Safety Management System Toolkit

Developed by the
Joint Helicopter Safety Implementation Team of the
International Helicopter Safety Team
Presented at
The International Helicopter Safety Symposium 2!
Montr"al# $u"bec#
%anada
&'()*(D
The 2+ International Helicopter Safety Symposium marked the beginning of an
international effort by the helicopter industry to reduce the accident rate by at
least ,- by 2./0 The International Helicopter Safety Team 1IHST2 3as formed to
lead efforts to3ard reaching the ob4ective0
The IHST formed the Joint Helicopter Safety *nalysis Team 1JHS*T2 to analy5e the
accident history and provide recommendations to reduce the accident rate and the
Joint Helicopter Safety Implementation Team 1JHSIT2 to develop cost effective
strategies and action plans to reduce accidents0
IHST is broadly inclusive and involves associations such as Helicopter *ssociation
International 1H*I2# 6uropean Helicopter *ssociation 16H*2# 6uropean Helicopter
'perators %ommittee 16H'%2# %ooperative Development of 'perations Safety and
%ontinuing *ir3orthiness Pro4ect 1%'S%*P2 of the International %ivil *viation
'rgani5ation 1I%*'2# Helicopter *ssociation of *ustralasia# %entro de Investiga78o
e Preven78o de *cidentes 1%69IP*2 in :ra5il# *merican Helicopter Society 1*HS2
International# *irborne ;a3 6nforcement *ssociation 1*;6*2# *ssociation of *ir
Medical Services 1**MS2# International *ssociation of 'il and <as Producers 1'<P2#
Tour 'perators Program of Safety 1T'PS2 the military# aircraft and engine
manufacturers# the insurance industry# helicopter industry customer base# and line
personnel i0e0 pilots# other cre3members and maintenance technicians0
The JHS*T=s initial report provides recommendations directed at specific missions
as 3ell as advice that pertain to the 3orld3ide helicopter fleet0 JHS*T=s first and
foremost finding is the need to implement a Safety Management System 1SMS20
This document represents JHSIT=s proposal for helping organi5ations understand
the fundamentals of a SMS and serves as a guide to setup a SMS tailored to small
organi5ations0
6>amples and tools for each SMS attribute are accessible on the IHST 3ebsite?
http?@@3330ihst0org@SMStoolkit@0 (efer to the *ppendi> (esource <uide in the
back of this document for an itemi5ed list of available materials0
.
I9T('DA%TI'9
The JHS*T analy5ed .B! reported helicopter accidents for the year 2 as recorded
in the 9TS:=s A0S0*0 database0 The JHS*T found that a ma4or contributing factor in
most accidents 3as the failure to adeCuately manage kno3n risks0 Due to the lack of
a systematic process# including leadership and accountability# operators did not
adeCuately prioriti5e and address the risks that lead to most accidents0
The SMS Toolkit 3ill help small operators develop a fit for purpose system that 3ill
sho3 both a return on investment# and@or cost effectiveness from both financial and
safety perspectives0 It 3ill help organi5ations develop a SMS designed to fit the si5e#
nature and comple>ity of their organi5ation0 This toolkit provides easy to use
guidance and proven methods that 3ill assist in developing a systematic approach to
managing ha5ards that cause accidents0 'rgani5ations that adopt the processes
setout in this toolkit 3ill benefit from the reduced e>posure to risk# reduced costs
associated 3ith incidents and accidents# and better retention of personnel0 The safety
recommendations in this document must be economically viable and operationally
appropriate to the individual operating environment and mission0
Definition of an SMS
SMS can be defined as a coordinated# comprehensive set of processes designed to
direct and control resources to optimally manage safety0 SMS takes unrelated
processes and builds them into one coherent structure to achieve a higher level of
safety performance# making safety management an integral part of overall risk
management0 SMS is based on leadership and accountability0 It reCuires proactive
ha5ard identification# risk management# information control# auditing and training0 It
also includes incident and accident investigation and analysis0
Developing a SMS Tool
The JHSIT revie3ed several SMS models# regulations and guidance material from
around the 3orld in order to develop a SMS model specifically designed for the
helicopter industry0 The toolkit is a compilation of the best practices and solutions0
%ontributions came from small# medium and large helicopter operators as 3ell as
airlines# industry groups and governments0
The intent of this document is to assist organi5ations in achieving their desired safety
performance ob4ectives 3hile allo3ing them to choose the best 3ay to reach that
outcome0 This is commonly kno3n as a Dperformance based approach#E and
encourages organi5ations to choose the solution that best suits their needs and
ensures they meet their performance ob4ectives0 The toolkit helps the organi5ation
determine their level of compliance and develop an action plan to include the
necessary components0
2
)hy is SMS 9eededF
SMS is needed to help facilitate the proactive identification of ha5ards and ma>imi5e
the development of a better safety culture# as 3ell as modify attitudes and actions of
personnel in order to make a safer 3ork place0 SMS helps organi5ations avoid 3asting
financial and human resources and management=s time being focused on minor or
irrelevant issues0 SMS lets managers identify ha5ards# assess risk and build a business
case to 4ustify controls that 3ill reduce risk to acceptable levels0
SMS is a proven process for managing risk that ties all elements of the organi5ation
together laterally and vertically and ensures appropriate allocation of resources to
safety issues0
*ttributes of a SMS
*lthough the details and level of documentation of a SMS may vary# there are ..
fundamental attributes that 3ill assist in ensuring the SMS is effective for any
organi5ation0 The core attributes of the IHST=s SMS are?
