SAFETY MANAGEMENT SYSTEMS

19 Juli 2020
References:
• ICAO Annex 19
• ICAO Document 9859
• CASR Part 19, 2017
• SMS Audit Form 120.91/97/98
Presented AQSM-Otman
 ICAO Annexes
• Annex 1 Personnel Licensing
• Annex 2 Rules of the Air
• Annex 3 Meteorological Service for International Air Navigation
• Annex 4 Aeronautical Charts
• Annex 5 Units of Measurement to be Used in Air and Ground Operations
• Annex 6 Operation of Aircraft
• Annex 7 Aircraft Nationality and Registration Marks
• Annex 8 Airworthiness of Aircraft
• Annex 9 Facilitation
• Annex 10 Aeronautical Telecommunications
• Annex 11 Air Traffic Services
• Annex 12 Search and Rescue
• Annex 13 Aircraft Accident and Incident Investigation
• Annex 14 Aerodromes
• Annex 15 Aeronautical Information Services
• Annex 16 Environmental Protection
• Annex 17 Security: Safeguarding International Civil Aviation Against Acts of Unlawful Interference
• Annex 18 The Safe Transport of Dangerous Goods by Air
• Annex 19 Safety Management (new, July 2013)
 ICAO Document 9859
(SAFETY MANAGEMENT MANUAL, 3rd Edition 2013)

CONTENTS
• CHAPTER 1 – OVERVIEW of the MANUAL
• CHAPTER 2 - SAFETY MANAGEMENT
FUNDAMENTALS
• CHAPTER 3 - ICAO SAFETY MANAGEMENT SARPs
• CHAPTER 4 - STATE SAFETY PROGRAMME (SSP)
• CHAPTER 5 - SAFETY MANAGEMENT SYSTEM (SMS)
– 5.1 INTRODUCTION TO SMS
– 5.2 SCOPE
– 5.3 SMS FRAMEWORK
– 5.4 SMS IMPLEMENTATION PLANNING
– 5.5 PHASED IMPLEMENTATION APPROACH
 KM 20, 2009
(17 Feb 2009)

CONTENTS

1. LANDASAN HUKUM
2. RUANG LINGKUP dan PENERAPAN
3. REFERENSI
4. DEFINISI
5. UMUM
6. KEBIJAKAN KESELAMATAN dan SASARAN
(Component 1)
7. MANAJEMEN RESIKO KESELAMATAN
(Component 2)
8. JAMINAN KESELAMATAN (Component 3)
9. PROMOSI KESELAMATAN (Component 4)
CASR Part 19 (Aug 2017)
 REGULATION
Audited
TO COMPLY
CASR Part 60, Synthetic Training Devices SQSM
O
P
E
CASR Part 141, Certification and Operating Requirements for Pilot Schools R TPM
A
T
I
CASR Part 61*, Licensing of Pilots and Flight Instructors + CASR Part 67 O TPM
N

TPM
CASR Part 91, General Operating and Flight Rules
A i
A i TPM
I i
CASR Part 43, Maintenance, Preventive Maintenance, Rebuilding, and R N
Alteration W E TPM
O S
R S
T
H
CASR Part 65*, Licensing of Aircraft Maintenance Engineer + CASR Part 67 I TPM
i

CASR Part 19, Safety Management System S SMSM

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F
* Plus IELP E
T
CASR Part 830, Accident and Serious Incident Investigation Procedure Y CCM
Need Compliance Statement
 Flight School Audit

Audit Scope
SI 91-
SI 141-01 SI 19-05
XX
Airworthi Airworthi Manual and Internal
Reporting
Operation ness Implemen-
ness tation
System Audit
(DGCA Form (DGCA Form 91- (DGCA Form
Prepared(DGCA
141-04) by Form
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141-04) 11)
(DGCA Form 120-98)
(DGCA
Form120-97)
120-91)
 After OC 91 Approval, full requirements of CASR Part
91 must be comply (no separate check-list available).
The Operation Area, does not mean School Operation
(141) only, but will include Flight Operation (91).
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A. Maintenance Facilities
B. Personnel-Qualification / Supervision
C. Maintenance Program/ Inspection Items
D. Record Systems
E. Airworthiness Directive Compliance
F. Inspection Program
G. Aircraft Weight and Balance
H. Fueling and Servicing
I. Spot Inspection of Aircraft During Maintenance

