ACAC SMS Training

TRAINING IN SAFETY
MANAGEMENT SYSTEMS
ARAB CIVIL AVIATION CONFERENCE
Amman, Jordania 19-23 July 2009
1
Welcome to Safety
Management
System Workshop
2
ACAC, Safety Management Systems Training
Speakers:
• CHRISTER PRAHL
• ATM Safety Expert
• Electronic Engineer
• Degree in Communication
• Degree in Networking
• Pilot (IFR rated)
3
Speakers:
• MICHAEL NIELS THORSEN

• ATM Safety Expert
• Master of Science in Engineering
• Expert International Cooperation
• Expert Safety Management Implementation
• Expert Organisational Structures
4
Round the table
Name and Position
5
Agenda for today:
09.00 – 10.30 Registration and Welcome

10.30 – 11.00 Break
11.00 – 12.30 ICAO presentation on Safety Management System
SES Regulations
12.30 – 14.00 Lunch
14.00 – 15.00 The Safety System
15.00 – 15.30 Break
15.30 – 16.30 The Safety Management System
16.30 – 17.00 Wrap - Up
6
General “House-Rules”
• Hand-outs will be given in connection with the lesson;

• CD will come at the end of the course;
• Questions during the lessons;
• Active participation is anticipated;
• Flexible approach, programme can be changed – also
on request;
• Turn off cell phone;
• Please stop the instructors if you don’t understand
them;
7
Objectives of the workshop
Provide participants the knowledge of Safety

Management Concept and ICAO Standards and
Recommended Practices (SARPs) on safety management in
Annexes 6, 11 and 14 and related guidance material
AND TO…
Develop participants knowledge to certify and oversee

the implementation of key components of an SMS, in
compliance with relevant ICAO SARPs.
8
ICAO - Safety Management System
• What is Safety?
• Zero Accidents?
• Freedom from danger or risks?
• Error avoidance?
• Any suggestions?
9
According to ICAO Doc 9859:
Safety is the state in which the risk to harm the

persons or property damages is reduced, and
maintained at or below, an acceptable level
through a continuing process of hazard
identification and risk management.
10
A safety management system (SMS) is an organised approach to

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

structured management approach to control safety risks in operations.
Effective safety management must take into account the organisation’s
specific structures and processes related to safety of operations.
11
Safety Management System
Structure and Contents
10: Phased approach
to SMS
Implementation
8: SMS planning 9: SMS operation
7: Introduction to
5: Risks 6: SMS regulation
SMS
3: Introduction
1: SMS course 2: Basic safety
to safety 4: Hazards
introduction concepts management
12
Safety Management Manual
Objectives
Objectives of the Safety Management Manual are to provide States:
• Knowledge of safety management concepts, the ICAO Standards and

Recommended Practices (SARPs) on safety management contained in Annexes
1, 6, 8, 11, 13 and 14, and related guidance material;
• Guidance on how to accept and oversee the implementation of the key

components of an SMS in compliance with the relevant ICAO SARPs;
• Guidance on how to develop and implement an SSP in compliance with the

relevant ICAO SARPs.
13
Concept
SMS/SSP
Implementation
ICAO SARPS Safety Concepts
14
Generic SMS Requirements
ICAO requirements for implementation of SMS are currently applicable to:
• Air Traffic Service Providers (Annex 11)

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

and extend provisions relating to safety management.
15
SES Regulation - Objectives
The second SES package has been put forward by the European
Commission in order to make the European sky safer and more
sustainable by:
• Introducing a performance framework for European ATM with quantified

target setting;
• Creating a single safety framework to enable harmonised development of
safety regulations and their effective implementation;
• Opening the door to new technologies enabling the implementation of
new operational concept and increasing safety levels by a factor of ten;
• Improving management of airport capacity.
16
The 1st SES legislative package
The legislative package adopted in 2004 comprises four base regulations,

which reinforce safety and foster the restructuring of European airspace
and air navigation services. The regulations provide the framework for the
creation of additional capacity and for improved efficiency and
interoperability of ATM system in Europe.
• The Framework regulation (EC No 549/2004) - laying down the

framework for the creation of the single European sky;
• The Service provision regulation (EC No 550/2004) - laying down
common requirements for the provision of air navigation services;
• The Airspace regulation (EC No 551/2004) - on the organisation and
use of airspace in the Single European sky;
• The Interoperability regulation (EC No 552/2004) - on the
interoperability of the European Air Traffic Management network.
17
(EC) No 549/2004 - Framework
The objective of the Framework regulation is to enhance current safety
standards and overall efficiency of the general air traffic in Europe,
to optimise ATM system capacity and minimise air traffic delays by
establishing a harmonised regulatory framework for air traffic
management in Europe.
The Framework regulation establishes harmonised institutional, regulatory

and consultation arrangements to enable the creation of the Single European
Sky.
In brief these are:
• National Supervisory Authorities (NSA)
• Single Sky Committee
• Military Issues
• Industry Consultation Body
• Implementing Rules
• Performance Review
• Safeguards
18
(EC) No 550/2004 – Provision of Air
Navigation Services in SES
The Service provision regulation establishes common requirements to ensure
that air navigation services are provided safely and efficiently, on a continuous and
interoperable basis, throughout the European Community. It introduces a
harmonised system of certification and lays down rules for designating service
providers.
The stipulations of this regulation apply to the provision of air navigation

services to General Air Traffic (GAT) and can be summarised as follows:
• National Supervisory Authorities (NSA)

