................................................................................................... 8
Performance and limitations of human: ....................................................................................... 9
Health and fitness: ....................................................................................................................... 10
Alcohol, medication, and drug: .................................................................................................... 10
Accident causation: ...................................................................................................................... 11
Aloha flight 243: ........................................................................................................................... 22
British Airways flight 5390: .......................................................................................................... 23
Safety culture: .............................................................................................................................. 24
Management dilemma: ............................................................................................................... 25
Safety reporting and investigation: ............................................................................................. 27
Safety data collection and analysis: ............................................................................................ 30
Implementation of Safety Management System (SMS): ................................................................ 35
Scope: ............................................................................................................................................ 35
Safety policy and objective: ......................................................................................................... 36
Safety risk management: ............................................................................................................. 38
Safety assurance: ......................................................................................................................... 44
Safety promotion:......................................................................................................................... 48
SMS implementation planning: ................................................................................................... 49
Methodology: ....................................................................................................................................... 64
Discussion: ............................................................................................................................................ 65
Safety in the workplace:................................................................................................................... 65
Impact on productivity: .................................................................................................................... 68
Recommendation: ................................................................................................................................ 68
Conclusion:............................................................................................................................................ 70
Reference: ............................................................................................................................................. 72
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Abstract:
History of aviation has witnessed numerous accidents, incidents, and fatalities due to safety
deficiency. After introducing of Safety Management System (SMS) by International Civil
Aviation Authority (ICAO), there was a drastic change in the number of aviation accidents and
incidents regardless of increasing fleet size and rapid expansion of the sector. From the
integration of SMS, there were very few researches carried out related to the function and
operation of the safety management system in the approved Part 145 organisations. As a new
method, there might have been a significant gap in the implementation of the safety
management system in approved organisations.
The aviation sector is one in the industry that is highly reliant on high levels of safety. Such
comes from the fact that any accidents are likely to cause significant losses to human life while
also affecting the economic system. In line with this, there has been a need to continually
improve the safety levels within the aviation sector. As technology keeps improving, there is
an inclination towards the use of technology in improving systems and ensuring that there
are high safety levels in the industry. Based on these aspects, the Safety Management
Systems (SMS) have been adopted in the industry with a focus on enhancing safety in aviation.
SMS is usually a proactive and systematic method used in ensuring safety through a reliance
on the aspects of goal setting, planning, and the measurement of performance. Importantly,
SMS rests on the promotion of a safety culture in the workplace, and this involves the
incorporation of different members within the organisations in ensuring safety and the
elimination of hazards.
One of the safety management systems in use today is the Part 145 Organization (MRO). The
MRO standard was established and adopted in the industry since it goes beyond the
conventional aspects of safety by cross-cutting through different areas. While the
incorporation of MRO is based on regulation, the system goes beyond regulatory aspects and
towards the management of an organized approach in the identification of risks and hazards.
Much more so, there is a focus on the active mitigation of hazards to an acceptable level.
The need for an SMS is based on the fact that there is an increased likelihood of errors and
violations within the sector where this results in profound effects. The interaction between
humans and technologies imply that humans, as well as technology, are likely to bring about
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errors that result in safety risks. Different models have been used to depict how errors occur
and some of the models overviewed in the paper. The different models considered appraise
the need for human as well as technological facilitations that lead to limitations in error
making. In line with this, the SMS is developed with a focus on eliminating the human as well
as technological linked errors.
The paper that follows aims to review and analyses the function and operation of the Safety
Management System (SMS) into the Part 145 organisations (MRO). The goal is to find out,
methods used to ensure the safety management system and the gap that exists to ensure
safety. The literature review and discussion segments highlight the important role of SMS in
the aviation sector. Importantly, information sharing is seen as vital in ensuring the
maintenance of systems of integrity within the industry. Growth and maintenance of safety
are not only considered from an organisational perspective but also an industry-wide
perspective. The paper also gives recommendations regarding the applicability of the SMS
within the industry and how continual improvements can enhance safety in aviation.
Introduction:
The safety management system in a systematic and proactive method to ensure safety in the
organisation involved in the aviation sector. It is the same business approach to maintain
constant safety in the workplace through goal setting, planning, and measuring performance.
Besides this, the safety management system ensures a better safety culture in an organisation
so that people working in the field have close to none chance to commit an error or mistake
which can result in safety breach.
The safety management system in Part 145 organisation (MRO) goes beyond the regulation
and manages an organised method to identify potential risk and hazard in an organisation
and active mitigation to an acceptable level. It is a business-like approach similar to an
organisation’s finances are managed, with safety plans, safety performance analysation,
safety targets and constant monitoring of safety performance of part 145 organisation (MRO)
and other organisation related to the aviation sector. Safety management system ensures an
efficient and effective emergency response system and safety risk management way before
it even occurs.
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Safety is a shared responsibility across all the personnel working in different departments in
an organisation. Safety management system requires the involvement of all of the staff
working inside an organisation to make them responsible for the safety performance of the
organisation and create a safety culture in it. The safety management system is a top-down
driven system; therefore, the higher management team and accountable manager of an
organisation is responsible for the implementation of safety management in the organisation
along with continuing compliance with the safety management system. However, without
sincere effort to support and maintain safety, it is not possible for the accountable manager
to accomplish effective safety management all over the organisation.
As there are several types and sizes of the organisation in the aviation sector, therefore there
is no “one size fits all” model for safety management. It is required for the organisations to
adopt safety management system to suit the type, size, nature and complexity of the function
and operation of the organisation and the related hazard, emergencies, and associated risks
inherent with its activities. (CAA UK, 2014).
The safety management system is not only about identifying and monitoring of safety in an
organisation. After the identification and mitigation process, safety management system
continues to improve safety in the organisation through collecting safety data to create a
database. As a result, the prediction of safety breaches is carried out to find out a solution to
the problem before it occurs. As everyone in an organisation has to play a definite role
delivering to the system, the challenge is to provide the necessary support, motivation,
guidance, and leadership to ensure accomplishment of safety management in an economic
and viable way. Therefore, the personnel working in an organisation are liable to address
accidents and incidents for the betterment of understanding and mitigation of safety
associated hazards and risks. (SMS Pro, 2019).
Aim:
This dissertation aims to review and analyse the function and operation of the Safety
Management System (SMS) into the Part 145 organisation (MRO). The goal is to find out,
methods used to ensure the safety management system and the gap that exists to ensure
safety.
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Objective:
The dissertation will provide a detailed explanation of the methods used in the aviation sector
to ensure safety and gap analysis process to find out lacking. Besides that, there will be an
extensive explanation to evaluate safety performance evaluation method and its efficiency.
Literature review:
In the early 1900s till the late 1960s, the aviation sector transformed into a quick mode of
transportation. People started taking flights for their journeys. Due to the lack of technical
limitations, flights had faced several deficiencies in safety. Several accidents and incidents
occurred during that time. Investigations were carried out by regulatory authority to find
lacking. By 1950s, advancement of technology and safety concept had led to a gradual
decrease in the frequency of accidents. From the early 1970s till the mid of 1990s human
factor was introduced in the aviation sector in order to let operators and MROs know about
the performance and limitations human have.
So that, personnel involved in the industry may know about their limitations that lead to error
or mistakes eventually which turns into risk or hazard for himself and others. As a result,
aviation became a safer mode of transportation and the effort to make flights safe progressed
into another dimension. It led to safer flights, reduction in loss of lives and properties. Which
led to a search for safety increase to another standard at that time. In the mid-1990s concept
of safety had changed and researchers were working for a systematic approach (ICAO, 2013).
The evolution of safety (ICAO, 2013).
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In late June 2006, the Federal Aviation Administration issued a safety management system
standard for all types and size of operators and MROs. The combined effort of the regulatory
body of the United States (US) and other government was released in an advisory circular
entitled “Introduction to Safety Management Systems for Air Operators”. On November 24th
of 2006, on a circular by International Civil Aviation Organization (ICAO) recommended
member states to ensure endorsement of safety management system in air operators, repair
stations, Part 145 organisations (MRO).
ICAO’s approach towards the safety management system is aligned and managed through the
business alike with a focus on deleveraging consistent and harmonised safety and
performance-based safety regulation. To monitor the effectiveness and efficiency of safety,
several tools are used to indicate the status and find out the lacking in the performance.
Inputs in the performance monitoring tools are enhanced by the collection of safety data.
With the help of the business-like approach not only safety has increased but also productivity
and quality have increased (ICAO Journal, 2006).
Fundamentals of Safety Management System (SMS):

