ICAO Annex 19

‘Safety Management’

TE.GEN.00409-001
Outline

The case for Safety Management

ICAO Annex 19

ICAO Annex 19 2
Part I

The case for Safety Management

ICAO Annex 19

ICAO Annex 19 3
Concept of safety

What is safety
Zero accidents (or serious incidents)?
Freedom from danger or risks?
Error avoidance?
Regulatory compliance?
…?

Controlled risk and controlled error is acceptable in an inherently safe system.

Safety is a systems property, it can only be determined for the whole system under
consideration.
Safety constraints need to be enforced at all system levels. SMS provides the
framework for this to happen in a systematic way.

ICAO Annex 19 4
 Rate of accidents since 1945 &
Evolution of safety thinking

Technical Better technology

HF management, CRM,
Human FRM etc…

Quality Assurance, QMS

Organisational Threat & Error management

Safety
System safety management
SMS & SSP
addressing all of it :
better technology
Human &
Organisational factors
compliance
risks
etc..

Global rate of accidents involving passenger fatalities per 100 million passenger miles, scheduled commercial air transport
operations, excluding acts of unlawful interference

5
Why do we need to do more?

Fast pace of technological change – new business models

Changing nature of accidents

• New types of hazards – emergence of organisational accidents

Reduced ability to learn from experience

• time to market for new products has greatly decreased

Increasing complexity and coupling of system ‘components’

• cause and effect are less and less related in a direct/linear way

More complex relationships between humans and automation, role of

software

Changing regulatory and public views (perception) on safety

6
Organisational accidents

The immediate cause of many accidents is identified as human or

technical failure, but these in turn usually stem from organisational
failures which are the responsibility of management.

“Individual accidents are by far the larger in number. Organisational

accidents are comparatively rare, but often catastrophic, events
that occur within complex modern technologies.”

“Organisational accidents have multiple causes involving many

people operating at different levels of their respective
companies…Organisational accidents are the product of recent
times, or more specifically, a product of technological innovations
which have radically altered the relationship between systems and
their human elements.”

James Reason, Managing the Risk of Organizational Accidents, Ashgate publishing, 1997.

ICAO Annex 19 7
 What is a safety management system (SMS)?

Processes
Decision-
Making

Safety risk Hazard

The predicted probability and Risk
A condition that could cause
severity of the consequences or contribute to an aircraft
or outcomes of a hazard. incident or accident.

A series of defined, organisation-wide processes that provide for effective risk-based decision-
making related to a company’s daily business.

ICAO Annex 19 8
 Key processes of an SMS

Hazard identification

• A method for identifying hazards related to the whole organisation (operational + systemic hazards)

Safety reporting

• A process for the acquisition of safety data not only related to product safety

Risk Management

• A standard approach for assessing risks and for applying risk controls

Performance Measurement

• Management tools for analysing how effectively the organisation’s safety goals are being achieved

Safety Assurance

• Processes based on quality management principles that support continual improvement of the
organisation’s safety performance

ICAO Annex 19 9
 QMS versus SMS
 Both QMS and SMS promote systems approach and continual improvement.
 QMS and SMS may use the same tools and techniques:
 e.g. performance monitoring – Key Performance Indicators (KPIs),
 management of business risks,
 process mapping / system and process analysis,
 auditing, surveys.
 An effective QMS will support the implementation of effective safety management
processes.
BUT

Quality management systems (QMS) are geared towards customer expectations and
contractual/regulatory obligations.
SMS is about identifying hazards and managing risks.
Processes designed to produce a quality product/service alone will not guarantee safety
(safety is a systems property, not a component property).

ICAO Annex 19 10
Part II

The case for Safety Management

ICAO Annex 19

ICAO Annex 19 11
 Starting point:
ICAO High-level Safety Conference 2010

RECOMMENDATION 2/5: ICAO should develop, in close collaboration with States, international and national organizations, a
new Annex dedicated to safety management responsibilities and processes which would address the safety management
responsibilities of States framed under the State Safety Programme (SSP).

In response to the HLSC 2010 recommendation, the ICAO Air Navigation Commission recommended that the new Annex be
developed in two phases:

• Phase 1 involved the consolidation of existing safety management provisions previously contained in as
many as 6 different Annexes, into a single new Annex.

• The development of enhanced requirements is the focus of Phase 2 that started in November 2012.

• The first amendment of Annex 19 Edition 1 is scheduled for November 2016. It will then follow a three-
year amendment cycle.