• Licensing of Controllers
• Common Requirements
• Certification of Air Navigation Service Providers (ANSPs)
• Designation of Air Traffic Service Providers
• Relations between Service Providers
• Transparency of Accounts
• Access to and Protection of Data
• Charging Schemes 19
(EC) No 551/2004 – Organisation
and use of Airspace in SES
The objective of the Airspace regulation is to put an end to the fragmentation of European
Union (EU) airspace and to create an efficient and safe airspace without frontiers. The
organisation and management of airspace should be improved by merging all the national
flight information regions (FIRs) into a single portion of airspace within which ATS will be
provided according to the same rules and procedures.
The Airspace regulation forms part of the first package of legislation on air traffic management
designed to create a SES. This objective will make for improved safety, optimum use of
European
airspace, reduced air traffic delays and sustainable air transport growth.
The following is summarising this regulation:

• Establishment of European Upper Flight Information Region (EUIR)
• Reconfiguration of Upper Airspace
• Optimised Route and Sector Design in the Upper Airspace
• Flexible Use of Airspace
• Safeguards
20
(EC) No 552/2004 – Interoperability
of the European ATM Network
The aim of the Interoperability regulation is two-fold:
• To achieve interoperability between the different systems, constituents and
associated procedures in the European ATM network by establishing a
harmonised system for certification of components and systems;
• To ensure the introduction of new agreed and validated concepts of operations
and technology in air traffic management.
The following topics summarise the Interoperability regulation:

• Essential Requirements
• Implementing Rules for Interoperability
• Community Specifications
• EC Declaration of Conformity of Suitability for Use of Components
• Safeguards
• Transitional Arrangements
21
The SES Implementation
Implementing the provision of the SES regulations would bring a number of

significant benefits:
• Improved level of safety of air navigation services;

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

• Directives: Mandatory with National exemptions
• Implementing Rules: Guidelines
23
The 1st SES legislative package
The First Report on the implementation of the Single Sky Legislation

was published in December 2007.
It presents:
• the achievements,
• identifies new challenges
• proposes the way forward.
Based on the report findings, the Commission came forward with

proposals for a 2nd Single Sky package, including extension of EASA
competencies to ATM and adoption of the European ATM Master Plan.
24
The 2nd SES legislative package
To tackle issues such as traffic increase, financial burden and
environmental awareness, the Commission has come up with 2nd SES
legislative package aimed to:
• Create a single safety framework to enable harmonised development

of safety regulations and their effective implementation;
• Improve the performance of the ATM system through setting of
targets;
• Open the door to new technologies enabling the implementation of
new operational concept and increasing safety levels by a factor of
ten;
• Improve management of airport capacity
25
(EC) No 2096/2005 – Common Requirements
for the Provision of Air Navigation Services
The objective of this Regulation is to establish common requirements for the safe and
efficient provision of air navigation services in the European Community and to set uniform
and high safety standards for ANSPs.
The common requirements cover the following areas:
• Technical and operational competence and capability

• Organisational structure and management
• Safety and quality management
• Security
• Human resources
• Financial strength
• Liability and insurance cover
• Quality of services
• Reporting requirements
The common requirements do not cover military operations and training and do not apply to
activities or resources allocated to activities outside the provision of air navigation services.
26
The Regulation identifies and adopts the mandatory provisions of the following
EUROCONTROL Safety Regulatory Requirements (ESARRs) which are relevant for the
certification of air navigation service providers:
• ESARR3 - on the use of safety management systems by air traffic management

(ATM) service providers;
• ESARR4 - on risk assessment and mitigation in ATM;
• ESARR5 - on ATM services' personnel, in particular the requirements for engineering
and technical personnel undertaking operational safety related tasks.
• The detailed requirements relating to safety of services are contained in Annex II to
the Regulation.
27
Subjects summarising (EC) No 2096/2005 are as follows:
• Certification of ANSPs
• Derogations
• Demonstration of Compliance
• Compliance Monitoring
• Peer Review of NSAs
28
Similarities and Differences between
ICAO and SES
t c an ICAO Methodology we
Wha ng? a n
ro c ?
go w h at out it
W ab
Likelihood Assessment
do
Hazard Identification
Severity Assessment
System Description
System Description
Documentation
Risk Mitigation
Planning
Step 0:
Step 1:
Step 2:
Step 3:
Step 4:
Step 5:
Step 6:
Step 7:
EUROCONTROL Methodology (ESARR)
Preliminary
Functional System Safety
System Safety
Hazard Assessment Assessment
Assessment
(FHA) (SSA)
(PSSA)
29
ICAO Safety Regulation
• ICAO Annex 11 – Paragraph- 2.26 – ATS Safety Management

includes relevant requirements related to ATS
• Para 2.26.1 requires the States to implements systematic and

appropriate Safety Management Programmes, further detailed in
Para 2.26.4
• Para 2.26.2, requires States to establish the acceptable level of

safety and safety objectives applicable to the provision of ATS
within their airspace and at their aerodromes with acceptable level
of safety further detailed in 2.26.3
30
ICAO Provisions
• Para 2.26.5 requires that any significant safety-related change to

the ATC system shall only be implemented after a safety
assessment has demonstrated that an acceptable level of safety will
be maintained.
• Para 2.26.5 also requires that the responsible authorities shall

provide for post-implementation monitoring to verify that the
defined levels of safety continues to be met
31
ICAO Provisions
• PANS-ATM doc.4444 includes in Chapter 2 requirements for:
• ATS maintaining acceptable level of safety (section 2.1)

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

(examples):
• A new operating procedure, including departure and arrival procedures, to

be applied within an airspace or at an aerodrome;
• A reorganization of the ATS route structure;
• A resectorisation of an airspace;
• Physical changes to the layout of runways and /or taxiways at an
aerodrome; and
• Implementation of new communications, surveillance or other safety-
significant systems and equipment, including those providing new
functionality and or capabilities.
33
The new Manual on Safety Management for Aerodromes and Air

Traffic Services (Doc 9859)
Provides detailed guidance on implementation of the provisions of Annexes