In aviation, safety is, “the state in which the possibility of harm to persons or of property
damage is reduced to, and maintained at or below, an acceptable level through a continuing
process of hazard identification and safety risk management’’ (timetofly.eu, 2014).
Safety in an organisation cannot be completely free of risk. Human often occurs error while
working in different sectors. Aviation is one of them where most of the error happens due to
human. Therefore, safety needs to be monitored, and safety risks must be continuously
mitigated. Safety culture in an organisation depends on the domestic and international norms
and culture. It is better to keep risks under the appropriate level of control (ICAO, 1998).
Concept of safety:
Aviation development in recent days has changed the way it was in earlier ages. It is
characterised by complexity and almost constant shifting. As a result, the operators, 145
organisations, MROs need to adopt the change in order to survive. From international
aviation authorities, Federal Aviation Administration (FAA) and ICAO recognised the need for
a system-oriented approach to safety that was practised previously along with a more
managerial approach to safety.
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An organisation regardless of the nature of its function or size, for efficient and effective
management related to aviation, requires some primary management system. These are
financing, budgeting, communication, resource allocation, and so on. Recently, safety
management has been included in this list.
Safety management system takes a protective approach to safety management, and it is

beyond the audit and checklist-based inspection. In the safety management system, safety
risk and hazard are identified way before it can occur using assessment metrics. Then, risks
and hazards are categorised in different sections for better understanding and along with a
definite method to prevent before that occurs (ICAO, 2011).
Performance and limitations of human:

In the workplace, the human part is the most flexible, adaptable, and valuable. On the other
hand, it is one of the vulnerable parts as well. Because human responses to different kinds of
influences and can deviate from the course of action. Which may adversely affect its
performance and harm itself or others. Human performance and limitation are an
understanding of nature, capabilities, limitations, predictable actions and unpredictability of
humans and the application of its understanding in real-life working situations.
The interaction of human factors (Work Safe BC, 2008).
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Professor Elwyn Edwards (1972) proposed: "Human Factors is an applied technology that is
concerned with optimizing the relationships between people and their activities by the
systematic application of the human sciences, integrated within the framework of systems
engineering’’ (CAA UK, 2002 & ICAO, 1998).
Health and fitness:

In the Part 145 organisation may have to work physically depending on the job task. Besides,
personnel may have to work in cramped spaces, extreme temperature, or bad weather.
Therefore, the maintenance engineer needs to meet specific requirements in respect of age,
experience, medical fitness, and skill.
According to ICAO requirement on Article 13 (paragraph 7):
"The holder of an aircraft maintenance engineer's license shall not exercise the privileges of
such a license if he knows or suspects that his physical or mental condition renders him unfit
to exercise such privileges’’ (Course Hero, 2019 & CAA UK, 2002).
Factors affecting fitness and performance (Caleb D. Bazyler, 2015).
Alcohol, medication, and drug:

Article 13 (paragraph 8) of the UK ANO (Air Navigation Order) states:
"The holder of an aircraft maintenance engineer's license shall not, when exercising the
privileges of such a license, be under the influence of drink or a drug to such an extent as to
impair his capacity to exercise such privileges’’ (CAA UK, 2007).
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Putting drug screening to the test (SHRM, 2010).
Accident causation:
The concept of accident causation (ICAO, 2013).
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Swiss Cheese Model:

Accidents in any sector are the combination of several successful breaches of multiple
systems. Breaches in the multiple systems can be triggered by a number of enabling factors
that leads to such occurrences, such as, failure in machines or equipment or operational
errors by personnel working in the organisation. To illustrate the breaches in the system,
Professor James Reason developed a model called the Swiss Cheese model.
Swiss Cheese model (Taija Lahtinen, 2016).
Complex systems such as aviation are secured by layers of defences. Therefore, single point
failure effects less significant in the layer of defences and neglected often. Sometimes these
single point failures remain inactive for a long time and get activated sequentially with
another error. As a result, human failure in a certain defence system activates all the latent
failures and leads towards accident or incident. Professor Reasons Swiss Cheese model
proposes that all the accidents or incidents include a combination of both active and latent
condition (Franck Guarnieri, 2015).
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The organisation accident (ICAO, 2013).
Active failures are the error or violence that has an immediate adverse effect. With a view to
quick gain, these unsafe acts occurred. Mostly, pilots, air traffic controller and maintenance
engineers are the person prone to commit active failure in the aviation sector. Active failure
by this frontline personnel often results in a harmful outcome.
Latent conditions are the failure that does not occur instantly. It is the result of long term of
error and violence which remains dormant for a long time and are not considered a harmful
act — the person related to these acts far removed from the time and place of the occurrence.
Latent conditions become evident while a system fails or breached. Poor safety culture,
improper equipment or procedure or design, poor management system are the prime factors
that lead to a gradual development of safety breach (ICAO, 2013).
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SHELL Model:
A complex system can be expressed in simple models. In this way, the ideas related to it can
be illustrated easily. Similarly, in aviation to illustrate the complexity of human factor simple
models were used. In the year 1984, Frank Hawkins proposed that liveware-liveware
interaction bears significant scope of error making. Therefore, he proposed to add another
liveware in the SHEL model and made it SHELL to include liveware-liveware interaction.
SHELL model of maintenance organization (A. Shanmugam (2015).
Liveware-Hardware: This element of the SHELL model represents the interaction between
liveware and hardware or also can be said as machines. Such as the display of a computer or
any machine should match the sensory and information processing property of the human
user. Similarly controls of a machine expected to match the understanding of a human so that
the rate of confusion reduces.
Liveware-Software: Liveware and software interface is between human and the system. Such
as manual, procedure, checklist, computer program. As procedures and instruction read can
be different to different person due to their different point of view. Therefore, the liveware-
software interface can be misunderstood or misread easily. Moreover, that may lead to a
disaster. Errors in this interface may happen due to misinterpreting and ignored due to
confliction with common sense. In most of the cases, error in the liveware-software interface
is difficult to detect and very hard to resolve.
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Liveware-Environment: Human and environment interface was an age-old concept. Form

early days humans had adapted themselves with the environment. Such as, due to lack of air
pressure at high altitude and high G forces in aircraft, pilots used to wear G suits, oxygen
masks and helmets. With the development of technology, successfully the environment was
altered to match human comfort.
Liveware-Liveware: the liveware-liveware interface is the interface between humans. It

concentrates on the behaviour and performance of a person in a group while playing an
essential role as a member of the group. Alternatively, function as a group and the
interactions in the workplace while playing a role. Errors in liveware-liveware are mostly
related to miscommunication and misunderstanding between individuals, ineffective
leadership by manager or supervisor, poor teamwork in a group. Human resource
management is also within the scope of this interface (SKYbrary, 2016).
Scott A. Snook’s Model:
Scott A. Snook’s practical drift theory helps us understand how procedures of a system often
drift away from the original design with unnoticeable changes. Sometimes organisations
process and procedures cannot detect the circumstances that arise in daily operation. During
the design phase of a system, the interaction of people and technology, operational
procedure are taken under consideration to identify human-hardware, human-software
interaction and expected the performance of the personnel along with his limitations.
Furthermore, the identification of risk and hazard is carried out. All these assumptions
underlined the baseline of system performance.
There are three essential assumptions underlying the system design.
These include:
▪ Easy availability of the technologies required for the realization of system production
objectives.
▪ The target users are adequately trained for productive use of the technology.
▪ The human and system behaviour will be based on the pre-determined procedures
and regulations.
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The practical drift (ICAO, 2013).
Assumptions above create a baseline of standard for system performance which is graphically
represented as a straight line in practical drift diagram. In daily operation, the standard of
work does not follow the baseline performance all the time. There are several issues including
changes in the operation, workload, regulatory environment that drifts the performance
away from the standard regularly. As the drift is the result of daily practice, it is referred to as
practical drift. . Practical drift is a common occurrence, not only in the aviation industry, but
in all other industries. It is a common phenomenon that is not dictated by the design of a
system. Rather, there are five reasons for the occurrence of this phenomenon (ICAO, 2013).
Reasons behind practical drift may include:
▪ Failure of a technology to consistently function as initially anticipated.