ICAO Annex 19 12
Transfer of common SSP/SMS elements from the
existing ICAO Annexes

Annex 1
Personnel Licensing

Annex 6
Operation of Aircraft
•Annex 19
•to the Convention on
International Civil Aviation
Annex 8
Airworthiness
Safety Management
Annex 11
Air Traffic Services

Annex 13
Aircraft Accident &
Incident Investigation
First Edition
November 2013

Annex 14
Aerodromes

ICAO Annex 19 13
 ICAO Annex 19 – Contents
Foreword

Chapter 1 - Definitions

Chapter 2 - Applicability

Chapter 3 - State Safety

Management Responsibilities

Chapter 4 - Safety
Management System

Chapter 5 - Safety Data

Collection, Analysis and
Exchange

Appendix 1 - State Safety Attachment A - Framework for a

Oversight System (8 critical State Safety Programme (SSP): 4
elements of oversight) components and 11 elements

Appendix 2 - Framework for a Attachment B - Legal Guidance for

Safety Management System the Protection of Information from
Safety Data Collection and
(SMS): 4 components and 12 Processing Systems
elements

ICAO Annex 19 14
 Status of Annex components

STANDARDS
uniform application is recognised as necessary (differences to
be notified to ICAO)

RECOMMENDED PRACTICES
uniform application is recognised as desirable (no need to
notify differences to ICAO)

APPENDICES
form part of the Standards and Recommended Practices

ATTACHMENTS
comprise material supplementary to the SARPs, but do not
have the value of SARPs (mostly guidance for application)

ICAO Annex 19 15
 ICAO Annex 19 – addressee
STATES SERVICE PROVIDERS
Foreword

Chapter 1 - Definitions

Chapter 2 - Applicability

Chapter 3 - State Safety Chapter 4 - Safety Management

Management Responsibilities System

Chapter 5 - Safety Data Collection, Appendix 2 - Framework for a

Safety Management System (SMS)
Analysis and Exchange *

Appendix 1 - State Safety

Oversight System

Attachment A - Framework for a *

State Safety Programme (SSP) These provisions, transferred from Annex 13, provide the
necessary foundation for the collection, protection, analysis
Attachment B - Legal Guidance for and exchange of safety data to complement the SSP
the Protection of Information from provisions.
Safety Data Collection and
Processing Systems *

ICAO Annex 19 16
 ICAO Annex 19 – Applicability

Chapter 2:

• The Standards and Recommended Practices

contained in this Annex shall be applicable to safety
management functions related to, or in direct
support of, the safe operation of aircraft.

ICAO Annex 19 17
 ICAO Annex 19 – Applicability
Chapter 3 / Chapter 4:

approved training organizations in accordance with Annex 1 that are exposed to safety risks related to aircraft
operations during the provision of their services;

operators of aeroplanes or helicopters authorized to conduct international commercial air transport / CAT
(Annex 6, Part I or Part III, Section II);

approved maintenance organizations providing services to operators of aeroplanes or helicopters engaged in

international CAT (Annex 6, Part I or Part III, Section II);

organizations responsible for the type design or manufacture of aircraft, in accordance with Annex 8;

air traffic services providers in accordance with Annex 11; and

operators of certified aerodromes in accordance with Annex 14.

international general aviation operators of large or turbojet aeroplanes in accordance with Annex 6 Part II
Section III.

ICAO Annex 19 18
 ICAO Annex 19 – Applicability

International General Aviation

• The SMS of an international general aviation operator, conducting operations of

large or turbojet aeroplanes in accordance with Annex 6, Part II, Sec 3, shall be
commensurate with the size and complexity of the operation.

• Recommendation.— The SMS should as a minimum include:

• a process to identify actual and potential safety hazards and assess the
associated risks;

• a process to develop and implement remedial action necessary to

maintain an acceptable level of safety; and

• provision for continuous monitoring and regular assessment of the

appropriateness and effectiveness of safety management activities

ICAO Annex 19 19
SSP/SMS Components

Safety Policy
Safety Risk
and
Management
Objectives

Safety Safety
Assurance Promotion

ICAO Annex 19 20
 Annex 19 and the EU/EASA System

European Aviation Safety

Programme and Plan

Oversight State’s Safety Programme SMS

EASA Authority EASA Organisation
(selective Authority Requirements )
Requirements Requirements

Safety data collection, analysis and exchange

Selective EASA Authority – and Organisation Requirements &
EU Regulation 376/2014 on Occurrence Reporting and follow-up

ICAO Annex 19 21
 Annex 19 - further information

ICAO Safety Management website:

http://www.icao.int/safety/SafetyManagement/Pages

ICAO Annex 19 22
Thank you for your attention!