.2 SMS Management Plan
22 Safety Promotion
G2 Document and Data Information Management
H2 Ha5ard Identification and (isk Management
+2 'ccurrence and Ha5ard (eporting
/2 'ccurrence Investigation and *nalysis
!2 Safety *ssurance 'versight Programs
,2 Safety Management Training (eCuirements
B2 Management of %hanges
.2 6mergency Preparedness and (esponse
..2 Performance Measurement and %ontinuous Improvement
SMS :usiness Tools for Managers
It is important to vie3 a SMS as a business@operations tool for o3ners@%6'=s0 The risk
management processes 3ithin the SMS includes the need to determine the cost of
implementing versus not implementing control measures0 6>ample?
* t3o aircraft# four pilot organi5ation e>periences their third I+# hot start
incident in t3o years caused by the poor starting techniCue combined 3ith 3eak
aircraft batteries0 The o3ner@%6' determines through discussions 3ith the chief
pilot# that a one time training e>pense of I2# 3ill prevent a recurrence0
The cost of implementing the solution is I,# 1I2# J H pilots K I,#20 The cost
of not implementing is I.+# 1I+# J G hot starts K I.+#20
G
Ho3ever# training may not be the only ans3er0 In the same scenario# if the training
costs I2## it 3ould be more cost effective to install eCuipment that prevents hot
starts if it can be done for I.2#0
Simple models that help managers arrive at the most appropriate ans3er are provided
in this SMS Toolkit# and can ensure even the smallest operator can achieve their
safety goals 3ithout the using a comple> SMS0
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This chapter identifies the reCuirements associated 3ith each of the fundamental SMS
attributes0 Successful safety management systems are tailored to fit the si5e# nature
and comple>ity of an organi5ation0 *lthough the details and level of documentation
of a SMS may vary# respecting fundamental attributes 3ill assist in ensuring the SMS is
effective for any organi5ation0
.0. SMS Management Plan
* SMS Management Plan should clearly define safety ob4ectives# ho3 the organi5ation
intends to e>ecute and measure the effectiveness of the SMS# and ho3 the SMS 3ill
support the organi5ation=s business plan and@or ob4ectives0 The plan should?
M
M
M
M
M
6>press management=s commitment to safety and clearly state the policies#
ob4ectives and reCuirements of the SMS
Define the structure of the SMS as 3ell as the responsibilities and authority of
key individuals for managing the SMS
Define each element of the SMS
%onvey the e>pectations and ob4ectives of the SMS to all employees
6>plain ho3 to identify and maintain compliance 3ith current safety regulatory
reCuirements
Parallel *pproaches in :usiness and SMS
The :usiness *pproach
Mission
Nision
%orporate <oals
Policies
(eCuirements
:usiness Processes?
Identify 9on%ompliance
Implement Solutions
Measure Performance
E SMS is the safety
;essons ;earned approach to the
businessE
The Safety *pproach
Mission
Nision
Safety <oals
Policies
(eCuirements
S(* Processes?
Identify Ha5ards @ 9on%ompliance
Implement Ha5ard %ontrols
Measure Performance
;essons ;earned O Improve
Process
(epeat the Process (epeat the Process
&igure .0.
+
.02 Safety Promotion
Safety must be recogni5ed as a Dcore value0E Procedures# practices# training and the
allocation of resources must clearly demonstrate management=s commitment to
safety0 6ffective methods to promote safety include?
M
M
M
M
M
M
M
M
Publish a statement of management=s commitment to the SMS
Management should demonstrate their commitment to SMS by e>ample
%ommunicate the outputs of the SMS to all employees
Provide training for personnel commensurate 3ith their level of responsibility
Define competency reCuirements for those individuals in key positions
Document# revie3 and update training reCuirements
Share Dlessons learnedE that promote improvement of the SMS
Have a safety feedback system 3ith appropriate levels of confidentiality that
promote participation by all personnel in the identification of ha5ards
Implement a DJust %ultureE process that ensures fairness and open reporting in
dealing 3ith human error
M
.0G Documents and Data Information Management
'rgani5ations should have procedures to identify and manage the information
necessary to ensure compliance 3ith SMS policies# procedures and goals0 Pey
elements include?
M Document and publici5e the organi5ation=s safety policies# ob4ectives and SMS
procedures
Identify the safety regulations that govern the organi5ation
Provide all employees access to pertinent regulatory information
%onsolidate documentation describing the systems for each SMS component
Provide change control for all applicable documents
Have a process to communicate changes in documents to all personnel
M
M
M
M
M
/
.0G Document and Data Information Management 1continued2
M
M
Promptly remove obsolete documents
6stablish periodic revie3 of documents
.0H Ha5ard Identification and (isk Management
The SMS needs to include a process to identify ha5ards and develop processes to
identify and manage risks0Pey elements of ha5ard identification and risk
management programs are?
M Proactive identification of e>isting and potential ha5ards0 This includes those
ha5ards associated 3ith organi5ational change 3hen the organi5ation is
undergoing rapid gro3th# introducing ne3 services# ne3 eCuipment or ne3
personnel
* process to prioriti5e risk management
* method to track identified ha5ards
M
M
* risk assessment matri> is a useful tool to identify the level of risk and the levels of
management approval reCuired for any (isk Management Plan0 There are various
forms of this matri># but they all have a common ob4ective to define the potential
conseCuences or severity of the ha5ard versus the probability or likelihood of the
ha5ard0
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.0+ 'ccurrence and Ha5ard (eporting
'ccurrences are unplanned safety related events# including accidents and incidents
that could impact the safety of guests# passengers and personnel# eCuipment or the
3ork environment0
The identification of a ha5ard provides an opportunity to learn ho3 to prevent
accidents and incidents it might cause0 Procedures need to be in place for internal
reporting of ha5ards0 Timely collection of information allo3s the organi5ation to react
to the information0
* ha5ard reporting form should be simple# convenient and available to all employees0
Ha5ard reporting programs should include?