▪ Lack of universally applicable regulations. In other words, the applicability of the
regulations is context-based.
▪ Altering the system functionality such as through the inclusion of more components.
▪ System procedures whose desirable execution is dependent on operational
conditions.
▪ Interaction between the system and other systems.
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Dirty dozen:
In approved maintenance organization, the personnel involved in maintenance tends to
commit 12 most common errors during maintenance. These 12 common human errors are
referred to as Dirty Dozen.
Errors in work place can be the result of one cause or combination of multiple causes from
the list mentioned (Gordon Dupont, 1993).
These dirty dozen causes of error are:
Lack of communication:
▪ The use of worksheets and logbooks to remove doubt and communicate.
▪ The discussion of the work that needs to be done and what has already been done.
▪ Never assuming anything.
Complacency:
▪ Training can help in identification of faults.
▪ One should not sign anything they have not done or seen.
Lack of knowledge:
▪ Training is essential.
▪ The use of updated manuals.
▪ Referring to a technical representative or an individual with knowledge.
Distraction:
▪ Focus on finishing the job or unfastening the connection.
▪ The uncompleted work should be marked.
▪ Torque seal or lock-wire should be used if possible.
▪ Double inspection.
▪ Go back three steps on return to the job.
▪ The usage of a detailed check sheet.
Lack of teamwork:
▪ A job should always be a subject of discussion in terms of what to be done, the person
to do it and how it should be done.
▪ Always ensure that everybody agrees to the job execution requirements and
procedures. However, agreement should be sought after everyone understands what
the job entails.
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Lack of assertiveness:
▪ Use the journey log book to record it if not critical.
▪ Signing should be for what is serviceable.
▪ Do not compromise standards.
Fatigue:
▪ You should be well informed of the symptoms of fatigue and check if you are
experiencing any.
▪ You should also check for the symptoms in other people you are working with.
▪ Regular exercises and adequate sleep are highly recommended.
▪ Plan your tasks in such a way that the complex ones do not feature at the bottom or
start of the circadian rhythm.
▪ You should have your work checked by others.
Lack of resources:
▪ The inspection process should begin by comprehensively checking all the suspect
areas likely to ground the aircraft.
▪ All the anticipated parts should be pre-ordered and stocked.
▪ All parts sources should be known and documented and arrangements done for either
loaning or pooling.
▪ You should ensure a standard is consistently maintained.
Pressure:
▪ Ensure that the pressure is not self-induced.
▪ Concerns should be communicated.
▪ Extra help can be requested.
▪ Say ‘No’.
Stress:
▪ Have knowledge of how stress affects work.
▪ Use rationality in examining the problem.
▪ A rational course of action should be determined and followed.
▪ Time off is necessary.
▪ Discuss with a second person.
▪ Monitoring by third party should be used.
▪ Engage in body exercise.
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Lack of awareness:
▪ In the event of an accident think about what is likely to occur.
▪ Consider whether there will be a conflict between work and repair or modifications.
▪ Consider the views of a third party.
Norms:
▪ Work within the instructions or have them changed.
▪ Have knowledge of the norms.
Errors and violation:

Regulations and operating procedures should always be followed. Unfortunately, any
violations or errors can lead to non-compliance. This would require corrective actions to be
taken against the instances of non-compliance. Such an action has negative consequences
because it can reduce error reporting if other processes are not instituted.
Errors: An error is defined as “an action or inaction by an operational person that leads to
deviations from organisational or the operational person’s intentions or expectations’’
(Barbara, 2018).
It is important for the state and Service Providers (SPs) to be conscious of the fact that users
are prone to making errors as far as SMS is concerned. This is regardless of the modernity of
the technology in use, the adequacy of training provided or the level of detail in the processes,
regulations, and operating procedures. This means focus should be on reducing the chances
of making errors and not completely doing away with them. To achieve this, the possible
errors should be analysed and the most suitable remedial measures taken.
The probable errors are of different categories including:
▪ Lapses and slips: Slips are basically the actions that fail to execute as planned. On the
other hand, any memory failures are known as lapses. Lapses and failure impede
successful execution of the planned actions. A good example of a lapse is accidentally
skipping some checklist items. An example of a slip is operating a gear lever rather
than the intended flap lever (SKYbrary, 2016).
▪ Mistakes form the second category and they hamper the realization of the planned
results or outcomes. A plan can be correctly executed, but the presence of mistakes
would lead to incorrect results.
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Execution and planning failures adapted from Rasmussen (SKYbrary, 2016).
None of the above error categories is desirable. Therefore, appropriate counter-measures or

strategies should be put in place.
These strategies are as described below:
▪ Reduction strategies: As the name suggests, the focus of these strategies is to reduce
or completely get rid of the error source factors. Examples include getting rid of
environmental distractions or enhancing various ergonomic factors.
▪ Capturing strategies: The underlying assumption is that an error will be made. The
focus of these strategies is controlling the effects of the error at the infant stages.
Unlike reduction strategies whose goal is to eliminate errors, capturing strategies use
checklists, among other procedural remedies/interventions.
▪ Tolerance strategies: These strategies focus on establishing robust systems that can
withstand errors without any serious effects. An example of such measures is the
implementation of redundant systems which improves the robustness of a system
with regard to errors.
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In most cases, staff performance is a product of multiple factors, including but not limited to
environmental, organisational, and regulatory factors. As such, it is prudent for safety risk
management to put into consideration a variety of factors such as the corporate policies, staff
scheduling, communication procedures, budget constraints and resource allocation. These
factors can significantly contribute to errors. (transit2safety.com, 2018).
Violation: A violation is “a deliberate act of wilful misconduct or omission resulting in a

deviation from established regulations, procedures, norms or practices” (SKYbrary, 2016).
It is a deliberate action by a malicious person. In most of the instances, violation of a rule is

motivated by the need for professional or personal growth. The severe consequences of
breaches may be experienced in the long term. For instances, minor violations if ignored at
the initial stages can lead to serious hazards.
Violations are of different categories as provided below:
▪ Situational violations: There are triggered by specific factors in the work environment
such as high workloads and time pressures.
▪ Routine violations: As the name suggests, these bleaches are considered a norm in the
business environment. They usually result from difficulties in task completion if the
established procedures are complied with. These difficulties may arise because of
diverse factors, including workability issues or inadequacies in the interface design.
These deviations also commonly known as drift may initially appear minor. However,
their frequency may increase over time leading to possible severe consequences. It is
worth-noting that some routine violations are acceptable and may be eventually
incorporated in the standard operating procedures. This should only be done after
thorough safety analysis had been performed and their safety confirmed.
▪ Organisation induced violations: These violations are largely similar to routine
violations. However, this is a more advanced version of the routine violations and
happens when organisations try to meet high output demand while disregarding their
safety defences (transit2safety.com, 2018).
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Aloha flight 243:

Among all the accidents attributed to the human factor, Aloha flight 243 was taken as a
program of research. In this program, authorities investigated the problems associated with
human factor and aircraft maintenance engineering. Furthermore, they have focused on
inspection to find the specific reason for a human to occur error. In April 1988, 18 feet of
upper cabin structure of Aloha flight 243, suddenly being ripped away in flight due to the
failure of structural integrity. Aloha flight 243 was conducted by Boeing 737 aircraft and was
inspected for airworthiness by two of the engineering inspectors. One of the inspectors had
22 years of experience, and the chief inspector had 33 years of experience.
Aloha Airlines Flight 243 (coloringpagewiki.com, no data).
But, neither of the experienced inspectors have found anything. After the accident analysis
by concerned authority, it was reviled that there were over 240 cracks in the upper cabin
structure of Aloha flight 243, which existed in the time of inspection (NATIONAL
TRANSPORTATION SAFETY BOARD, 1989).
Aloha accident investigation (NTSB) revealed several human factors related issues such as:
▪ Conformity of the maintenance crew.
▪ Degradation of performance due to completing maintenance during night.
▪ Lack of assertiveness.
▪ Fatigue and,
▪ Complacency.
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British Airways flight 5390:

10th June in the year of 1990 in the UK, British Airways flight 5390, which was operated by
BAC 1-11, took off from Birmingham International airport. At the altitude of 17,300 feet
during flight, the left windscreen blew off due to cabin pressurization. Before the flight, that
windscreen was replaced. According to the report of the accident, windscreen blew off when
the cabin pressure increased, and that overcame the retention of the screwing bolt. Out of a
total of 90, 84 screwing bolts were smaller in diameter than the specified one in the
maintenance manual. As a result, the pilot in command sucked halfway out of the windscreen
aperture. While the cabin crew retained him so that he could have sucked into the engine. On
the other hand, the co-pilot flew the aircraft and landed safely at Southampton Airport.
BA Flight 5390 (Chas Early, 2018).
The shift maintenance manager of British Airways decided to carry out maintenance by
himself on a night shift short-handed. To replace the existing windscreen, he consulted the
aircraft maintenance manual. According to his conclusion, it was a straightforward job. So, he
took one bolt from the old bolts as a sample which was a 7D and looked for a replacement at
the store. The storeman advised him to use 8D bolts instead as it was the specified size in the
maintenance manual. Since there was a shortage of that specific size, he decided to take 7Ds
as it was placed previously. However, he used to touch and sight to compare and finally
selected 8C by mistake. 8C is longer and thinner. Along with it, the counter shank on the
screwing bolt was lower than it should be. And the shift maintenance manager failed to notice
that as well. After completion of his job, he signed off and this maintenance procedure.
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Considering all the facts revealed by Department for Transport (UK), there were numerous
human factor issues contributing to the incident (aviationchief.com, 2018).
That includes:
▪ Working practice,
▪ Poor lighting in store area,
▪ Perceptual error made by the shift maintenance manager,
▪ Failure to wear glasses,
▪ Circadian effect and,
▪ Possibly, designing, and organizational factor.
Safety culture:
As a member of society, a person’s culture is the combination of shared beliefs, values, norms,
and biases. For efficient and effective safety management it is essential to understand the
cultural components and the interaction between them. The most influential cultural element
among all these is professional, organisational, and national culture. Safety culture of an
organisation is dependent upon these influences. Safety reporting and safety culture in a
company depend upon the priority of safety value within the organisation.
Organisation culture reflects the characteristics of a person working in a company. The