6, 11, 14 and the PANS-ATM
• First Draft was endorsed by 11th Air Navigation Conference (Montreal, Sep/Oct 2003)
• Current version in ICAO NET web
• Based on the same approach to safety as recommended by the ATM Operational Concept
(Doc 9854)
34
The Concept of Safety Management
Safety
Culture
Safety
Monitoring
Safety
Philosophy Assessment
Of Safety Safety Maintenance of
Management Policy Safety Improvement of
Auditing Safety Performance
Safety
Promotion
Supporting
Organisational
Requirement
Safety Management
35
Legal and Regulatory Foundation
for Safety Management
Implementation of safety management programs refers to the day
to day keep safety oversight management by the service providers
• States shall establish systemic and suitable ATS safety management

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

must be sufficient to support the desired process.
• Planning - Strategic planning and development of appropriate activities must be based on
systematic and comprehensive assessment of risks.
• Management personnel standards - Safety must be integrated into line and operating
management responsibilities, and their roles must be clearly defined in written standards of
performance.
• Training for operations and emergencies
• Procedures - The organization must develop written procedures for design, operations and
maintenance activities to control routine work and probable emergencies.
• Management of change
• Mechanical integrity - The organization must establish systematic and comprehensive
means to assess the integrity of process equipment.
• Management of contractors - Safety must be a prominent consideration in the selection of
contractors, and appropriate means to monitor the work of contractors must be in place
and working.
• Involvement of the work force
• Accident/incident reporting, investigation and follow-up - Monitoring and auditing methods
must be in place to monitor the on-going, day-to-day performance of the safety system, as
well as to audit thoroughly compliance to all requirements on a periodic basis.
37
Global Safety System
Documentation:
• AD – Technical ICAO
• Implementing Rules
Guidelines
• Guidance Material EASA Regulations
• Acceptance Means of Compliance Requirements, EU OPS
• Notices of proposal amendments EUROCONTROL Recommendations
Legislation
EC
States
National Legislation
Ministries NSA
•Aviation Law
CAA •Airport Law
•Regulations
•Standards
Manuals
Service Providers Working Procedures
Documentation
38
Organisation:
• The world global Safety System consist of all

the existing safety management systems on
all levels in all the areas of aviation like the
service providers, the airspace users, the
maintenance organisations etc.
39
Supporting Issues:
• Auditing
• Inspections
40
Security:
• Improved security of ATM systems and

information
• Provides assistance and information
• In Flight Emergency Response
• ICAO Annex 17
41
Security:
Until the events of 11 September 2001, the ICAO model was regarded as adequate and
sufficient to ensure the safety of passengers, aircraft and goods. However, in December
2001 the ICAO adopted an Amendment 10 to Annex 17, which set out a number of
additional safety and security requirements. These include the following:
1. Aircraft security check

2. Background check
3. Screening
4. Application of Security
5. Security Restricted Areas
6. Objectives
7. International cooperation
8. National Organization and appropriate authority
9. Airport Operations
10. Quality Control Programme
11. In-flight aircraft security measures
42
Security:
ICAO Security Concept:

National Civil Aviation Security Program
National Aviation Security Committee
Airport Operator Quality National

Security Security Control Training
Program Programs Program Program
Authority
Airport
Emergency
Plan
Contingency Airport Security
Plan Committee
43
Quality Definitions:
Quality – the totality of features and characteristics of a product or service that bear on
its ability to satisfy a given need.
Quality Policy – the overall quality intentions and direction of an organisation as regards
quality, as formally expressed by top management.
Quality Management – that aspect of the overall management function that determines
and implements the quality policy.
Quality System – the organisational structure, responsibilities, procedures, processes and

resources for implementing quality management.
Total Quality Management – a management approach of an organisation centred on

quality, based on the participation of all its members and aimed at long term success
through customer satisfaction and benefits to the members of the organisation and society.
Quality Assurance – the activities an organisation carries out to provide to external and
internal parties confidence that the organisation will consistently meet the requirements for
quality.
44
Quality:
Airport Quality Process:
• Evaluation of user needs and expectations

• Design and implementation of service
• Operation and achievement of service
• Measurement of quality of service
• Evaluation and Corrective action
45
Quality Definitions:
Airport Quality Elements:

Safety
Security
Efficiency
Service
Capacity
Environment
Health
46
Quality:
The implementation of QMS, completed in March 2002, included data and

product quality assurance and control processes. These processes drew on
the following existing resources:
• day-to-day consistency checking systems for both data and products,

• forecast verification system developed in 2000 which gave for each
forecast a score relative to the ICAO desirable accuracy for each of the
weather elements.
• The QMS also included on-going review processes for continual
improvement and for the provision of adequate resources to sustain the
QMS.
Further, as important components of the QMS, customer needs
assessment and satisfaction survey became an institutionalized part of the
system.
47
Safety:
As stated before:
• The world global Safety System consist of all

the existing safety management systems on
all levels in all the areas of aviation like the
service providers, the airspace users, the
maintenance organisations etc.
48
Safety Versus Quality and Security:
It is accurate to say that SMS and QMS share many commonalities. They both:
a) have to be planned and managed;
b) depend upon measurement and monitoring;
c) involve every function, process and person in the organization; and
d) strive for continuous improvement.
SMS differs from QMS in the following way:

a) SMS focuses on the safety, human and organizational aspects of an organization
(i.e. safety satisfaction);
while
b) QMS focuses on the products and services of an organization (i.e. customer
satisfaction).
49
Safety Management System
• Safety – The state in which the risk of harm to persons

or property damage is reduced to, and maintained at or
below, an acceptable level through a continuing process
of hazard identification and risk management.
• Management – Allocation of resources.
• System – Organized set of processes and procedures.
SMS – An organised set of processes and procedures,

based upon a principled allocation of resources, that allows
the control of safety risks to an acceptable level
50
The Safety Management System
• What is SMS?
• A system for managing safety as part of the overall
management objective and policy;
• Why SMS?
• To regulate airport operations and improve safety levels,
especially in areas not covered by applicable ICAO or
applicable national standards and regulations;
• How?
• Existence of comprehensive technical
Standards/specifications, a safety management policy, their
implementation and maintenance at all times.
51
SMS Tool-box:
• The scope of SMS encompasses most of the activities
of the organization.
• SMS must start from senior management, and safety

must be considered at all levels of the organization.
• SMS aims to make continuous improvement to the

overall level of safety.
• All aviation stakeholders have a role to play in SMS.
52
The components of SMS:

1) Safety policy and objectives
2) Safety risk management
3) Safety assurance
4) Safety promotion
53
SMS at glance:
Safety
Safety Policy and Safety Risk

Objectives Management
Management
Commitment
Safety Assurance Safety Promotion
Effectiveness Efficiency
Aviation Community Stakeholders
54
The Elements of SMS:
Safety policy and objectives

• Management commitment and responsibility
• Safety accountabilities of managers
• Appointment of key safety personnel
• SMS implementation plan
• Coordination of emergency response planning
• Documentation
55
The Elements of SMS:
Safety risk management

• Hazard identification processes
• Risk assessment and mitigation processes
Safety assurance
• Safety performance monitoring and measurement
• The management of change
• Continuous improvement of the SMS
Safety Promotion:
• Training and Education
• Safety Communication
56
Safety Risk Management
What is Risk Management?

• The identification, analysis and elimination, and/or
mitigation to an acceptable level of risks that threaten the
capabilities of an organization.
What is the objective of Risk Management?

• Aims at a balanced allocation of resources to address all
risks and viable risk control and mitigation.
Why is Risk Management important?

• A key component of safety management systems.
• Data-driven approach to safety resources allocation, thus
defensible and easier to explain.
57
Four steps for hazard identification process:

1. Reporting hazards, events or safety concerns.
2. Collecting and storing the data.
3. Analyzing reports.
4. Distributing the information distilled from the analysis.
58
Risk Assessment and Mitigation Process
Risk Assessment:
Regularly
Commitments
Documentation
Mitigation:
Measures to address the potential hazard or to
reduce the risk probability or severity.
Risk mitigation = Risk control
59
Risk Management System
Risk Management at glance:
Hazard Identification Equipment, Procedures, Organisation, etc
Risk Analysis Analyse the likelihood of the consequence

Probability occurring
Risk Analysis Evaluate the seriousness of the consequence
Severity if it occurred
Risk Assessment and Is the risk assessed acceptable and within
Tolerability the organisational safety performance criteria
Yes, Accept the risk

Risk
Control/Mitigation No, take action in order to reduce the risk to
an acceptable level
60
Risk Mitigation at glance:
Assessment of the
Hazard identification and Control and Accepting the mitigations
defences within the
Risk Assessment Mitigation of the risks of the risk(s)
safety system
H H H H • Does it address
Intolerable
Region the risk(s)?
•Is it effective?
•Is it appropriate?
Tolerable •Is additional mitigation
Region
Each Consequence Technology warranted?
•Do the mitigations
Training Strategies generate
Acceptable
Regulations Region additional risks?
•Etc…
R R R R
Each Risk Feedback – safety assurance

61
Risk Management Assessment
• There is no such thing as absolute safety – In aviation it is not possible to
eliminate all risks.
• Risks can be managed to a level “as low as reasonably practicable”

(ALARP)
• Risk mitigation must be balanced against:

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

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

affected by them.
62
Safety Assurance
Safety Assurance is built upon the following:

63
Safety Assurance
Safety performance monitoring and measurement
The process by which the safety performance of the

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

• Problem areas or bottlenecks in daily operations.
• Perceptions and opinions of operational personnel.
• Areas of dissent or confusion.
• Check list
•Questionnaires
•Informal confidential interviews
65
Safety Assurance
Internal safety investigations include occurrences or events

that are not required to be investigated or reported to State.
• In-flight turbulence (flight operations)
• Frequency congestion (ATC)
• Material failure (maintenance)
• Ramp vehicle operations (aerodrome)
66
Safety Information Sources
• The protection of safety information from inappropriate use is essential

to ensure its continued availability in future, since the use of safety
information for other than safety-related purposes may reduce the
availability of such information, with an undesirable effect on safety.
• During the 35th Assembly of ICAO, it was noted that existing national
laws and regulations in many States may not address adequately the
protection of safety information from inappropriate use.
• Following the Assembly, ICAO has produced a legal guidance for the
protection of information from SDCPS and it is included in Attachment E
to Annex 13.
67
Annex 13
General Principles
• The sole purpose of protecting safety information from inappropriate use is to ensure its continued
availability so that proper and timely preventive actions can be taken and aviation safety improved.
• It is not the purpose of protecting safety information to interfere with the proper administration of justice
in States.
• National laws and regulations protecting safety information should ensure that a balance is struck
between the need for the protection of safety information in order to improve aviation safety, and the
need for the proper administration of justice.
• National laws and regulations protecting safety information should prevent its inappropriate use.
• Providing protection to qualified safety information under specified conditions is part of a State’s safety
responsibilities.
Principles of Protection
• Safety information should qualify for protection from inappropriate use according to specified conditions
that should include, but not necessarily be limited to: the collection of information was for explicit safety
purposes and the disclosure of the information would inhibit its continued availability.
• The protection should be specific for each SDCPS, based upon the nature of the safety information it
contains.
• A formal procedure should be established to provide protection to qualified safety information, in
accordance with specified conditions.
• Safety information should not be used in a way different from the purposes for which it was collected.
• The use of safety information in disciplinary, civil, administrative and criminal proceedings should be
carried out only under suitable safeguards provided by national law.
68
Annex 13
Principles of Exception
• Exceptions to the protection of safety information should only be granted by national laws and
regulations when:
• There is evidence that the occurrence was caused by an act considered, in accordance with the
law, to be conduct with intent to cause damage, or conduct with knowledge that damage would
probably result, equivalent to reckless conduct, gross negligence or wilful misconduct;
• An appropriate authority considers that circumstances reasonably indicate that the occurrence
may have been caused by conduct with intent to cause damage, or conduct with knowledge that
damage would probably result, equivalent to reckless conduct, gross negligence or wilful
misconduct;
• A review by an appropriate authority determines that the release of the safety information is
necessary for the proper administration of justice, and that its release outweighs the adverse
domestic and international impact such release may have on the future availability of safety
information.
Public Disclosure
• Subject to the principles of protection and exception outlined above, any person seeking
disclosure of safety information should justify its release.
• Formal criteria for disclosure of safety information should be established and should include, but
not necessarily be limited to, the following:
• Disclosure of the safety information is necessary to correct conditions that compromise safety
and/or to change policies and regulations;
• Disclosure of the safety information does not inhibit its future availability in order to improve
safety;
• Disclosure of relevant personal information included in the safety information complies with
applicable privacy laws;
• Disclosure of the safety information is made in a de-identified, summarized or aggregate form. 69
Annex 13
Responsibility of the Custodian of Safety Information