M
M
&eedback to the reporting person
* process for analy5ing data# safety reports and other safety related
information
'ngoing monitoring to confirm the effectiveness of corrective action
'ngoing monitoring to identify ha5ardous trends
* non punitive discipline policy for persons that report ha5ards
Provisions for anonymous reporting of ha5ards
M
M
M
M
.0/ 'ccurrence Investigation and *nalysis
6very ha5ard# incident or accident needs to be investigated for the purpose of
gathering information that may help prevent similar occurrences0 *n initial risk
assessment 3ill assist in determining the e>tent of the full investigation0 (eports that
demonstrate a high potential ha5ard should be investigated in greater depth than
those 3ith lo3 potential0 The investigation or ha5ard analysis should?
M Determine
blameE
D3hatE and D3hyE the event happened# rather than# D3ho=s to
M 6nsure the person1s2 conducting the investigation is technically Cualified and
has access to other personnel 3ith e>pertise that may assist 3ith the
investigation
Identify immediate causal and contributing factors
;ook at organi5ational factors that may e>acerbate the ha5ard or incident
M
M
,
.0/ 'ccurrence Investigation and *nalysis 1continued2
M
M
Identify both acts of DomissionE and DcommissionE
Provide a report to the manager 3ith the authority to implement
recommendations
.0! Safety *ssurance 'versight Programs
<ood oversight programs evaluate the effectiveness of the organi5ation=s SMS0 They
help management improve safety services0
6valuation of the safety program should include e>ternal assessments by professional
or peer organi5ations0 Safety oversight is provided in part by some of the attributes
of the SMS such as# occurrence reporting and investigation0 Ho3ever# safety
assurance and oversight programs need to proactively seek out potential ha5ards
based on available data as 3ell as evaluating the organi5ation=s safety program0 This
can best be accomplished by?
M %onducting internal assessments of operational processes at regularly
scheduled intervals
Atili5ing checklists tailored to the organi5ation=s operations 3hen conducting
safety evaluations
*ssessing the activities of contractors 3here their services may affect the
safety of the operation
Having assessment of evaluator=s processes conducted by an independent
source
Documenting results and corrective actions
Documenting positive observations
%ategori5ing findings to assist in prioriti5ing corrective actions
Sharing the results and corrective actions 3ith all personnel
M
M
M
M
M
M
M
B
.0! Safety *ssurance 'versight Programs 1continued2
M Atili5ing available technology such as Health Asage Monitoring Systems 1HAMS2
to supplement Cuality and maintenance programs as 3ell as supporting
programs to monitor and evaluate aircre3 operations
.0, Safety Management Training (eCuirements
*ll personnel should be given introductory and recurrent SMS training0
establishing training reCuirements for the organi5ation# you should?
M
)hen
Include a safety orientation for all ne3 personnel# stressing the organi5ation=s
commitment to safety and everyone=s roll in the SMS
Document competency reCuirements for personnel
Have a system to track training reCuirements
Make effective use of conferences# 3orkshops# literature and trade 4ournals
M
M
M
.0B Management of %hanges
Anless properly managed# changes in organi5ational structure# personnel#
documentation# processes or procedures can result in the inadvertent introduction of
ha5ards and increased risk0 )hen making changes# the follo3ing should be done to
minimi5e the potential of increasing risk?
M *naly5e changes in operational procedures or processes to identify any reCuired
changes in training# documentation or eCuipment
%hanges in location# eCuipment or operating conditions should be analy5ed for
any potential ha5ards
6nsure all maintenance and operation manuals are kept posted 3ith the most
current changes
Have a process to ensure that all personnel are made a3are of and understand
any changes in reCuirements# procedures and applicable maintenance and
operator manuals
Define the level of management that must approve a change
M
M
M
M
.
.0. 6mergency Preparedness and (esponse
*n 6mergency (esponse Plan outlines in 3riting 3hat should be done 3hen an
emergency occurs# 3hat to do after an accident happens# and 3ho is responsible for
each action0 The better prepared an organi5ation is for an emergency# the better the
chances that in4uries to personnel and damage to eCuipment# property or the
environment can be minimi5ed0 The plan should?
M :e readily available at the 3ork stations of those that may be the first to be
notified or reCuired to respond
:e relevant and useful to people on duty
:e e>ercised periodically to ensure the adeCuacy of the plan and the readiness
of the people 3ho must make it 3ork
:e updated 3hen contact information changes
:e briefed to all personnel along 3ith their responsibilities
Should be practiced so personnel receive training in emergency response
procedures
M
M
M
M
M
The 6mergency (esponse Plan should include checklists that define actions and
responsibilities for the follo3ing?
M
M
M
M
M
M
&irst response personnel such as flight operations# to3er# fire and police
Secondary responder personnel such as public relations# legal and maintenance
Site security and accident investigation
9e>t of kin notification
%laims and insurance procedures
*ircraft recovery
..
.0.. Performance Measurement
The safety performance of the organi5ation needs to be proactively and reactively
monitored to ensure that the key safety goals continue to be achieved0 (elying on
accident rates as a safety performance measure can create a false impression because
not having accidents does not necessarily indicate the organi5ation is safe0 In reality#
there 3ill al3ays be latent conditions 3ithin the system that might lead to an
accident0 Performance measurements must be tailored to the si5e# nature and
comple>ity of the organi5ation and?
M The results of all safety performance monitoring should be documented and
used as feedback to improve the system
*ddress individual areas of concern0 The assessment of the improvements
made to 3ork procedures might be far more effective than measuring accident
rates
Must be specific# measurable# achievable# results oriented and timely 1SM*(T2
Safety performance measures must be linked to the organi5ation=s operations
performance measures# for e>ample?
'rgani5ation Performance Measure?