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 1. PART I. SMS MANUAL (Form 120-91)
A. GENERAL
B. SAFETY POLICIES and OBJECTIVE
C. SAFETY RISK MANAGEMENT
D. SAFETY ASSURANCE
E. SAFETY PROMOTION

2. PART II. SMS GAP IMPLEMENTATION (Form 120-91)

3. PART III. PHASE IMPLEMENTATION SMS (Form 120-91)

4. SMS REPORTING SYSTEM (Form 120-98)

5. SMS INTERNAL AUDIT (Form 120-97)

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 CASR Part 830
Investigasi Kecelakaan dan Kejadian Serius
Accident and Serious Incident Investigation

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 Appdx A: Mandatory Report

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 On-line Reporting (MOR)

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 Appdx B :
Serious Incident

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Appdx C :
Aircraft Damage

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 TPM (Rev 5)
SAFETY MANAGEMENT
7.1-SAFETY MANAGEMENT SYSTEM
7.1.1 BIFA has established a Safety
Management System (SMS) to ensure
continued compliance with the CASR Part
141 (141.83) => CASR Part 19.
7.1.2 In addition to ensuring regulatory
compliance, the SMS is a means of
ensuring the upkeep of our safety
performance and improving it in any
possible way. This in turn allows BIFA to
keep the business profitable

7.1.3 The BIFA SMS assists in:

• Ensuring compliance with regulations
• Controlling losses
• Encouraging everyone to be proactive
• Investigation of accidents and incidents
• Making safety an integral part of all activities
7.1.4 BIFA has developed a Safety
Management System Manual (SMSM)
which contains all the information, policies
and procedures pertaining to the Safety
Management System at BIFA.

7.1.5 The SMS Manual is a controlled

document which is authorized for use by
BIFA by the Directorate General of Civil
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Aviation.
SMS MANUAL
 SMS MANUAL
2-SAFETY POLICY AND OBJECTIVES
• Management Commitment and Responsibilities
1-GENERAL • Safety Policy
• Safety Objectives
• Appointment of Key Safety Personnel (Org)
• Coordination of Emergency Response Planning
=> Company Crisis Manual (=ERP)

3-SAFETY RISK MANAGEMENT 4-SAFETY ASSURANCE

•Hazards Identification •Safety Performance
•Management of Change
•Safety Risk Assessment and Mitigation •Safety Assessment and Oversight
•Reporting (Hazard and Occurrence) •Continuous Improvement
•Investigation •Safety Audit
•Safety Review Board, and Safety Action Group

5-SAFETY PROMOTION
• Training and Education
• Safety Communication
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SAFETY KEY PERFORMANCE INDICATOR

Aviation Aviation
Miscelaneous
Occurrence Occurrence Rate

Number of : Number of Number of :

- Accident, Occurrences - Hazard Report,
(see above),
- Serious Incidents, per 4000 hours - Training Activities,
- Major Incidents, -Safety Review Board,
- Minor Incidents, Flight Time - Internal Safety
- Negligible Incidents Audits,
- Audit Findings,
- Non-Aviation
Occurrences
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Available ??
 PERFORMANCE INDICATORS

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Other Indicators Measurement ??
COMPANY CRISIS MANUAL
(CCM = ERP)
 COMPANY CRISIS MANUAL (CCM=ERP)
• Function • Classification
• Organization • Accidents
• Scope • Serious Incidents
• Basic Principles • Major Incidents
• Minor Incidents
• Negligible Incidents
• Night Operations
• Mayday and Pan Pan Calls
• Investigations

OCCURRENCES
OVERVIEW
and RESPONSES
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 2.OCCURRENCE CLASSIFICATION

OCCURRENCE
1
Accident
2 3 4 5
On- Off- Missing Serious Major Minor Negligible
Airport Airport Aircraft Incident Incident Incident Incident
Accident Landing -Uncertainty
-Alert
-Distress

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ory Report Voluntary Report

MOR
 9.INVESTIGATION

PRELIMINARY FACTUAL
INFORMATION
SERIOUS INCIDENTS

(Appendix E - FORM)

INTERNAL INVESTIGATION FACTUAL

ACCIDENT,

(BIFA) INFORMATION

FINAL
ANALYSIS
(No FORM available)
FORMAL INVESTIGATION
(DGCA/KNKT)
CONCLUSION
(Factors affecting/Most probable ?)