• Each SDCPS should have a designated custodian. It is the responsibility of the custodian of safety
information to apply all possible protection regarding the disclosure of the information, unless:
• The custodian of the safety information has the consent of the originator of the information for
disclosure; or
• The custodian of the safety information is satisfied that the release of the safety information is in
accordance with the principles of exception.
Protection of Recorded Information

• Considering that ambient workplace recordings required by legislation, such as cockpit voice
recorders (CVRs), may be perceived as constituting an invasion of privacy for operational
personnel that other professions are not exposed to:
• Subject to the principles of protection and exception above, national laws and regulations should
consider ambient workplace recordings required by legislation as privileged protected information,
i.e. information deserving enhanced protection; and
• National laws and regulations should provide specific measures of protection to such recordings
as to their confidentiality and access by the public. Such specific measures of protection of
workplace recordings required by legislation may include the issuance of orders of non-public
disclosure.
70
Change Management Process
Aviation organizations experience permanent change due

to expansion, introduction of new equipment or procedures.
Changes can have the following output:

• Introduce new hazards.
• Impact the appropriateness of risk mitigation.
• Impact the effectiveness of risk mitigation
71
Mentioned Changes can be:
External changes
• Change of regulatory requirements.
• Security.
• Reorganization of air traffic control…
Internal changes
• Management changes
• New equipment.
• New procedures…
72
A formal management of change process should:

• identify changes within the organization which may
affect established processes and services.
• prior to implementing changes describe the
arrangements to ensure safety performance.
73
Improvement Process
Continuing improvement aims at:

• Determining the immediate causes of below standard
performance and their implications in the operation of
the SMS.
• Rectifying situations involving below standard
performance identified through safety assurance
activities
74
Improvement Process
The mentioned improvements are achieved through:

• Proactive evaluation of facilities, equipment,
documentation and procedures through audits and
surveys.
• Proactive evaluation of the individuals’ performance, to

verify the fulfilment of their safety responsibilities.
• Reactive evaluations in order to verify the effectiveness

of the system for control and mitigation of risks, for
example: accidents, incidents and major events
investigations
75
Safety Promotion
Training and Education
Who?
• Operational personnel
• Managers and supervisors
• Senior managers
• Accountable executive
Why?
• To ensure that personnel are trained and competent
to perform the SMS duties.
How much?
• Appropriate to the individual’s involvement in the
SMS.
76
Safety Promotion
Training and Education
A building block approach:

• Operational personnel
• Organization safety policy
• SMS fundamentals and overview
• Managers and supervisors
• The safety process
• Hazard identification and risk management
• Senior managers
• Organizational safety standards and national regulations
• Safety assurance
77
Safety Promotion
Safety Communication
Safety communication aims to:

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

• Safety policies and procedures
• News letters
• Bulletins
• Website
Safety communication is an essential foundation for the

development and maintenance of a positive culture.
79
Maintenance
Internal Evaluation Process
• Management commitment
• Just culture
• Established processes
80
Maintenance
Internal Audit Process
An annual audit program should include:
• Definition of the audits, in terms of;

• criteria,
• scope,
• frequency, and
• methods;
• Description of the processes used to select the auditors;
• The requirement that individuals shall not audit their own work;
• Documented procedures for assignment of responsibilities, planning
and conduct of audits, reporting results and maintaining records;
• Audits of contractors and vendors.
81
Maintenance
External Audit Process
Surveillance and compliance

the authority needs to ensure that international, national and local
standards are complied with prior to issuing any licence or approval and
continue to be complied with afterwards;
Areas and degree of risk
the audit should assess how risks are identified and how any necessary
changes are made to ensure that all safety standards are met;
Competence
the audited organisation should have adequately trained staff for all
safety related positions
Safety management
ensure that the organisation’s SMS is based on sound principles and
procedures, and that the organisation is meeting its safety performance
targets.
82
Maintenance
Proactive and Reactive Evaluations
Proactive – before something has happened

• Taking actions
• Mitigate
• Training
Reactive – after something has happened

• Investigate why it is as it is
• Make improvements
83
Organisation
Cultural Levels of the organisation
The characteristics of a good company safety culture include:
• Informed - Managers know what is really going on and workforce is

willing to report their own errors and near misses
• Wary - ready for the unexpected
• Just - a ‘no blame’ culture, with a clear line between the acceptable
and unacceptable
• Flexible - operates according to need
• Learning - willing to adapt and implement necessary reforms
84
Organisation
The values of an Organisation:
• The safety management organisation is defining