(eduction in insurance rates
M
M
M
'rgani5ation 'b4ective?
(educe %osts
Safety 'b4ective?Safety Performance Measure?
Decrease number and severity of hangar (eduction in total number of events?
incidentsM 9umber of damage only events
M 9umber of near miss accidents
M ;essonslearnedfromevent
analyses
M 9umber of corrective action plans
developed and implemented
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20. 'rgani5ational (eCuirements
In a SMS# policies and procedures are the 3ays organi5ations e>press and achieve their
desired level of safety0 Policies characteri5e the nature and performance of an
organi5ation# and procedures define ho3 to e>ecute policies0
202 Policy
Policy is information 3hich establishes a basic reCuirement for ho3 the organi5ation
functions 13hat you 3ant to do20 It should be short and to the point0 %ustomers
should also kno3 3hat the organi5ation=s policies are so they can base their
e>pectations on them0 Policies guide the development of procedures0
&or e>ample# an organi5ation may establish a fuel management policy to avoid lo3
fuel emergencies0 That policy might state that day N&( flights must have adeCuate
fuel reserves to allo3 the safe completion of the flight 3ith a minimum of G minutes
fuel on board at landing0
20G Procedures
Procedures define the actual methods that the organi5ation uses to apply their
policies 1ho3 you do 3hat you 3ant done20 In the fuel management e>ample above#
the procedure may include various methods of positively determining the Cuantity of
fuel onboard# the estimated duration of flight# and the pro4ection of fuel consumption
as part of the preflight procedures0
.G
20H Human (eCuirements
People e>ecute policies and procedures# and responsibilities# duties and authorities
define their role0
(esponsibility
(esponsibility involves the reCuirement to actually perform certain 3ork0 The
responsible person must be trained and competent0 There must be a 3ay for the
responsible person to take appropriate action 3hen performance or conduct reCuires#
such as counseling# training# re Cualification# discipline or removal of the person to
3hom authority has been delegated0
*uthority
*uthority is the po3er vested to an individual0 To be effective# the assigned
responsibility must include commensurate authority0 *uthority does not have to be
absolute# but it does have to be effective0 Training must include limitations of
authority0
*uthority should be documented in employees= personnel records as 3ell as the policy
manual0 This allo3s others to recogni5e their authority and to establish the transfer
of authority from the responsible person to the employee0
Duty
Duty is something a person ought to do0 It is a moral# ethical obligation to act0 &or
e>ample# all employees have the duty to report unsafe conditions0 To be effective# a
single method of reporting should be established to ensure that information is
effectively managed0 6very person=s duties should be identified and the methods
that they should use to e>ecute those duties should be described0
Duties apply to persons at every level of an organi5ation0 Some may have long term
safety impact# such as the duty of mechanics to accurately maintain aircraft records0
Some duties are immediate such as a medical technician=s duty to 3aive off a landing
due to an unsafe condition on a landing pad0 Some duties are described at a higher
level i0e0 management=s duty to maintain a safe 3ork place# and that duty is tied to
their responsibilities and authority0
The organi5ation must train their personnel in their duties and authority0 The duties
and authorities should be spelled out in a short position description0 The o3ner=s or
%6'=s oversight may simply occur through day to day contact and could include onsite
training0 The goal should be to build a SMS that has 3ell balanced duties#
responsibilities and authorities0
.H
%H*PT6( G
IMP;6M69TI9< * SMS
Integrating a coherent SMS can be done in incremental steps0 This allo3s the
organi5ation to become acCuainted 3ith the reCuirements and results before
proceeding to the ne>t step0 The follo3ing checklist is a guide in validating that the
attributes of a SMS are implemented0 *lso included is a sample SMS that can be
adopted for a small organi5ation?
Management Plan
R
R
R
R
R
Policies# ob4ectives and reCuirements of the SMS are published
'rgani5ational structure and key individuals and responsibilities are defined
6lements of the SMS are defined
6>pectations and ob4ectives of the SMS are conveyed to employees
* method to identify and maintain compliance 3ith safety and regulatory
reCuirements
Safety Promotion
R
R
R
R
R
R
R
R
R
Senior management=s commitment to the SMS published
Senior management visibly demonstrates their commitment to SMS
'utputs of the SMS is communicated to all employees
Initial and recurrent training is provided to all personnel
%ompetency reCuirements are defined for those individuals in key positions
Training reCuirements are documented and periodically revie3ed
;essons learned are shared to promote improvement of the safety program
6mployee safety feedback system is established
* DJust %ultureE process is in place
Document and Data Information Management
R
R
R
R
R
R
R
R
Safety policies# ob4ectives and SMS reCuirements publici5ed
Safety regulations that govern the organi5ation identified
Pertinent safety and regulatory information provided to all employees
Documentation describing the systems for each SMS component consolidated
%hange control system in place for applicable documents
Personnel are educated on changes in documents
'bsolete documents are promptly removed
Periodic revie3 of documents
.+
Ha5ard Identification and (isk Management
R
R
R
R
Procedures e>ist to proactively identify potential ha5ards
Potential ha5ards are considered 3hen making changes 3ithin the organi5ation
(isk Management Plans are prioriti5ed and approved by appropriate level of
management
Identified ha5ards are tracked for closure
'ccurrence and Ha5ard (eporting
R
R
R
R
R
R
6mployees receive feedback on reported ha5ards
Safety data analy5ed
%orrective actions monitored for effectiveness
Ha5ards are monitored to identify trends
* non punitive disciplinary policy in place for reporting ha5ards
Provisions for anonymous submittals of ha5ards
'ccurrence Investigation and *nalysis
R
R
R
R
R
R
R
Investigations conducted to determine root cause