aspects of organisational culture can be witnessed within a company while employees are
interacting with each other. Safety values in an organisation reflect its safety culture while
safety versus efficiency, productivity versus quality is in a balance with each other.
There are several areas that can be affected by organizational culture. These include:
▪ The nature of interactions between various group members such as between senior
employees and their juniors.
▪ The nature of interactions between the sector and other important stakeholders such
as the regulatory authority staff.
▪ The extent of information sharing both at the internal level and with relevant
regulatory bodies.
▪ Teamwork either at the industry or regulatory authority levels.
24
▪ The conduct of staff members when exposed to demanding or stressing operational

environments.
▪ The adoption and use of a give technology.
▪ The habit to take very punitive or stringent measures in response to operational
errors. These errors can arise from areas such as regulatory bodies and service
providers.
There are various factors that affect or influences business cultures, including but not limited
to:
▪ Supervisory strategies and techniques.
▪ Business operating procedures and regulations.
▪ The safety improvements aim and the minimum tolerable levels.
▪ The attitude of the top management with regard to safety and quality concerns.
▪ The adequacy of staff training and incentives/ motivation.
▪ The nature of the relationship between various regulatory bodies and the
product/service providers.
▪ The policies guiding the work and life balance.
Safety in an organisation can be observed while the organisation develops and promote safety
culture in the organisation. Personnel involved in it feels responsible for safety. It can be
achieved by reporting the hazard, identification of safety risk is taken into consideration for
the safety management inside the company. On the other hand, management must create a
working environment where personnel feel safe with their work and have sufficient personnel
safety equipment. That’s how safety culture inside a company motivates the employee to
maintain safety and develop a safety management system (SM CAA, 2015 & ICAO, 2013).
Management dilemma:
An organisation associated with production or delivery of service are more likely to come
across safety risk. Along with the expansion or increase in production, the safety risk increases
accordingly. Not only that, lack of safety management or insufficient resources also increases
the safety risk. Therefore, an organisation working in the aviation sector must define its
working procedure and production keeping safety in mind.
25
Technology, safety procedure, safety training are the tools to enhance safety in the
organisation and decrease the loss of life and property. Theoretically, the safety space is the
zone where an organisation balances desired production while maintaining required safety
protection through safety risk controls. There should be a balanced allocation of resources
between production and protection. Allocation of too much resources for production
purposes and minimal resources to protection can eventually result in an accident. Therefore,
it is highly recommended to have a clearly defined safety boundary that would give early
warnings in the event of undesirable resource allocations. These safety boundaries should be
reviewed on a regular basis to ensure they capture the current business environment (ICAO,
2013).
The safety space (ICAO, 2013).
26
Safety reporting and investigation:

Safety management can only be considered effective if accurate and prompt reporting of
information is guaranteed. This information should relate to the accidents, incident, or
hazards within the work environment. It is based on this information that comprehensive
security analysis can be done. This means the reliability of safety information is very essential.
The frontline staff forms the best source of reliable safety information. This is because they
can easily identify hazards based on the nature of their work. However, the data to be
analysed should be sourced from multiple areas to enhance the accuracy of safety reports
(ICAO, 2013).
Effective safety reporting — five essential characteristics (ICAO, 2013).
27
(to be continued on next page)
28
Example of safety reporting form (SM CAA, 2015)
29
Safety data collection and analysis:

A management system is considered effective if all decisions are made based on accurately
analysed safety data. The data required for such analysis include the hazard reports,
deviations or non-conformance to the standard operating procedures, and occurrences of
safety incidents or accidents. It is very essential to ensure that the data used is of high quality
if correct decisions are to be made.
Quality is therefore a facet that should be safeguarded throughout the SMS process. It is
unfortunate that most of the databases have no quality data needed to accurately inform
safety priorities and suitably risk mitigation strategies. Therefore, all data limitations or
constraints have to be fully accounted for; otherwise the entire process would lead to flawed
results and eventually wrong decisions (ICAO, 2013).
Safety data collection and quality:

Based on the previous discussions, it is evident that safety risk management practices should
be supported by high quality data.
To access the suitability of safety data, the following seven item criteria should be used.
▪ Validity: Data is valid if they are acceptable in line with the set criteria for the targeted
use.
▪ Completeness: Data should be comprehensive with no missing segments.
▪ Consistency: Data should be reproducible if the same data collection approach is used.
▪ Accessibility: The data should be easily accessible for subsequent stages, such as
analysis.
▪ Timeliness: The data should be current. This means it should capture or reflect the
actual situation of environment under investigation.
▪ Security: The data should be sufficiently protected from an unauthorised use or
alterations.
▪ Accuracy: The captured data should be devoid of any errors.
The results emanating from data that meets the above criteria are ideal for strategic decision
making (ICAO, 2013).
30
Safety database:
Safety database is the collection of information related to safety of an organization or the
issues that generated safety risk.
The types of data it contains are:
▪ Accident investigation data,

▪ Mandatory incident investigation data,
▪ Voluntary reporting data,
▪ Continuing airworthiness reporting data,
▪ Operational performance monitoring data,
▪ Safety risk assessment data,
▪ Data from audit findings/reports,
▪ Data from safety studies/reviews and,
▪ Safety data from other States, regional safety oversight organizations (RSOOs) or
regional accident and incident investigation organizations (RAIOs).
Safety databases mostly contain data in reports form. These reports provide the findings from
various complex events. These may be safety incidents or accidents. The information
captured in such safety reports include a description of the actions taken, the person involved
and the results of the actions. Besides safety incident or accident information, other forms
of information captured in these databases include the traffic volumes, weather information
and flight information. However, this information is stored in simple facts.
Organisations house their safety databases in different parts and provide an interface for the
database access. It is through the interfaces that safety analysts extract the reports they need.
The retrieval system is usually designed in such a way that the analysts can collectively or
individually extract the reports. The provided analytical tools allow the analysts to get reports
in formats of their choice. These may include graphs, maps, and spreadsheets (ICAO, 2013).
As an illustration, an of a state’s safety system is depicted in the schematic view on the next
page.
31
A schematic view of a State’s safety data system (ICAO, 2013).
Safety data analysis:

Once the data collection procedures are complete, the data should be subjected to suitable
analysis procedures. It is through analysis that potential hazards can be identified and their
potential consequences mitigated (ICAO, 2013).
The analysis is also used for other purposes such as:
▪ Helps determine additional facts that may be necessary.

▪ Verify the underlying factors for safety inadequacies.
▪ Helps in making valid and reliable conclusions.
▪ Close monitoring of safety performance trends.
32
Analytical method and tools:

The following safety analysis methods may be used:
▪ Statistical analysis: The significance level of the perceived safety patterns can be
determined using this approach. The results are statistically shown in graphical form.
The accuracy of the statistical results is determined by not only the data quality, but
also the accuracy of the analytical methods used. Therefore, these two aspects have
to be carefully considered if accurate findings are to be made.
▪ Trend analysis: In this method data trends or patterns in safety data are monitored. It
is based on these trends that predictions about future occurrences, such as likely
hazards are made.
▪ Normative comparisons: This involves sampling some of the real-world experiences
applicable in a work environment to determine the likelihood of potential events.
However, this approach is recommended in case of insufficient data from which
reliable conclusions can be made.
▪ Simulation and testing: This entail the use of both simulation and laboratory testing
methods in verifying the safety status of equipment, operating procedures, and
operations.
▪ Expert panel: This entails using specialists and professionals in analysing different
hazards that arise from a given condition. It is based on the findings of the analysis
that the most suitable remedial action is determined and implemented.
▪ Cost-benefit analysis: This is method whereby the benefits that would be realised by
implementing risk control measures are weighed against the expenses that would be
incurred in. The outcome of the analysis is used in determining whether measures are
viable or not (ICAO, 2013).
Management of safety information:

Organisations are of different complexities and sizes. It is these facets (complexity and size)
that influences the capabilities needed for effective safety data management.
However, on a general scale, a system should have the features below:
▪ Should have appropriate analytical tools that can summarize vast data volumes into
relevant information for fast decision-making purposes.
33
▪ Should be able to significantly reduce work for the safety personnel and their
managers.
▪ The interface should be user-friendly for easy data entry and manipulation.
▪ Should be cost effective.
There are various database management systems. These systems have different attributes
and offer different functional properties. These are some of the areas that should be
considered prior to determining the most appropriate system (ICAO, 2013).
However, a suitable database management system should be able to support the following
user actions:
▪ Ability to categorise and log different safety events.

▪ Monitor trends.
▪ Should be able to relate events and documents and link them appropriately.
▪ Check or verify historical records.
▪ Analyse data including charts and generate reports.
▪ Allow for the sharing of safety data among organisations.
▪ Comprehensively monitor events and all associated investigations.
▪ Monitor the execution of remedial actions.
Protection of safety data:

Aviation safety data is prone to misuse. To protect against such misuse, database systems
should have adequate security measures. However, protection should put into consideration
data accessibility. There should be a balance between the two. This means the data should
not only be accessible but also well secured (ICAO, 2013).
Based on the above descriptions, the protection considerations include but not limited to the
following:
▪ Sufficient but well secured accesses.