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

actors to take responsibility for their
work and taking into account the
Managers safety.
Flight Crew
Engineers
(Maintenance)
Ground Staff
(Luggage Personnel)
86
Procedures
Safety Programme
Safety Programme is an integrated set of regulations and activities

aimed at improving safety.
States are responsible for establishing a safety programme,
encompassing the following responsibilities:
• Safety regulation
• Safety oversight
• Accident/incident investigation
• Mandatory/voluntary reporting systems
• Safety data analysis and
exchange
• Safety assurance
• Safety promotion
87
State Safety Programme - SSP
Service Providers
State • States shall require as part of their

State Safety Programme (SSP) that a
Service Providers implement Safety
•States shall establish a State safety Management System acceptable to the
programme (SSP), in order to achieve an State that as minimum:
acceptable level of safety (ALoS) in •identifies safety hazards;
civil aviation. •ensures the implementation of
remedial action necessary to
•Acceptable level of safety (ALoS) to be
maintain agreed safety
achieved shall be established by the
performance.
State.
•provides for continuing monitoring
and regular assessment of
the safety performance; and
•aims at a continuous improvement
of the overall performance of the SMS.
88
Procedures
State’s safety programme
Develop the State’s safety programme around the

following four components:
1. State’s safety policy and objectives
2. State’s safety risk management
3. State’s safety assurance
4. State’s safety promotion
89
Procedures
Differences between State and Service Providers
Legal considerations – States Operators and service providers

• Establishing acceptable level(s) of • Establishing acceptable level(s) of
safety does not replace legal, safety for their safety management
regulatory, or other already system leaves unaffected the
obligations of operators or services
established requirements, but it
providers and other related parties,
must support compliance with them.
and it does not relieve the operator,
• Establishing acceptable level(s) of services providers and other related
safety for their safety programme parties from compliance with SARPs
leaves unaffected the obligations of and/or national regulations, as
States, and does not relieve States applicable.
from compliance with SARPs
90
Procedures
State’s safety programme + Service providers SMS =
Integrated safety system
Objective:
Public Safety
State Safety
Programme Ov
ers
ig h
t
Acceptance
Oversight
Objective:
Objective: Organisation’s Safety Organisation’s Achieve
Manage and Management Production commercial
control System (SMS) Processes goals and
safety risks customer
Risk Management saftisfaction
Safety Assurance
91
Safety Policy
Safety Policy - A statement of the organisation’s fundamental

approach to achieve acceptable or tolerable safety.
A written document that describes the generic principles upon which the
SMS is build and operated upon.
A typical safety policy document would consist of a policy statement that is
further expanded by a number of basic safety management principles to be
followed:
• commitment to safety,
• safety priority,
• safety responsibility,
• planning for safety,
• safety management,
• safety standards,
• safety achievement,
• safety assurance and
• safety promotion 92
Risk Management
Risk management - The identification, analysis and

elimination (and/or mitigation to an acceptable or tolerable level) of those
hazards, as well as the subsequent risks, that threaten the viability of an
organisation.
Risk Management consists of the following three elements:
• Hazard identification
• Risk assessment
• Risk mitigation
93
Risk Management at glance:
Hazard Identification Equipment, Procedures, Organisation, etc
Risk Analysis Analyse the likelihood of the consequence

Probability occurring
Risk Analysis Evaluate the seriousness of the consequence
Severity if it occurred
Risk Assessment and Is the risk assessed acceptable and within
Tolerability the organisational safety performance criteria
Yes, Accept the risk

Risk
Control/Mitigation No, take action in order to reduce the risk to
an acceptable level
94
Safety Assurance
Safety assurance -
all planned and systematic actions necessary to
afford adequate confidence that a product, a service, an organisation or a
functional system achieves acceptable or tolerable safety
The objectives of Safety Assurance is to implement dedicated surveillance and

documenting procedures and processes in order to ensure that risk are
being properly managed.
According to ICAO State Letter SA include the following activities:

• Management of change
95
Safety Assurance
Safety Assurance components:

• Safety Surveys
• Safety Monitoring
• Safety Records
Regulators should continuously evaluate the implemented safety

management arrangements and processes by aviation service
providers by means of external regulatory safety auditing and other
safety oversight methodologies.
96
Safety Promotion
• Just culture
• Key Performance Indicators
• Processes
97
Thank You for you
attention today
Any Questions?
See You tomorrow
98
Agenda for today:
09.00 – 10.30 Managing Safety

10.30 – 11.00 Break
11.00 – 12.30 WS on Safety Culture
12.30 – 14.00 Lunch

14.00 – 15.00 The Safety Components
15.00 – 15.30 Break
15.30 – 16.30 Joint session/discussions
16.30 – 17.00 Wrap up
Evaluation
Hand over of Diploma
99
Managing Safety
Safety Responsibility and accountability
Safety responsibility: the obligation to carry forward an assigned

safety related task to its successful conclusion. With responsibility
goes authority to direct and take the necessary action to ensure
success.
Safety accountability: the obligation to demonstrate the task
achievement and take responsibility for the safety performance in
accordance with agreed expectations. Accountability is the
obligation to answer for an action.
Clear and correctly allocated safety accountabilities and responsibilities

are prerequisite for achieving the organisation’s safety objectives
and for implementing an effective safety management and safety
improvement process
100
Safety Manager (SM)
An individual, responsible for the development, operation and

continuous improvement of the safety management system deployed
by an operator/service provider.
He acts as a focal point for safety management issues in the

organisation.
The approach to the assignment of Safety manager’s responsibilities

may differ depending on the type, size of the organisation, its
mission, complexity of operations and operating environment.
101
Safety Manager’s
Responsibilities
The appointment of the Safety manager (SM) is an essential step in the establishment of
the SMS organisational structure and a prerequisite for an efficient safety planning
process. Irrespectively of any other duties that may be allocated to them, safety
managers have the responsibility to:
• Promote safety awareness within the organisation;