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 SHELL Model in BIFA

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

Errors can be divided into the two following categories:

a. Mistakes are failures in the plan of action. Even if execution of the plan
was correct, it would not be possible to achieve the intended outcome.

b. Slips and lapses are failures in the execution of the intended action.
a. Slips are actions that do not go as planned. For example, operating the flap
lever instead of the (intended) gear lever.
b. Lapses are memory failures. For example, forgetting a checklist item.

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 2.5-Violation
Violation : a deliberate act of willful misconduct or
omission resulting in a deviation from established
regulations, procedures, norms or practices.

Violations can be categorized as follows:

• Situational violations
• Routine violations
• Organizationally induced violations
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 2.5-Kesalahan dan Pelanggaran
(Error and Violation)

I forgot to dial the I didn’t ring because . . .

number
Was error intentional ?

Lapse No Yes Violation

BAD
BAD SKILL ATTITUDE
Yes Yes
Did the error involve willfully and
Did the error involve a task or step
consciously breaking a rule or
being omitted ?
procedure ?

No No

Did the error involve an incorrectly Did the error involve an incorrect plan
executed task or step ? or incorrect assessment of a situation ?
Yes Yes BAD
BAD SKILL KNOWLEDGE

Slip
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I dialed the wrong number I thought I didn’t need to ring
 SMS to Reduce Hazard

1-5
Accidents

30-100
Serious Incidents

100-1.000
Incidents

1.000-4.000
Latent Conditions/Hazards

SMS goal is to reduce the risk of Latent

Conditions/Hazards => by Identifying Hazards
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 2.13-Hazard Identification
Hazard Identification Methodologies

• Reactive – Through analysis of past outcomes or events.

• Proactive – Through analysis of existing or real time
situations.
• Predictive – Through data gathering in order to identify
possible negative future outcomes or events.

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2.13-Hazard Identification Methods

Hazard Identification Methods

• Employee Complaint / Suggestion

• Formal Safety Audits
• Workplace Inspection / Observation
• Incident Investigation
• Historical Safety Records
• Safety Commitee Recomendation
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 2.14-Safety Risk Probability

LIKELIHOOD MEANING VALUE

FREQUENT Likely to occur many times (has occured frequently) 5

OCCASIONAL Likely to occur many times (has occured infrequently) 4

REMOTE Unlikely to occur, but possible (has occured rarely) 3

IMPROBABLE Very unlikely to occur many times (not known to have occured ) 2
EXTREMELY
Almost inconceivable that the event will occur 1
IMPROBABLE

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 2.15-Safety Risk Severity

SEVERITY MEANING VALUE

 Equipment destroyed
CATASTROPHIC A
 Multiple deaths
 A large reduction in safety margins, physical distress
HAZARDOUS  Serious injury B
 Major equipment damage
 A significant reduction in safety margin
MAJOR  Serious incident C
 Injuriy to persons
 Nuissance
 Operating limitations
MINOR D
 Use of emergency procedures
 Minor incident
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NEGLIGIBLE  Little consequences E
 2.14-Safety Risk Assessment Matrix
RISKRISK SEVERITY
SEVERITY
RISK
RISK
PROBABILITY
PROBABILITY CATASTROPHIC HAZARDOUS MAJOR MINOR NEGLIGIBLE
A B C D E
FREQUENT
5 5A 5B 5C 5D 5E
OCCASIONAL
4 4A 4B 4C 4D 4E
REMOTE
3 3A 3B 3C 3D 3E
IMPROBABLE
2 2A 2B 2C 2D 2E
EXTREMELY
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1B 1C 1D 1E
1
5.3-FRAMEWORK (COMPONENTs and ELEMENTs)

1-Safety Policy and 2-Safety Risk

Objectives Management
• 1-Management commitment • 6-Hazard identification
and responsibility
• 2-Safety accountabilities • 7-Risk assessment and
• 3-Appointment of key safety mitigation
personnel
• 4-Coordination of emergency
response planning
• 5-SMS documentation

3-Safety Assurance 4-Safety Promotion

• 8-Safety performance • 11-Training and education
monitoring and measurement •
• • 12-Safety communication.
• 9-The management of change