Person1s2 conducting the investigation technically Cualified
Investigations identify 3hat can be done to prevent future occurrences
:oth the immediate causal factors and the contributory factors identified
Investigations include looking at organi5ational factors
*cts of DomissionE and DcommissionE identified
Investigation reports provided to manager that has accountability and authority
Safety *ssurance 'versight Programs
R
R
R
R
R
R
R
R
R
6valuations of operational processes conducted at regular intervals
%hecklists are utili5ed to conduct safety evaluations
%ontractor activities included in safety oversight programs
Processes evaluated by a non stakeholder
(esults and corrective actions documented
Positive observations documented
&indings categori5ed
(esults and corrective actions shared 3ith all employees
*vailable technology used
./
Safety Management Training (eCuirements
R
R
R
R
R
Safety orientation for all ne3 employees
%ompetency reCuirements documented
Training reCuirements documented
(egularly scheduled safety meetings
Pey personnel continuously educated on safety management best practices
Management of %hanges
R
R
R
R
R
'perational procedures analy5ed
%hanges in location# eCuipment or operating conditions analy5ed
Maintenance and operator manuals are posted 3ith current changes
Personnel are made a3are of and understand any changes
;evel of management 3ith authority to approve changes identified
6mergency Preparedness and (esponse
R
R
R
R
R
R
R
R
R
R
R
R
Plan is readily available at 3ork stations
Plan is relevant and useful
6mergency response plan periodically tested
:e updated 3hen contact details change
Personnel briefed on the plan and their responsibilities
Training in emergency response procedures provided
(esponsibilities defined for immediate response personnel
(esponsibilities defined for secondary response personnel
(esponsibilities defined for site security and accident investigation
Procedures for ne>t of kin notification
Procedure for claims and insurance
Procedures for aircraft recovery
Performance Measurements
R
R
R
R
Safety performance monitoring used as feedback to improve the system
*ddress individual areas
*re SM*(T 1Specific# Measurable# *chievable# (esults 'riented# Timely2
;inked to the organi5ation=s business performance measures
.!
Safety Management System
for
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Date?
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S*&6TL M*9*<6M69T SLST6M M*9A*;
This Safety Management System 1SMS2 Manual has been developed to direct all
personnel in the safe operations of the organi5ation0 The manual defines the policy
that governs the operation of the organi5ation0
SMS is a pro active# integrated approach to safety management0 SMS is part of an
overall management process that the organi5ation has adopted in order to ensure that
the goals of the organi5ation can be accomplished0 It embraces the principle that the
identification and management of risk increases the likelihood of accomplishing the
mission0 Ha5ards can be identified and dealt 3ith systematically through the Ha5ard
(eporting Program that facilitates continuing improvement and professionalism0
*uditing and monitoring processes ensures that aircraft are operated in such a 3ay as
to minimi5e the risks inherent in flight operations0
Safety Management Plan
Safety holds the key to this organi5ation=s future and affects everything 3e do0
This SMS Manual defines the organi5ation=s Safety Management Plan0 The Safety
Management Plan is the tool used to define ho3 SMS supports the organi5ation=s
'perations Plan0 'rgani5ation management is committed to the SMS# and is reCuired
to give leadership to the program and demonstrate through everyday actions# the
commitment to safety and its priority in the achievements of the organi5ation0
The processes in place in the Safety Management Plan include the active involvement
of all managers and supervisors# 3ho# through planning and revie3# must continue to
drive efforts for continuing improvement in safety and safety performance0 The term
DSafety ManagementE should be taken to mean safety# security# health# and
environmental management0 The key focus is the safe operations of air3orthy
aircraft0
The processes in place in the Safety Management Plan include the active involvement
of all managers and supervisors# 3ho# through planning and revie3# must continue to
drive efforts for continuing improvement in safety and safety performance0 The term
DSafety ManagementE should be taken to mean safety# health# and environmental
management0 The key focus is the safe operations of air3orthy aircraft0
Safety audits are essential components of the Safety Management Plan0 They revie3
systems# identify safety issues# prioriti5e safety issues# must involve all personnel#
and enhance the safety of operations0
.B
Mission Statement
The Mission is to provide Cuality service to our customers0 This includes? 1describe
the missions you perform20
Safety Policy
Management is committed to providing safe# healthy# secure 3ork conditions and
attitudes 3ith the ob4ective of having an accident free 3orkplace0 The organi5ation=s
o3ner@%6' is committed to?
M 'ngoing pursuit an accident free 3orkplace# including no harm to people# no
damage to eCuipment# the environment and property
* culture of open reporting of all safety ha5ards in 3hich management 3ill not
initiate disciplinary action against any personnel 3ho# in good faith# discloses a
ha5ard or safety occurrence due to unintentional conduct0
* culture of open reporting of all safety ha5ards
Support for safety training and a3areness programs
%onducting regular audits of safety policies# procedures and practices
Monitoring industry activity to ensure best safety practices are incorporated in
to the organi5ation
Providing the necessary resources to support this policy
(eCuiring all employees to have the duty to maintain a safe 3ork environment
through adherence to approved policies# procedures# and training# and shall
familiari5e themselves# and comply 3ith safety policies and procedures
*ll levels of management are accountable for safety performance# starting 3ith
the o3ner@%6'0 To be a good leader# you must be a good safety leader
The organi5ation is strengthened by making safety e>cellence an integral part
of all activities
M
M
M
M
M
M
M
M
M
2
Safety Principles
Management embraces the follo3ing safety principles?