• Ensure that safety management has the same or higher priority level throughout
organisation as any other management and operational processes;
• Manage all aspects of the organisation’s SMS, including:
• Monitoring the effectiveness of SMS;
• Initiating corrective actions when necessary;
• Providing safety reports on SMS performance on periodic basis;
• Providing safety advice to top management and proposing corrective actions on
safety related-issues as needed;
• Ensuring that safety-related documentation and records are available and up-to-
date.
102
Safety Levels and Targets
The term "acceptable risk" describes an event with a probability of occurrence

and consequences acceptable to the society, i.e. the society is willing to take or
be subjected to the risk that the event might bring.
It is the role of the safety regulatory authorities to translate the society

expectations and perceptions into a qualitative or quantitative target level of
safety.
Definition:
The acceptable level of safety expresses the safety goals of an oversight
authority, an operator, or a services provider.
From the perspective of the relationship between oversight authorities and
operators/services providers, it provides the minimum safety objective(s)
acceptable to the oversight authority to be achieved by the operators/services
providers while conducting their core business functions.
103
Safety Performance Targets
Safety performance targets define the required level of safety performance of a

system. A safety performance target comprises one or more safety
performance indicators, together with desired outcomes expressed in terms of
those indicators.
Safety Targets can be presented in either:

• Absolute (i.e. less than 1 fatal accident per 1 000 000 operating hours)
• Relative Terms
104
Safety Indicators
• Definition on Safety Performance Indicators: A measure (or metric) used to

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

the set target levels.
• Safety indicators differ among the various sectors of the aviation industry
such as;
• air navigation services provision,
• airline operations and
• aerodrome operations
105
Safety Levels
The relationship between acceptable level of safety, safety

performance targets and safety performance indicators, and
safety requirements is as follows:
• acceptable level of safety is the overarching concept;
• safety performance targets are the quantified objectives
pertinent to the acceptable level of safety;
• safety performance indicators are the measures/metrics used to
determine if the acceptable level of safety has been achieved
106
Key Performance Indicators
• Easy judgments
• Confirmed values
• Committed results
107
Promotion and Awareness
• Newsletters – internal
• Posters
• Videos
• Intranet
• Presentations???
108
Safety Culture
• A construct
• An outcome, not a process
• The introduction of safety management concepts lays the
foundation upon which to build a safety culture
• Safety culture cannot be “mandated” or “designed”, it
evolves.
• It is generated “top-down”
109
Safety Culture
How to create a Safety Culture?
• Depends on where you are starting from - you don’t get to the
end in one step, unfortunately, all the steps have to be traversed
• Becoming a Safety Culture involves acquiring and then
maintaining a set of skills
• The two major factors are information and trust, so these have
to be developed
• Be systematic (SMS are a start) and then learn to operate with
the unknown as well
• Have the program run right from the top
• Appoint a senior champion who is dedicated and willing to stick it
out, even when it gets hard
• The champion reports direct to the board
• Recognise that it will be uncomfortable, safety cultures are
different, not just an add-on
110
Safety Culture
A Way Forward – developing a Safety Culture:
• Agree on ways to analyse incidents to reveal individual and system issues

• Develop reporting systems that are easy to use (compact, open-ended,
impersonal)
• Encourage the workforce (air and ground) to realise that all incidents are worth
reporting
• Experiment with changes when new information comes in, don’t be afraid to
admit failure first time round
• Practice management in wanting to know from near misses before they become
accidents
111
Source: David Marx
Positive culture
Informed culture Flexible culture

People are knowledgeable about the human, People can adapt
technical, organizational and environmental factors organizational processes when
that determine the safety of the system as a whole. facing high temporary
operations or certain kinds of
danger, shifting from the
conventional hierarchical
Reporting culture mode to a flatter mode.
People are prepared to Positive
report their errors and Learning culture
experiences
culture People have the willingness
and the competence to draw
conclusions from safety
information systems and the
Just culture will to implement major
People are encouraged (even rewarded) for providing
reforms.
essential safety-related information. However, there is a clear
line that differentiates between acceptable and unacceptable
behaviour.
112
Just Culture
• Get rid of the idea that blame is a useful concept (this is hard to do)
• Define clear lines between the acceptable and the unacceptable
• Have those involved draw up the guidelines, do not impose from above if
you want them to be accepted
• Have clear procedures about what to do with other forms of non-
compliance
113
Just Culture
Confidentiality
• People are reluctant to draw attention to errors made by themselves or their
colleagues, due to personal embarrassment. They must be confident that their
identity, or the identity of any person implicated in the report will not be
disclosed without their permission or unless this is required by law. An
assurance should also be given that any subsequent safety action taken will, as
far as possible, ensure the anonymity of the persons involved.
Punitive Action
• A person who breaks the law or breaches a regulation or company procedure
through a deliberate act or gross negligence cannot expect immunity from
prosecution. However, if the offence was unpremeditated and unintentional, and
would not have come to light except for the report, he/she should be protected
from punishment or prosecution.
Loss of Licence
• The circumstances of a report may indicate that the performance of an
individual is below the acceptable level. This may indicate the need for further
training, or even cancellation of an individual's licence. Such action must never
be punitive.
114
Workshop
Safety Culture
Just Culture
Promotion
Safety Awareness
115
The Safety Components
Organizational cultural transformation is not for the faint of heart. In fact, many
attempts at transforming an organization fail, for a variety of reasons:
• "Playing at it" or "dabbling" with it until it's no longer fun

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

all stakeholders that the operations have been and continue
to be undertaken in a safe manner.
• Safety Records are all documents developed under the

umbrella of Quality and Safety Management System.
119
Examples of Safety Records
• Safety Assessment Report Safety Assessments

Safety Monitoring
• Incident Report
• Accidents
• Training Records
• Safety Performance Monitoring SAFETY
Records RECORDS
• Safety Occurrence Report

• Safety Survey Report Training
• Other Examples??
Policies, Strategies,
Procedures
120
Manual
• Basic Safety Concept
• Introduction to Safety Management
• Hazards
• Safety Risks
• ICAO Safety Management
requirements
• Introduction to Safety Management
System (SMS)
• SMS Planning
• SMS Operation
• Phased approach to SMS
implementation
• State Safety Programme (SSP)
121
Joint Session / Discussion
122
Wrap - up
Today were following topics covered and

discussed:
• ICAO Safety Management System

• SES Regulations
• The Safety System
• The Safety Management System…
123
Any Questions?
See You Tomorrow
124
Use of SMS can be generally interpreted as applying a quality management

approach to control safety risks. Similar to other management functions, safety
management requires planning, organising, communicating and providing direction.
The SMS development is built after the following structure:
1. Setting the Organisational Safety Policy

2. Safety Planning and Implementation of Safety Management Procedures
3. Risk and Quality Management methods
4. Safety Culture
125
Main SMS Components
In line with the guidance outlined in ICAO Doc 9859 - Safety Management Manual,
the SMS components may be assigned to the following broad domains:
• Safety Planning
• SMS Organisational Structure
• Safety Achievement
• Safety Assurance
• Safety Promotion
A successful implementation and operation of an SMS is highly dependent on

organisational aspects such as individual and group attitudes, values, competencies and
patterns of behaviour which are frequently referred to as elements of the “safety
culture”.
A positive safety culture is characterised by a shared awareness of organisations’

personnel of the importance of safety in their operational tasks.
126
Organisational foundation for
Safety Management
Organisational Processes
Workplace Latent
• Policy Making
Conditions Conditions
• Planning
Active • Communication
Defences
Failures • Allocation of resources
• Supervision
•…
Activities over which any organisation has a reasonable degree

of direct control
127
Safety Management
Deficiencies in
equipment design
Incomplete/incorrect standard
Organisational Processes operating procedures
training deficiencies
Workplace Latent
• Inadequate hazard
identification and risk
management
Active • Normalization of deviance Defences
Failures
Conditions present in the system before the accident, made

evident by triggering factors.
128
Safety Management
Workplace Latent
Technology
Active
Defences Training
Failures
Regulations
Resources to protect against risks that organisations involved in the

production activities generate and must control.
129
Safety Management
• Workforce Stability
Workplace Latent
Conditions • Qualifications and experience Conditions
• Morale
Active • Credibility
Defences
Failures • Ergonomics
•…
Factors that directly influence the efficiency of people in

aviation workplaces
130
Safety Management
Workplace Latent
• Errors
Active • Violations
Defences
Failures
•…
Actions or inaction of people (pilots, ATCOs, maintenance engineers,

Aerodrome staff, etc.) that have an immediate adverse effect
131
Safety Management
Improve Identify
Workplace Latent
Monitor
Contain Reinforce
Active
Defences
Failures
Accident / Incident
132
SMS and QMS
• SMS results in the design and implementation of organizational

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

ACAC SMS Training

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

ACAC SMS Training

Uploaded by

Copyright:

Available Formats

TRAINING IN SAFETY

ARAB CIVIL AVIATION CONFERENCE

Amman, Jordania 19-23 July 2009

• MICHAEL NIELS THORSEN

09.00 – 10.30 Registration and Welcome

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

Provide participants the knowledge of Safety

Develop participants knowledge to certify and oversee

According to ICAO Doc 9859:

Safety is the state in which the risk to harm the

A safety management system (SMS) is an organised approach to

(ICAO Doc 9859 - Safety Management Manual)

The objective of a Safety Management System is to provide a

specific structures and processes related to safety of operations.

8: SMS planning 9: SMS operation

Objectives of the Safety Management Manual are to provide States:

• Knowledge of safety management concepts, the ICAO Standards and

• Guidance on how to accept and oversee the implementation of the key

• Guidance on how to develop and implement an SSP in compliance with the

ICAO SARPS Safety Concepts

ICAO requirements for implementation of SMS are currently applicable to:

• Air Traffic Service Providers (Annex 11)

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

• Introducing a performance framework for European ATM with quantified

The legislative package adopted in 2004 comprises four base regulations,

• The Framework regulation (EC No 549/2004) - laying down the

The Framework regulation establishes harmonised institutional, regulatory

The stipulations of this regulation apply to the provision of air navigation

• National Supervisory Authorities (NSA)

The following is summarising this regulation:

The following topics summarise the Interoperability regulation:

Implementing the provision of the SES regulations would bring a number of

• Improved level of safety of air navigation services;

• Improved decision-making and enhanced enforcement in ATM.

• Regulations: Mandatory to the letter

The First Report on the implementation of the Single Sky Legislation

Based on the report findings, the Commission came forward with

• Create a single safety framework to enable harmonised development

The common requirements cover the following areas:

• Technical and operational competence and capability

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

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

• ICAO Annex 11 – Paragraph- 2.26 – ATS Safety Management

• Para 2.26.1 requires the States to implements systematic and

• Para 2.26.2, requires States to establish the acceptable level of

• Para 2.26.5 requires that any significant safety-related change to

• Para 2.26.5 also requires that the responsible authorities shall

• PANS-ATM doc.4444 includes in Chapter 2 requirements for:

• ATS maintaining acceptable level of safety (section 2.1)

• PANS-ATM Doc 4444 clarifies a significant safety-related change as

• A new operating procedure, including departure and arrival procedures, to

The new Manual on Safety Management for Aerodromes and Air

Provides detailed guidance on implementation of the provisions of Annexes

• States shall establish systemic and suitable ATS safety management

• Organizational structure - Staffing, documentation, resources and leadership commitment

• The world global Safety System consist of all

• Improved security of ATM systems and

1. Aircraft security check

ICAO Security Concept:

National Aviation Security Committee

Airport Operator Quality National

Quality System – the organisational structure, responsibilities, procedures, processes and

Total Quality Management – a management approach of an organisation centred on