▪ Blocking all unauthorised access or use of the safety data.
▪ There should be stringent policies guiding data access.
▪ The communication networks, data storage and all information systems should be
secured.
34
Implementation of Safety Management System (SMS):

The safety management system is a system to ensure safety in the workplace through
continuous monitoring of the safety issues and effective management of safety risk. It is a
constant process to identify the hazard and accordingly manage safety in the aviation sector.
SMS is a proactive method to find out and mitigate the risk before it occurs. It is a system that
is adequate with the organisation’s regulatory requirements and safety goals. There are
several major elements that every SMS should have. These elements help in not only hazard
identification, but also for safety risk management (SM CAA, 2015 & ICAO, 2013).
The element ensures that:
▪ All the required information is easily accessible/ available.

▪ The organisation has access to suitable tools capable of doing the intended work.
▪ The available tools are adequate for organisational constraints and needs.
▪ Safety risk considerations inform all decisions made in an organisation.
Scope:
A SMS is concerned about safe aircraft operations. This is by ensuring that aviation service
providers perform their activities in ways that guarantee the safety of aircraft operations. It
is important to note that SMS can also other activities not directly related to aircraft safety.
Examples of such activities include legal, human resources and finance-related activities. This
means it is important to consider both internal and external systems likely to influence the
safety performance of an organisation. Additionally, it is important to consider all the possible
inputs not only during the infant stages of the SMS implementation, but also throughout
future internal assessments (SM CAA, 2015 & ICAO, 2013).
Involved organizations and personnel are:
▪ Aviation professionals,
▪ Aviation regulatory and administrative authorities,
▪ Industry trade associations,
▪ Professional associations and federations,
▪ International aviation organisations,
▪ Service providers.
35
Safety policy and objective:

Similar to any other facet organisations are expected to have safely policies. The aspects that
should be captured in these policies include the methods and processes to be used in realizing
the safety objectives. It is the responsibility of the senior management to develop SMART
objectives. Additionally, the role of the senior management towards the realisation of the
safety objectives should be well documented. However, regular improvements have to be
made to ensure that safety measures are always up to date (SM CAA, 2015 & ICAO, 2013).
Commitment and responsibility:

It is expected that service providers should maintain safety policies that adheres to both the
national and international requirements (SM CAA, 2015 & ICAO, 2013).
The policy should have the following features:
▪ Should exhibit high level safety commitment.

▪ Should explicitly describe the allocation of all the required resources for successful
safety policy implementation.
▪ Should have detailed procedures to be followed during safety reporting.
▪ Clearly stipulate unacceptable or prohibited behaviours for service providers. This
should be expounded by a clear statement of the consequences for non-adherence
and exceptional circumstances under which such consequences would not apply.
▪ The policy should have signatures for relevant officials in an organisation.
▪ All stakeholders should be informed of the policy and their endorsements sought.
▪ The policy should be subjected to frequent reviews to ensure that it is always up to
date.
Accountability:
Accountability is an essential element of the SMS framework. It basically means responsibility
for an organisational safety performance. This responsibility should be exhibited at the
individual personnel level, product level and at the general SMS implementation levels. As an
illustration, accountability can be exhibited by ensuring that remedial actions are instituted
for any reported error or hazard (SM CAA, 2015 & ICAO, 2013).
36
Service providers can ensure accountability through the following actions:
▪ Assigning accountability and responsibilities to specific executives. This is geared

towards ensuring that the executives effectively implement and maintain the SMS on
behalf of the organisation.
▪ Should ensure that safety accountability lines are explicitly defines across the
organisation. This includes defining the roles of the senior management in safety
activities or operations.
▪ Clearly define the accountability expectations of all employees, including the top
management with regard to the SMS safety performance.
▪ Ensuring that the accountabilities have been sufficiently documented and
communicated to all relevant stakeholders.
▪ Clearly stating the personnel with the ultimate authority for decision making on
matters relating to tolerability of various safety risks.
Emergency response planning:

Emergency Response Planning (ERP) is the documented process that needs to be followed
when an emergency occurs. Purpose of the ERP is to ensure that, there is an orderly and
efficient transition from normal to emergency operations. It also includes the tasks to be
performed during an emergency and allocate authority to monitor and authorise the
processes. Sole purpose of ERP is to save life and property in the time of emergency and
return to normal operation as soon as possible. Successful response to an emergency begins
with adequate planning. An ERP provides the basis for a systematic approach to managing the
organisation’s affairs in the aftermath of a significant unplanned event in the worst case, a
major accident (SM CAA, 2015 & ICAO, 2013).
An ERP is intended to ensure that:
▪ The emergency authority is delegated to capable personnel.

▪ Emergency responsibilities are assigned to specific employees.
▪ All emergency processes and procedures are comprehensively documented.
▪ Emergency efforts are well coordinated and especially between the internal and
external stakeholders.
▪ Management of a crisis does not interrupt vital operations.
37
▪ Identification of all likely emergency events and the most suitable mitigation
strategies.
The ERP cannot be effective, unless it meets several conditions which are outlines below:
▪ The ERP should reflect the nature of the organisation and especially in terms of size
and complexity of operations.
▪ The plan should be always within the reach of all relevant stakeholders and in some
cases to other collaborating organisations.
▪ The procedures and checklists should not be general. Rather they should be specific
to well-defined emergency situations.
▪ The contact details of the relevant parties should be included for quick reference.
▪ Mock exercises should be used in regular testing of the plan.
▪ The plan should be subjected to regular reviews in order to capture the latest
emergency response needs.
Safety risk management:

Safety Risk Management (SRM) is deemed complete it is comprised of the assessment
procedures and the mitigation strategies for various risks. Primarily the overall objective of
SRM is to examine various risks linked to various hazards and determine and roll out the most
suitable mitigation strategies. This means risk management is one of the most essential
elements of the overall safety management process. This applies to both at the organisational
and state levels (SM CAA, 2015 & ICAO, 2013).
Hazard identification:
Safety risk management requires to find out hazard before the management process. Any
deficiency in the process can result in confusion between hazard and safety risk. The proper
understanding of the matter results in effective safety risk management.
In general term, a hazard is basically a condition that is likely to result in injuries, death of
personnel, destruction of property, or reduce the capability of a person to perform a given
task. In the context of the aviation industry, a hazard largely unsafe use of aviation equipment,
and operating aircrafts in unsafe ways.
38
A diagram showing the hazard analysis and risk assessment process (CAA UK, 2014).
To identify hazard, methodologies are as follows:
▪ Reactive: Reactive is the process of identifying hazard that already occurred.

Investigation reveals the reasons related to the hazard. So, the lacking in the system
can be studied to find the reason contributing to the hazard or latent condition that
eventually influencing hazard in workplace.
▪ Proactive: This method of hazard identification involves the analysis of current or real-
time situations. Audit, investigation, and evaluation in safety assurance is the best way
to find out real-time hazard in existing processes (SM CAA, 2015 & ICAO, 2013).
▪ Predictive: Collected data in the previous two process can be a great source for
prediction of possible future hazard. Predictive hazard identification is the method to
find out hazard that are likely to happened in the near future. In this case, collected
data form other two method can be a great source for initiating mitigating action.
39
Hazard documentation and follow-up risk management process (ICAO, 2013).
The safety risk management process (ICAO, 2013).
40
Safety risk probability:

Controlling safety risks in the aviation industry is a process that involves several steps. In the
first step, the probability of the consequences of various hazards materializing is assessed.
Probability is the likelihood of a safety consequence occurring or happening. The table below
shows five categories or levels that denotes the likelihood of a safety consequence occurring.
A description and value of the categories have also been provided (SM CAA, 2015 & ICAO,
2013).
Safety risk probability table (ICAO, 2013).
Safety risk severity:

After the completion of the probability assessment, the assessment of the severity of the
safety risk is done. This is done based on the likely consequences of the hazard materializing.
In basic terms, safety risk severity is the level or degree of harm likely to be experienced as a
result of a hazard materializing.
Severity assessment is done based on a few considerations including:
▪ Injuries and fatalities: These are the likely number of deaths that may result from a
hazard materializing.
▪ Damage: This is the degree of damage that may occur to the equipment, property, or
the aircraft as a result of a hazard materializing.
Based on the descriptions provided above, a risk severity table comprising of five categories
can be developed. A description and a value assigned to each of the categories have been
provided. However, table on the next page is just an example of how it should be done (SM
CAA, 2015 & ICAO, 2013).
41
Safety risk severity table (ICAO, 2013).
Safety risk tolerability:

A safety risk index can be obtained from the risk probability and severity analysis. The index
is comprised of an alphanumeric designator and shows the aggregate outcome of the two
assessments (probability and severity). A safety risk matrix as the one shown below is used to
present the severity/probability combinations.
Safety risk assessment matrix (ICAO, 2013).
42
The derived safety risk index should be mapped onto a safety risk tolerability matrix. This
matrix is organisation dependent and details the tolerability metrics or criteria for a given
organisation. An example of such a matrix showing the tolerability description, assessed risk
index and the suggested criteria is provided below (SM CAA, 2015 & ICAO, 2013).
Safety risk tolerability matrix (ICAO, 2013).
An alternate safety risk tolerability matrix (ICAO, 2013).
43
Based on the matrices provided above, there are various measures an organisation can take
to secure their operations. These include:
▪ Implement measures intended to minimize the level of exposure of an organisation

to risks.
▪ Implement measures that would minimize the severity of impacts of a given hazard.
▪ Completely do away with an operation is its consequences cannot be mitigated.
Safety assurance:
A SMS should operate as per the expectations of an organisation. Therefore, there should be
quality assurance systems in place to ensure that this is achieved. A safety assurance system
is comprised of activities and processes for monitoring the operations of an SMS.
Organisations should regularly monitor both their internal processes and the operating
environment. They would enable them to detect any deviations or changes that may require
modifications of the current risk controls. The chances can then be incorporated into safety
management processes.
It is worth noting that quality assurance and safety assurance are two processes in an
organisation that complements each other. The two processes are largely similar with each
requiring sub-processes such as analysis, auditing, documentation, and reviews to be
regularly undertaken so that a given performance criteria can be achieved. The only
difference between the two is the focus area. Quality assurance is concerned with adherence
to regulatory requirement. On the other hand, safety assurance is concerned with monitory
safety risk controls (SM CAA, 2015 & ICAO, 2013).
Safety performance monitoring and measurement:

According to ICAO Safety Management Manual (SMM) (Doc 9859):
▪ Service providers should have safety performance verification mechanisms in place.

Additionally, they are expected to have the effectiveness of their risk controls
validated.
▪ The service providers are also expected to ensure verification of their safety
performance. The verification should be done based on the SMS’s safety performance
goals.
44
Safety data and risk-based surveillance concept (ICAO, 2013).
In most of the cases, the safety reporting systems provide or generate the information needed
to measure the safety performance of an organisation.
There are two types of reporting systems, they are:
Mandatory incident reporting systems: It is the reporting system of serious accidents or

incidents in the aviation sector. Such as air crash, skid away from the runway, etc. It is carried
out in a detailed manner to find out the root cause of the incident or accident. Detail reporting
helps to gather more information about high-risk failures that have consequential effects in
the aviation sector. Therefore, collecting information enables proper information related to
the occurrence. Initiating a study in those issues can reduce the frequency of the accident or
incident by preventing the facts related to the safety hazard.
45
Voluntary incident reporting systems: In voluntary reporting systems, information pertaining

to inadvertent errors and hazards can be submitted without an associated administrative or
legal requirement for such an action. It is not uncommon for organisations or agencies to
provide incentives to get such reports. The decision to implement these reports is at the
discretion of the organisation or agency involved. They may decide to implement the report
or not to do so. In case they decide to implement the report, they should do it to improve the
safety of aircraft operations. The voluntary reporting systems are deemed to be non-punitive.
This is because the reporters are protected and this motivates them to continually provide
information for continued enhancement of safety performance (SM CAA, 2015 & ICAO, 2013).
Change management:
The performance of risk mitigation strategies can be affected by change in the operating
environment. Change in this case refers to aspects such as the emergence of new hazards into
the work environment. These changes should always be noted down and appropriate controls
put in place to mitigate the severity of their consequences. Safety reviews have also to be
conducted from time to time because they provide very important information on which
decisions can be made.
Management of change process of an organization should take into consideration of the three
followings:
▪ Criticality: Criticality assessments determine the systems, equipment or activities that

are essential to the safe operation of aircraft. System design process requires an
evaluation of criticality. It also assessed while a change occurs. There are some
systems, equipment and activities have higher safety criticality. Those need to be
studied for change and make sure that the corrective actions have been taken to
control potentially developing safety risk.
▪ Stability of systems and operational environments: In an organisation, change may be
planned accordingly, so that the organisation has control over it. These changes are
organisational expansion or contraction, product development or expansion or
integration of new technological interventions. There are multiple examples of
unplanned changes. The notable ones include labour unrests, economic cycles, and
changes to the operating environments.
46
▪ Past performance: Organisations can use past performance trends to forecast how
their critical systems would perform under different conditions. This would also
enable organisations to determine the most suitable corrective actions to apply under
different conditions.
Systems are prone to changes from time to time and this would imply changes have to be
made to the initial system design/description. It is therefore highly recommended that
organisations should regularly review their SMS to ensure it remains valid (SM CAA, 2015 &
ICAO, 2013).
Continuous improvement of SMS:

Continuous improvement of an approved part 145 organisation is measured through the
safety performance indicators, and that reviles the effectiveness of safety management
system in the organisation. Not only that, continuous improvement to safety management is
achieved through constant verification and follow-up actions. Independent audit and internal
evaluation indicate the achievement of the safety management system in the organisation.
It is recommended that organisations should perform internal evaluations that would guide
their decision-making processes. It is during these internal evaluations that major activities
including hazard identification and mitigation strategies are discussed. The internal
assessment procedures comprise of various activities, including policymaking, safety
assurance, risk management, safety promotion and safety management (SM CAA, 2015 &
ICAO, 2013).
▪ The internal audits normally entail a scheduled and systematic evaluation of the
aviation activities of service providers. It is advisable that the evaluation should be
performed by a different entity from the one under investigation. The audits are
beneficial because they provide the senior managers with a clear picture of their SMS
performance. This in turn enables them to take the necessary actions.
▪ The SMS external audits can be performed by different bodies including third parties
and industry associations chosen by the service provider. These audits compliment
the internal audits thus providing a detailed account of the SMS performance.
47
Safety promotion:
The overall goal of safety promotion is to nurture a safety culture in an organisation. This
makes it easy for an organisation to realise safety objectives. A safety culture is achieved by
impacting the right attitude, behaviour and values needed to boost the safety efforts of an
organisation. This requires a combination of information sharing, training, and effective
communication. However, the top leadership has a duty to offer the leadership needed to
nurture a safety culture.
It is important to note that for safety efforts to succeed, numerous facets have to be
considered including the processes, procedures, and policies. There should be strict
adherence to these facets in order for safety efforts to be adequately supported (SM CAA,
2015 & ICAO, 2013).
Training and education:

Part 145 organisations need to prepare, organise, and maintain a safety management
program for the personnel working in this sector with a view to ensuring their training and
make them competent to perform their SMS duties. The scope of the safety management
training program should be suitable for each person involved in the system to maintain safety
requirements.
The safety manager is responsible for organising safety training and providing recent
information related to the safety issues that come across the organisations. Safety training of
appropriate personnel regardless of their position in the organisation is a sign of good
management and the commitment of manager to effective safety management.
The training and course syllabus should consist of the following:
▪ Organizational safety policies, goals, and objectives.

▪ Organizational safety roles and responsibilities related to safety.
▪ Basic safety risk management principles.
▪ Safety reporting systems.
▪ Safety management support (including evaluation and audit programs).
▪ Lines of communication for dissemination of safety information.
▪ A validation process that measures the effectiveness of training and,
▪ Documented initial indoctrination and recurrent training requirements.
48
Safety training inside the organisation should confirm the proper understanding of safety and
its value in the organisation. Personnel working within the organisation should understand
and contribute to safety management as their responsibility (SM CAA, 2015 & ICAO, 2013).
Safety communication:
It is the obligation of organisations to ensure they communicate their SMS goals to all relevant
personnel. Besides communicating the goals, the safety performance issues and trends need
to be discussed from time to time through briefings and bulletins. It is also the responsibility
of the top management to ensure that the findings from investigations are widely shared. The
staff members in organisations should also be encouraged to promptly report any hazards
they may detect in the course of their duties. This information would be important in
improving the safety performance of the organisation (SM CAA, 2015 & ICAO, 2013).
Therefore, safety communication is intended to realise the following goals:
▪ Ensure that the relevant personnel are fully aware about the presence of the SMS.
▪ Ensure that safety information is sufficiently relayed to all staff members.
▪ To make employees aware of corrective actions.
▪ Promptly provide information about any new of modified safety procedures
SMS implementation planning:

All SMS components and their related interfaces need to be clearly defined. The processes of
the SMS have also to be clearly described. This is the first stage in describing the applicability
and the scope of the SMS. This is very important because it allows for identification of gaps
relating to not only the SMS but also to all its elements and components. The description
should focus on areas such as the SMS interfaces, both internal and external to the
organisation. An example of external interfaces are those between an organisation an
external subcontractors. It is also recommended that organisations should document their
reporting and accountability structures together with organisational procedures. Similar
information may be contained in the administrative manuals of service providers (SM CAA,
2015 & ICAO, 2013).
49
Integration of management system:

The safety management system and the Quality Management Systems (QMS) complement
each other. The QMS focuses on adherence to the set requirement and regulations. This is
emphasized because it helps organisations to meet their contractual and customer
expectations. On the other hand, the SMS is concerned about an organisation’s safety
performance. The overall goal of SMS is identifying hazards, examine their risks and roll out
suitable risk controls (SM CAA, 2015 & ICAO, 2013). However, there are major similarities
between the QMS and SMS as provided below:
▪ The two require effective planning and management.