• 10-Continuous improvement
of the SMS

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Phase
1,2,4
1-Safety Policy and Objectives
• SMS Element 1.1 Management commitment and responsibility
 The service provider shall define the organization’s safety policy which shall be in accordance
with international and national requirements, and which shall be signed by the accountable
executive of the organization. The safety policy shall reflect organizational commitments
regarding safety; shall include a clear statement about the provision of the necessary resources
for the implementation of the safety policy; and shall be communicated, with visible
endorsement, throughout the organization. The safety policy shall include the safety reporting
procedures; shall clearly indicate which types of operational behaviours are unacceptable; and
Phase 2 shall include the conditions under which disciplinary action would not apply. The safety policy
shall be periodically reviewed to ensure it remains relevant and appropriate to the organization.

• SMS Element 1.2 Safety Accountabilities

 The service provider shall identify the accountable executive who, irrespective of other
functions, shall have ultimate responsibility and accountability, on behalf of the organization, for
the implementation and maintenance of the SMS. The organization shall also identify the
accountabilities of all members of management, irrespective of other functions, as well as of
employees, with respect to the safety performance of the SMS. Safety responsibilities,
accountabilities and authorities shall be documented and communicated throughout the
organization, and shall include a definition of the levels of management with authority to make
decisions regarding safety risk tolerability
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Phase 2
1-Safety Policy and Objectives
• SMS Element 1.3 Appointment of key safety personnel
 The service provider shall identify a safety manager to be the responsible individual
Phase 2 and focal point for the implementation and maintenance of an effective SMS

• SMS Element 1.4 Coordination of emergency planning

 The service provider shall ensure that an emergency response plan that provides for
the orderly and efficient transition from normal to emergency operations and the
return to normal operations is properly coordinated with the emergency response
Phase 2
plans of those organizations it must interface with during the provision of its services.

• SMS Element 1.5 SMS Documentation

 The service provider shall develop an SMS implementation plan, endorsed by senior
management of the organization that defines the organization’s approach to the
management of safety in a manner that meets the organization’s safety objectives.
The organization shall develop and maintain SMS documentation describing the
safety policy and objectives, the SMS requirements, the SMS processes and
procedures, the accountabilities, responsibilities and authorities for processes and
procedures, and the SMS outputs. Also as part of the SMS documentation, the
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develop and maintain a safety management system manual
(SMSM), to communicate its approach to the management of safety throughout the
organization.
Phase
2-Safety Risk Management
3,4

• SMS Element 2.1 Hazard identification,

 The service provider shall develop and maintain a formal process that ensures that
hazards in operations are identified. Hazard identification shall be based on a
combination of reactive, proactive and predictive methods of safety data collection.
Phase 3

• SMS Element 2.2 Risk assessment and mitigation,

 The service provider shall develop and maintain a formal process that ensures
analysis, assessment and control of the safety risks in operations.

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Phase
3, 4
3-Safety Assurance
• SMS Element 3.1 Safety performance monitoring and measurement
 The service provider shall develop and maintain the means to verify the safety
performance of the organization and to validate the effectiveness of safety risk
controls. The safety performance of the organization shall be verified in reference to
Phase 3 the safety performance indicators and safety performance targets of the SMS.

• SMS Element 3.2 Management of change

 The service provider shall develop and maintain a formal process to identify changes
within the organization which may affect established processes and services; to
describe the arrangements to ensure safety performance before implementing
Phase
changes; and to eliminate or modify safety risk controls that are no longer needed or
3, 4
effective due to changes in the operational environment

• SMS Element 3.3 Continuous improvement of the SMS

 The service provider shall develop and maintain a formal process to identify the
causes of substandard performance of the SMS, determine the implications of
substandard performance of the SMS in operations, and eliminate or mitigate such
causes.
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Phase
4-Safety Promotion
1, 4

• SMS Element 4.1 Training and education

 The service provider shall develop and maintain a safety training programme that
ensures that personnel are trained and competent to perform the SMS duties. The
Phase scope of the safety training shall be appropriate to each individual’s involvement in
1, 4
the SMS.
• SMS Element 4.2 Safety communication
 The service provider shall develop and maintain formal means for safety
communication that ensures that all personnel are fully aware of the SMS, conveys
safety-critical information, and explains why particular safety actions are taken and
why safety procedures are introduced or changed

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Complete PM 78