M
M
*l3ays operate in the safest manner practicable
* culture of open reporting of all safety ha5ards in 3hich management 3ill not
initiate disciplinary action against any personnel# 3ho in good faith# due to
unintentional conduct# disclose a ha5ard or safety incident
9ever take unnecessary risks
Safe does not mean risk free
6veryone is responsible for the identification and management of risk
&amiliarity and prolonged e>posure 3ithout a mishap leads to a loss of
appreciation of risk
M
M
M
M
'rgani5ation Structure and Safety (esponsibilities
The organi5ation=s structure is described in the operations manual0 The '3ner@%6' is
responsible for the follo3ing safety accountabilities?
M
M
M
*ll operations are conducted in the safest manner practicable
6nsuring the safety of all employees# customers# passengers and visitors
Development of long term safety ob4ectives# including establishment of safety
policies and practices
Implementation of management systems that 3ill establish and maintain safe
3ork practices
M
2.
The chief pilot is responsible for the follo3ing safety accountabilities?
M 6nsuring all flight operations personnel understand applicable regulatory
reCuirements# standards# and organi5ation safety policies and procedures
Identification and development of resources to achieve safe flight operations
'bserve and control safety systems by monitoring and supervision of aircre3s
Measure aircre3 performance compliance 3ith organi5ation goals# ob4ectives
and regulatory reCuirements
(evie3 standards and the practices of organi5ation personnel as they impact
flight Safety
M
M
M
M
The chief of maintenance is responsible for?
M 6nsuring all flight maintenance personnel understand applicable regulatory
reCuirements# standards# and organi5ation safety policies and procedures
Identification and development of resources to achieve safe maintenance
operations
'bserve and control safety systems by monitoring and supervision of
maintenance personnel
Measure maintenance personnel performance compliance 3ith organi5ation
goals# ob4ectives and regulatory reCuirements
(evie3 standards and the practices of maintenance personnel as they impact
flight Safety
M
M
M
M
%ompliance 3ith Standards
*ll personnel have the duty to comply 3ith approved standards0 These include
organi5ation policy# procedures# aircraft manufacturer=s operating procedures and
limitations# and government regulations0 (esearch sho3s that once you start
deviating from the rules# you are almost t3ice as likely to commit an error 3ith
serious conseCuences0
:reaking the rules usually does not result in an accidentS ho3ever# it al3ays results in
greater risk for the operation# and the organi5ation supports the principle of# D96N6(
take unnecessary risks0E
22
Intentional 9on compliance 3ith Standards
:ehavior is a function of conseCuences0 Management is committed to identifying
deviations from standards and taking immediate corrective action0 %orrective action
can include counseling# training# discipline# grounding or removal0 %orrective action
must be consistent and fair0
'rgani5ation management makes a clear distinction bet3een honest mistakes and
intentional non compliance 3ith standards0 Honest mistakes occur# and they should
be addressed through counseling and training0
(esearch has sho3n that most accidents involve some form of fla3ed decision
making0 This most often involves some form of non compliance 3ith kno3n
standards0 9on compliance rarely results in an accidentS ho3ever# it al3ays results in
greater risk for the operation0
'rgani5ation policy agrees 3ith the follo3ing conclusions?
M
M
M
M
M
%ompliance 3ith kno3n procedures produces kno3n outcomes
%ompliance 3ith standards helps guarantee repeatable results
:ad rules produce bad results
%omplacency affects the safe operation of the aircraft and cannot be tolerated
Standards are mechanisms for change
M The hardest thing to do# and the right thing to do are often the same thing
(e3arding People
(e3ard systems are often upside do3n0 (einforced bad behavior breeds continued
bad behavior0 This is unacceptable0 This organi5ation is committed to the principle
that people should be re3arded for normal# positive performance of their duties that
complies 3ith organi5ation standards0 Personnel 3ill not be re3arded for
accomplishing the mission by breaking the rules0
2G
Safety Promotion
Safety is promoted as a Dcore value0E Procedures# practices and allocation of
resources and training must clearly demonstrate the organi5ation=s commitment to
safety0 )e must change the perception that the mission is 3hat=s most important no
matter the risk0 The follo3ing methods are used to promote safety?
M
M
M
M
Posting the Safety Policy in prominent locations around the base of operations
Starting meetings 3ith a comment or revie3 about safety issues
Having a safety bulletin board
Having an employee safety feedback process
Document and Data Information %ontrol
*ll safety documents are controlled through the technical library0 This includes the
SMS# operations# maintenance and training manuals0 %hange control procedures are
incorporated into each of these documents0
The safety officer is responsible for maintaining safety related data# including the
minutes of safety meetings# information on ha5ard and risk analysis# risk
management# remedial action# incident and accident investigations# and audit
reports0
Ha5ard Identification and (isk Management
(isk management is the identification and control of risk0 It is the responsibility of
every member of the organi5ation0 The first goal of risk management is to avoid the
ha5ard0 The organi5ation should establish sufficient independent and effective
barriers# controls and recovery measures to manage the risk posed by ha5ards to a
level as lo3 as practicable0 These barriers# controls and recovery measures can be
eCuipment# 3ork processes# standard operating procedures# training or other similar
means to prevent the release of ha5ards and limit their conseCuences should they be
released0 The organi5ation should ensure that all individuals responsible for safety
critical barriers# controls# and recovery measures are a3are of their responsibilities
and competent to carry them out0 The organi5ation should establish 3ho is doing
3hat to manage key risks and ensure that these people and the things they should do
are up to the task0
The systematic identification and control of all ma4or ha5ards is foundational0 The
success of the organi5ation depends on the effectiveness of the Ha5ard Management
Program0
2H
Ha5ards are identified through employee reporting# safety meetings# audits and
inspections0
The organi5ation o3ner@%6' is responsible for accepting or denying operations# and
manages risk through the (isk *ssessment Matri> 1(*M20
)hen a ma4or change in operations# eCuipment or services is anticipated# the
management of change process should include ha5ard identification and risk
management processes0
The (*M is a graphic portrayal of risk as the product of probability on one a>is
1e>posure# freCuency or likelihood2 and potential conseCuence on the other a>is 1loss
generated from the outcome20
The (isk *ssessment Matri> sho3s an assigned value# and has a broad application for
Cualitative risk determination as 3ell as graphically presenting risk criteria0
The data from the risk assessment1s2 is entered into the risk assessment form and is
maintained by the chief pilot0 These risk assessment forms make up the list of
ha5ards for the organi5ation0
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'ccurrence and Ha5ard (eporting
*ll occurrences and ha5ards identified by an employee shall be reported to the safety
officer using the H*I 3eb based reporting system called the 6vent (eporting System#
found at 3330eventreporting0org0 If employees are unable to report through that
3eb site# they may report all occurrences and ha5ards identified on the belo3
'ccurrence and Ha5ard (eport0
'ccurrence and Ha5ard Identification (eport
The purpose is to assure that intervention prevents reoccurrence0
VVVV'ccurrence (eport
.0 Date?VVVVVVVVVV
H0 6mployee name?