▪ Performance indicators have to be decided by the organisation. These indicators are
used in performance monitoring and measurement.
▪ They both involve the functions of an organisation touching on product/service
delivery in the aviation sector.
▪ The two are subject to period reviews to ensure continuous improvements.
Gap analysis:
Safety gap analysis is a process to compare the existing safety management system of a Part
145 organisation with the SMS framework requirement. Most of the aviation organisation
already have compliance in SMS with national regulatory authority. It is important to note
that the existing control systems and organisational structures should form the basis for SMS
development. It is important to perform a gap analysis in order to develop an effective SMS
implementation plan. This is because the analysis helps identify gaps that should be captured
in the plan. To ensure a proper gap analysis, ICAO has created a gap analysis checklist which
contains several questions. Answering the questions leads to proper gap analysis for a
company (SM CAA, 2015 & ICAO, 2013).
(Gap analysis checklist can be found on the following page)
50
51
52
53
54
Gap analysis checklist (SM CAA, 2015).
55
(SM CAA, 2015).
Safety performance indicator:

The definition of measurable performance outcomes by an SMS is in determination of the
system’s operations in line with the design expectations and not just meeting the regulatory
requirements. The monitoring of known safety risks, the detection of emerging safety risks,
and the determination of any corrective actions is done through safety performance
indicators.
Another role of the safety performance indicators in the provision of objective evidence for
use by the regulator in the assessment of the effectiveness of Part 145 organisations SMS and
monitoring the achievement of its safety related objectives. The safety performance
indicators in an organization consider factors that are linked to the safety risk tolerance,
regulatory requirements, public expectations, and cost/benefits of improvements
implementation to the system. The selection and development of safety performance
indicators should be in consultation with the regulatory authority of Part 145 organizations.
56
The necessity of the process is for the facilitation of the harmonisation and aggregation of the
safety performance indicators for the aviation sector by the regulator. Analysis method is
given on the next page to analyse safety performance for an air operator which can be used
for the performance analysation (SM CAA, 2015 & ICAO, 2013).
Using the example on the next page, safety performance indicator and their target can be
identified for the performance evaluation.
57
(ICAO, 2013).
58
(ICAO, 2013)
59
(ICAO, 2013).
60
(ICAO, 2013).
61
(ICAO, 2013).
62
(SM CAA, 2015).
63
Methodology:
In order to reduce the loss of lives and property, International Civil Aviation Organization
(ICAO) begun a significant revision of their Global Aviation Safety Plan. Accordingly, ICAO
developed and established a Safety Management System, which was a business-like approach
to implement performance-based safety regulation. To support the implementation of safety,
ICAO published Safety Management Manual (SMM) in the year of 2006. It is a well-described
guideline for airline operators, Part 145 organisation, MROs, and related organisation to
establish the safety management system in the organisation. ICAO member states were
required to establish and implement SMS. Currently, all the 192 member states of ICAO are
developing safety management system to meet the requirement of ICAO regulations while
some of the member states have already developed SMS.
It is clear that to review and analyse the function and operation of safety management system
into a Part 145 organisation, Safety Management Manual (SMM) is the best tool to gather
knowledge and generate a clear idea of SMS function and operation. On the other, SMM
contains all the required tools to ensure safety management in an organisation with a tool to
evaluate safety performance. Besides, SMM also has tools to find out safety management
system gap analysis, emergency response procedure, hazard prioritisation, safety risk
mitigation and so on.
To fulfil the aim of the dissertation, vast research has been carried out on the ICAO website,
journals, publications along with verified online journals, online articles, different blogs. To
understand the implementation and capability of the organisation, several case studies were
carried out based on accidents and incidents occurred in the aviation sector in the past, based
on available limited online information. All the information collected online such as online
journals, articles, blogs, case studies, and discussions are due to proper collection of
information and necessary data. Selection of online sources is due to ease of data collection
as it contains crucial information related to the safety management system in the aviation
industry. It is true that there is so many online information that is partial, contradictory and
in some cases false. To verify the secondary information from online is crossed match with
the primary source of information ICAO Annex 19, Safety Management Manual (SMM). After
scrutinising the secondary information with the primary source, data was collected for the
dissertation.
64
Furthermore, to understand safety management in real life environment, some Part 145
approved MRO’s were approached for a discussion about the implication of SMS in the
organisation. Such as safety procedure of organisation, safety risk assessment system, safety
performance analysis procedure and gap analysis. Due to confidentiality and business policy,
the MRO organisations have denied for the discussion as these information and processes are
valuable to similar organisations. Which has resulted me to conduct research based on
available information provided by ICAO, FAA, EASA, CAA UK, SM CAA, and online resources.
Discussion:
Safety in the workplace:
Implementation of safety management system increases the safety in the workplace. Training
of safety management system improves the understanding of safety and enhances safety
culture in an organisation. Safety culture is related to the belief, values, biases, and their
subsequent reflection shared by a person as a member of society. Safety culture reflects the
commonly held beliefs and understanding of personnel working in an organisation.
Summarises the responses received from 10 States on the operational risk areas identified
(EASA, 2017).
65
Training of safety management system and implementation of the process increases the
knowledge of the employee to maintain personal and safety of the workplace. Along with it,
the training highlights their responsibility towards safety. Healthy safety culture of an
organisation creates a high level of trust and respect between personnel working together
and the management team. Along with it, personal safety responsibility, reliability in working
tools and working place create a better work atmosphere, security of life and property.
Fatal accident worldwide per year, 1994 – 2013 (EASA, 2017).
The proper understanding of safety management improves safety in an operational

environment. Such as the design of the workplace to facilitate appropriate environment for
the personnel working in it. The noise level and personnel safety tools to work in a noisy
environment, the lighting of the workshop, office, hanger area, maintenance area etc.
temperature control for the personnel working in the tropical region. The regulatory authority
already has included a safety management system in the compliance category. To comply
with the rules and regulation of Part 145, it is necessary to accomplish a safety management
system in the organisation. Not only that, the regulatory authority will complete an audit to
evaluate the complacency of the safety management system and Part 145 approval.
66
Moreover, implementation of the safety management system brings better health and safety
in the workplace, improved quality of work done, better productivity, less accident incident
and better performance of the organisation (SMS Pro, 2019 & FAA Safety Team Central
Florida, 2013).
Implementation survey based on the input provided by 16 States during 2013 (EASA, 2017).
67
Impact on productivity:
On an investigation carried out by Ahvaz Jundishapur University of Medical Sciences to find
the effect of safety system on productivity of a company in food industry revealed that
implementation of safety program increases the level of productivity in the organization.
Therefore, there is a direct relationship in safety management and productivity of an
organization or company. A different study revealed the relationship between safety program
and job satisfaction and disease. The study concluded that, poor ergonomic factors at
workplace resulted in an increase in complains of employee, absence at work, finally decrease
in the productivity of the organization. Referring to the table to calculate safety performance
indicator, it is clear that, safety management system not only ensure the safety inside the
organization but also it measures the safety performance. Because, organizations that is
related to production or delivering service have higher chance to face safety risk. And with
increase in production rate, possibilities of safety risk increase also. Appropriate use of
technology, proper monitoring system, realization of safety responsibility can be a great
resource for safety management system (Reza Savare, 2016).
Recommendation:
The safety management system is a business-like strategic management process that can help
higher management authority to understand the consequences of the decision they take.
Although other management systems such as quality management system complement
safety management, it should be considered to be a separate management system with a
prime focus to maintain safety in the organisation.
A good safety management system is a collection of safety critical data and the proper
method of utilisation for the predictive approach to safety. As a result, the reliability of the
prediction depends on real-time evidence from multiple data sources. It is essential for the
safety management system to shift away from a compliance-based regulatory approach to a
performance one. For the effectivity of the process, both the operator and the regulator need
a different competence and skill set. With the cooperation of both party’s transformation is
possible. As there are different types of approved organisation, there is no one size fits all
safety management system. Dependent on the service an organisation provides along with
its size safety framework differs.
68
To benefit from a safety management system, organisation staff should maintain safety
culture and voluntarily report of their mistakes, errors, or any incorrect decisions they took
will not be considered as disciplinary actions. Although, for complete negligence or unlawful
acts should not be tolerated.
Collection of safety-critical data may reveal the privacy issues of the employee. Thus, it is
necessary to balance the rights of the employee against the organisation and regulator. For
the benefit of all, impartial data can be used to identify the hazard and associated risk to
improve safety (The International Transport Forum, 2017).
Based on the importance of safety in the aviation industry, there is a need for all organisations
in the industry to effectively implement a safety management system. A safety management
system is vital in ensuring not only the prevention of hazards but also the early identification
of likely risks. For any organisation in aviation, SMS is essential since it aids in improving
interactions and developments within the sector. The availability of the SMS is not the most
vital aspect of safety within the organisation, preferably, the functionality of its different
parts.
SMS offers a system that requires the input from various departments and areas in ensuring
its effectiveness. Such means that the human and technological components have to work
together in ensuring the workability of the SMS. Much more so, effective implementation is
necessary, and this is dependent on continual improvement to systems that affect human
beings and machines.
Conducting a gap analysis is also essential in ensuring the effectiveness of the SMS. A gap
analysis helps identify shortcomings and areas that need improvement in ensuring that the
system is effective in delivering safety. Following a gap analysis, there should be a focus on
improving areas that require interventions. A vital part within gap analysis is the identification
of violation areas and shortcomings that are contributed by technology as well as human
beings. To this end, there will be a high level of safety within an organisation in the aviation
sector.
An essential part of ensuring continual improvements is the sharing of safety data within and
across organisations. For organisations in the aviation sector, there should be a focus on
sharing safety data retrieved from SMS since this advances the growth of the industry.
69
The essence of data sharing revolves around the idea that improvements in the SMS will be
based on the different issues faced by organisations in the industry. The growth of the
industry will continually ensure that safety is a priority and that safety management systems
are useful in addressing current and future safety risks.
Conclusion:
Aviation is a complex industry that mainly deals with transportation. The other parts of the
industry are traffic operator, maintenance, planning, ticketing and so on. Therefore, it is a
tangled network consisting of several independent units which include human. As a result,
the human factor is connected in this sector where all elements are connected to it. Humans
play a vital role in the aviation sector to deliver services. Doing so, there are lots of things that
need to be coordinated in order to maintain safety. Along with quality assurance and financial
management, the safety management system is integrated and decisions in this part of the
management system impact on others.
It is necessary to understand various aspects of the safety management system and need to
align the understanding of its actual function. The safety management system is an
organisation tool to manage safety in the same way that a financial management system is
maintained in a business. Therefore, management of the safety management system is the
same business system to the main organisational safety requirement. Safety management
system provides information on safety and with the help of safety tools proactively find out
the possibilities of risk, measure and manage hazard, planning to meet emergency before it
occurs and so on. Hence, it identifies the possibilities of safety breaches and mitigates them
along with a development plan for improvement.
In this dissertation, a detailed discussion is carried out to find and observe the function and
operation of the safety management system in Part 145 organisation. I started from, the
fundamentals of safety in an organisation along with errors and violations. Then comes safety
reporting followed by safety data collection and analysis. To maintain safety, existing
predictive management system, safety risk management was evaluated in the dissertation to
find out how its effectiveness of function. There was also safety promotion, implementation
planning and gap analysis procedure to ensure the safety management system.
70
Evaluating all the reactive, proactive, and predictive methodology to establish safety in an
organisation. Is it clear that, implementation of the safety management system is not an easy
task.
For an organisation such as an airline operator or a Part 145 organisation, it requires a