VVVVHa5ard Identification (eport
20 Time?VVVVVVVVVV G0 ;ocation?VVVVVVVVVVVVVVVVV
VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV
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Safety 'fficer=s Signature? VVVVVVVVVVVVVVVVVVVVV Date? VVVVVVVVVVVVVVVVVV
2,
'ccurrence Definition
*n occurrence is defined as? *ny unplanned safety related event# including accidents
and incidents that could impact the safety of guests# passengers# organi5ation
personnel# eCuipment# property or the environment0
Ha5ard O Definition
* ha5ard is defined as? Something that has the potential to cause harm to a persons#
loss of or damage to eCuipment# property or the environment0
'ccurrences
The chief pilot is responsible to ensure all relevant comments from other managers
and agreed actions are recorded in the report0 (eports are closed 3hen all actions
have been taken0 'ccurrences shall be revie3ed in the monthly meeting0
Personnel may anonymously report ha5ards using the same report0
Personnel 3ho report shall be treated fairly and 4ustly# 3ithout punitive action from
management e>cept in the case of kno3n reckless disregard for regulations and
standards# or repeated substandard performance0
The DJust %ultureE Process sho3n belo3 is used 3hen deciding if disciplinary action is
appropriate0 1&or guidance in using this procedure see the IHST DSMS ToolkitE 3eb
page? 3330ihst0org@SMStoolkit@20
Just %ulture Process
Start 9oU
LesU
Pass substitution testF
9o
Defective training or
selection e>perienceF
9o
9egligent 6rror
(epeated Incident )ith
Similar (oot %ause
LesU
9o
)as the 4ob understoodF
Les
) as the action as
intendedF
Les
)ere the results as
intendedF
Les
Sabotage or Malevolent
*ct
9o
(eckless Niolation
9o
Pno3ingly violated
proceduresF
Les
*re the procedures
clearF
Les
9oU
9oU History of violating
proceduresF
LesU
9o :lame 6rror
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negative performance
appraisal
Documented for the
purpose of accident
prevention a3areness
and training 3ill
suffice0
Severe Sanctions
U Indicates a WSystem= induced error0 Manager@supervisor must evaluate 3hat part of the system failed and 3hat
corrective and preventative action is reCuired0 %orrective and preventative action shall be documented for
management revie30
2B
'ccurrence Investigation and *nalysis
Significant occurrences are investigated by the safety officer or his designee# and
shall be revie3ed by the o3ner@%6'0
The safety officer revie3s the database for previous occurrences in order to identify
trends0
&or human error in maintenance operations# the M6D* checklist shall be used0 &or
human error in flight operations# the H&*%S checklist shall be used0 These checklists
are posted on the IHST DSMS ToolkitE 3eb page 3330ihst0org@SMStoolkit@0
Safety *ssurance 'versight Programs
The organi5ation conducts monthly base inspections0 (ecords of base inspections and
the resolution of actions are maintained by the safety officer0 Issues identified in
inspections are included in the agenda of the Safety Meeting0 The safety officer is
responsible for storing these documents0
The safety officer directs annual audits of the SMS0 * sample checklist for audits can
be found on the IHST 3ebsite0 &indings and associated corrective actions shall be
recorded in the audit0
The safety officer should manage and store audit reports# 3hich include findings and
recommended corrective actions0 Positive findings should also be recorded0 &indings
and recommended actions should be communicated to all personnel0 * sample audit
checklist can be found on the IHST 3ebsite0
Safety Management Training (eCuirements
6mployees shall receive SMS training# including?
M
M
M
M
M
'rgani5ation commitment to safety
'rgani5ation=s Safety Policy
6mployee=s role in the SMS
Process for reporting occurrences
*pplicable emergency procedures
G
Minimum Safety Training (eCuirements
Type of Safety Training
Introduction SMS training
&irst *id
)HMIS
Job Specific Safety Training
*ffected Personnel
*ll employees
'ne attendant per
location
6ngineers# stores
*ffected Personnel
Nalidity
9@*
2 years
2 years
9@*
'ptional Safety Training (eCuirements
&ire &ighting 1basics2
)HMIS
Periodic SMS (efresher Training
*ll personnel
Pilots@cre3members
*ll employees
6mployee training files shall include the belo3 form to record training# the date that
training is ne>t due# and the means of demonstrating competency# verbal or 3ritten
as determined by the chief pilot0 Training records shall be kept in the personal file of
all personnel0 The chief pilot is responsible for revie3ing training files in order to
ensure recurrent training is conducted on a timely basis0
G.
Safety and SMS Training &orm
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22 Date recurrent training due?VVVVVVVVVVVVVVVVVVVVVVV
G2 Method of confirming competency and score?VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV
H2 %omments and areas for improvement? VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV
VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV
In signing belo3# I agree that I have taken VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVtraining
6MP;'L66 SI<9*TA(6? VVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVV D*T6? VVVVVVVVVVVVVVVVVVVVVV
G2
Management of %hange 1M'%2
Procedures are established and maintained to manage changes associated 3ith safety0
The systematic approach to managing and monitoring organi5ational change is part of
the risk management process0 Safety issues associated 3ith change are identified and
standards associated 3ith change are maintained during the change process0
Procedures for managing change include?
M
M
M
M
M
M
M
M
(isk assessment
Identification of the goals and ob4ectives and nature of the proposed change
'perational procedures are identified
%hanges in location# eCuipment or operating conditions are analy5ed
Maintenance and operator manuals are posted 3ith current changes
*ll personnel are made a3are of and understand changes
;evel of management 3ith authority to approve changes identified
The responsibility for revie3ing# evaluating and recording the potential safety
ha5ards from the change or its implementation
*pproval of the agreed change and the implementation procedure1s2 M
The M'% process has H basic phases? screening# revie3# approval and implementation0
:oth the effect of change and the effect of implementing change are considered0
There are methods for managing the introduction of ne3 technology0 *ll personnel
should be consulted 3hen changes to the 3ork environment# process or practices
could have health or safety implications0%hanges to resource levels and
competencies associated risks are assessed as part of the change control procedure0
&igure . G describes the M'% process used by this organi5ation0
GG
M'% Process
Screen
Do 3ork
under
normal
authority
9o
Les
(evie3 *pprove Implement
9e3 Type *@%
Design %hange
*MT *ssgmt0 %hg0
%ert0 Team
$*
&ield Maintenance
%re3 Scheduling
Dir0 of Maint0 $*
Dir0 of Maint0 $*
Dir0 of Maint0 $*
Perform
)ork
Processes
*ircraft
or
Maint0
Initiate
M'%
Procedure
Pilot *ssgmt0 %hange
Maint0 Proc0 %hange
Maint0 Prgm0 %hange
Les
9e3 6Cuipment
Proposed
%hange
Screen
for
M'%
Les %hange
6ffectF
Les
9o
%hange in 'ps0 Proc0
Les
Do 3ork
under
normal
authority
9o
Do 3ork
under
normal
authority
'ps0
Initiate
M'%
Procedure
&acility %hange
<round Support %hg0
Pilot *ssgmt0 %hange
<eographic ;oc0 %hg0
9e3 'peration Dir0 of 'ps0
%hief Pilot
Dir0 of 'ps0
Dir0 of 'ps0
%re3 Scheduling
Dir0 of 'ps0
&igure . O G
GH
6mergency Preparedness and (esponse
The detail of the 6mergency (esponse Plan is contained in the 'perations Manual0
The chief pilot is responsible for assuring that all personnel are trained to handle
organi5ation emergencies based on their role in the organi5ation0
6mergency drills shall be conducted at least annually to ensure employees are
competent0
6mergency contact numbers shall be posted and kept current at every organi5ation
telephone0
G+
Performance Management
%ontinual improvement and e>emplary service to our customers is a Dcore value0E
Safety performance is measured by the follo3ing performance measures?
M
M
M
M
M
M
(educe the number incidents that cause damage and the amount of damage
(educe the number of Incidents per .# hours flo3n
(educe the number of In4uries to organi5ation personnel# guests and passengers
Increase the number of actions raised from safety meetings
(educe the number of Dnear missE events
(educe the number of non compliances 3ith standard flight operations
procedures as measured by observation or flight data monitoring0
Increase compliance 3ith the safety incident management process 1reporting#
classification# root cause investigation# and implementation of corrective
actions20
(educe the number of non compliances 3ith standard flight operations
procedures as measured by observation or flight data monitoring0
(educe the number of non compliances 3ith standard flight operations
procedures as measured by observation or flight data monitoring0
M
M
M
The chief pilot is responsible for ensuring organi5ation performance is annually
revie3ed and employees are adeCuately informed of the results of the revie30
G/
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M
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M
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Policy Statements
'b4ectives
Duties and (esponsibilities
%ompetency (eCuirements
SMS Manual
DJust %ultureE
%ore Nalues
(esource Material
S*&6TL P('M'TI'9
M
M
M
M
M
Safety %ommunications 1memos# ne3sletters# posters2
Safety Performance (eports
6mployee &eedback System
Safety Training
(esource Material
D'%AM69T and D*T* M*9*<6M69T
M
M
M
M
Safety Promotion in SMS Manual
Document %ontrol
Data Management
(esource Material
H*Q*(D ID69TI&I%*TI'9 and (ISP M*9*<6M69T
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M Ha5ard Tracking and (esolution
(ISP *SS6SSM69T T'';S
M Safety %ase
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M (eporting Systems# &orms# &eedback
M (esource Material
'%%A((69%6 I9N6STI<*TI'9 and *9*;LSIS
M Investigative Tools
M (esource Material
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M
M
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*udit %hecklists
*udit (eport &orms
%ommunication of Ma4or &indings
(esource Material
S*&6TL M66TI9< T(*I9I9< (6$AI(6M69TS
M
M
M
M
'rientation %hecklists
Training Tracking System
Safety Meeting *gendas
(esource Material
M*9*<6M69T of %H*9<6S
M M'% &lo3chart and &orm
M (esource Material
6M6(<69%L P(6P*(6D96SS and (6SP'9S6
M 6(P %hecklist
M Drill %hecklist
M (esource Material
G,
P6(&'(M*9%6 M6*SA(6S
M Pey Performance Indicators
M (esource Materials
SMS (6S'A(%6 M*T6(I*;S
M (esource Materials
GB