significant investment of money and time to accomplish safety management system. Not only
that, but it also requires the commitment of higher-level management of an organisation to
successfully ensures safety. As for the regulating body, to meet the frequent change in the
aviation industry, they need to make significant changes to the regulation to suit the growing
industry. Also, the regulatory body needs to evolve from that of monitoring compliance to
become a partner in the operator's journey to identify the better hazard and the risks they
create and then measure to mitigate them. To play this role, regulatory authority and
operators need to share safety data. Therefore, for the successful implementation of safety
management system, critical safety data needs to be protected in such a way to balance it.
71
Reference:
▪ A. Shanmugam (2015), Ranking of aircraft maintenance organization based on human

factor performance, Available
at: https://www.sciencedirect.com/science/article/abs/pii/S0360835215003204
(Accessed: 25/01/2019).
▪ aviationchief.com (2018) , Accident Report of British Airways Flight 5390, Available
at: http://www.aviationchief.com/british-airways-flight-5390.html# (Accessed:
22/02/2019).
▪ Barbara G. Kanki (2018), Organizational factors and safety culture, Available
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▪ Civil Aviation Authority (CAA) UK (2014), Safety Management Systems (SMS) guidance for
organisations - CAP 795, Available
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(Accessed: 10/12/2018).
▪ Civil Aviation Authority (CAA UK) (2002), Fundamental Human Factors Concepts (CAP
719), Available at: https://publicapps.caa.co.uk/docs/33/cap719.pdf (Accessed:
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▪ Civil Aviation Authority (CAA UK) (2007), UK Overseas Territories Aviation Circular (OTAC);
Aircraft Maintenance Engineers – Personal Responsibility When Medically Unfit or Under
the Influence of Drink or Drugs , Available
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909495cf94ab/Aircraft-Maintenance-Engineers-–-Personal-Responsi.aspx (Accessed:
18/2019).
▪ coloringpagewiki.com (no data), Aloha Airlines Flight 243, Available
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72
▪ Caleb D. Bazyler (2015), Factors affecting fitness, training, and performance, Available
at: https://www.researchgate.net/figure/Factors-affecting-athletic-performance-
modified-from-Stone-et-al-81-Adapted-with_fig1_279327274 (Accessed: 15/01/2019).
▪ Course Hero (2019), Fitness and Health, Available
at: https://www.coursehero.com/file/p34f682f/These-subjects-are-discussed-in-this-
chapter-41-Fitness-and-Health-The-job-of/ (Accessed: 15/01/2019).
▪ Chas Early (2018), June 10, 1990: Miracle of BA Flight 5390 as captain is sucked out of the
cockpit – and survives, Available at: https://home.bt.com/news/on-this-day/june-10-
1990-miracle-of-ba-flight-5390-as-captain-is-sucked-out-of-the-cockpit-and-survives-
11363985642960 (Accessed: 22/02/2019).
▪ EASA (2017), European Aviation Safety Plan, Available
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Safety%20Plan-%28EASp%29-2014-2017.pdf (Accessed: 27/03/2019).
▪ Franck Guarnieri (2015), From theory to practice: itinerary of Reasons’ Swiss Cheese
Model, Available at: https://hal-mines-paristech.archives-ouvertes.fr/hal-
01207359/document (Accessed: 20/01/2019).
▪ FAA Safety Team Central Florida (2013), Safety Management Systems (SMS)
Fundamentals: Basics, Available
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sms-fundamentals-basics?next_slideshow=1 (Accessed: 21/03/2019).
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73
▪ ICAO JOURNAL (2006), Concept of safety management system embraced by many

countries, PROTECTING DATA COLLECTED FOR SAFETY PURPOSES - SAFETY
MANAGEMENT; GLOBAL APPROACH UNLOCKS POTENTIAL OF SMS , VOLUME 61(
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9683-human-factor-training-manual.pdf (Accessed: 13/01/2019).
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75

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KHONDOKAR YEAMIN | 15046575

Module Title: Individual Project

The evolution of safety (ICAO, 2013).

Fundamentals of Safety Management System (SMS):

Safety management system takes a protective approach to safety management, and it is

Performance and limitations of human:

The interaction of human factors (Work Safe BC, 2008).

Health and fitness:

According to ICAO requirement on Article 13 (paragraph 7):

Factors affecting fitness and performance (Caleb D. Bazyler, 2015).

Alcohol, medication, and drug:

Putting drug screening to the test (SHRM, 2010).

The concept of accident causation (ICAO, 2013).

Swiss Cheese Model:

Swiss Cheese model (Taija Lahtinen, 2016).

The organisation accident (ICAO, 2013).

SHELL model of maintenance organization (A. Shanmugam (2015).

Liveware-Environment: Human and environment interface was an age-old concept. Form

Liveware-Liveware: the liveware-liveware interface is the interface between humans. It

Scott A. Snook’s Model:

There are three essential assumptions underlying the system design.

The practical drift (ICAO, 2013).

Reasons behind practical drift may include:

▪ Failure of a technology to consistently function as initially anticipated.

These dirty dozen causes of error are:

Errors and violation:

The probable errors are of different categories including:

Execution and planning failures adapted from Rasmussen (SKYbrary, 2016).

None of the above error categories is desirable. Therefore, appropriate counter-measures or

These strategies are as described below:

Violation: A violation is “a deliberate act of wilful misconduct or omission resulting in a

It is a deliberate action by a malicious person. In most of the instances, violation of a rule is

Violations are of different categories as provided below:

Aloha flight 243:

Aloha Airlines Flight 243 (coloringpagewiki.com, no data).

British Airways flight 5390:

BA Flight 5390 (Chas Early, 2018).

Organisation culture reflects the characteristics of a person working in a company. The

▪ The conduct of staff members when exposed to demanding or stressing operational

The safety space (ICAO, 2013).

Safety reporting and investigation:

Effective safety reporting — five essential characteristics (ICAO, 2013).

(to be continued on next page)

Example of safety reporting form (SM CAA, 2015)

Safety data collection and analysis:

Safety data collection and quality:

The types of data it contains are:

▪ Accident investigation data,

A schematic view of a State’s safety data system (ICAO, 2013).

Safety data analysis:

The analysis is also used for other purposes such as:

▪ Helps determine additional facts that may be necessary.

Analytical method and tools:

Management of safety information:

However, on a general scale, a system should have the features below:

▪ Ability to categorise and log different safety events.

Protection of safety data:

▪ Sufficient but well secured accesses.

Implementation of Safety Management System (SMS):

The element ensures that:

▪ All the required information is easily accessible/ available.

Involved organizations and personnel are:

Safety policy and objective: