NACO-SMSTS-03.

00
Safety Management
System
Adebowale Ajose 10/11/2022
 Record of Revision

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Record of Revision

Issue Revision No Manual Number Revised By Revision Date

2 1 NAHCO-SMSTS-02.01 Ajose Adebowale 23/01/20

2 2 NAHCO-SMSTS-02.02 Ajose Adebowale 28/01/20
3 0 NAHCO-SMSTS-03.00 Ajose Adebowale 10/11/22

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 NAHCO-SMSTS-03.00
ICAO definition of safety:

“The state in which risks associated with

aviation activities, related to, or in direct
support of the operation of aircraft, are
reduced and controlled to an acceptable
level.”

ICAO Annex 19, 2nd Edition 2016

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 NAHCO-SMSTS-03.00
Regulatory Requirements

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 Learning objectives

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At the end of this module you should be able to:

Identify the regulatory requirements applicable to your organization

Recognize the set-up of the SMS according to the ICAO framework
Know the airport and airline expectations on your SMS

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 ICAO

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International Civil Aviation Organization

• 1944 Chicago Convention Annexes & Documents

• Part of United Nations
• 193 member states (AUG ‘20)
• Standards and recommended practices
• Global oversight on member states (CAAs)

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Civil Aviation Authority - CAA

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• National aviation rules (in line with ICAO Annexes)
• Operating certificates
• National oversight on operators

Nigeria Civil Aviation Authority (NCAA)

Nig. CAR - Civil Aviation Regulation.

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 International Air Transport

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Association IATA

01 02 03
Guidance for • Standard • Coordination and
operators programs (IOSA, representation of
ISAGO operators with
registration) ICAO

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 NAHCO-SMSTS-03.00
Operators (Regulated Organization types)

• Airlines
• Airports
• Air Traffic Services (ATC, Meteo, NavAids, …)
• Maintenance Organizations (repairs, incl. ULD)
• Aircraft manufacturer
• Training organizations (licensing of air personnel)
• Ground services provider (few countries)

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 SMS Regulatory Path

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ICAO Annex 19
ICAO Standard and Recommended Practice
- Annex 19 demand for SMS
implementation In member
states (State Safety Plan)
State Safety Plan
• CAA CAA
National Regulation
- National aviation regulation
(law) demand for SMS
implementation for operators

• Operators
Operators SMS
- SMS implementation
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• Safety management system (SMS) is a systematic approach to

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managing safety, including the necessary organisational
structures, accountabilities, policies and procedures. (ICAO)

• Safety Management System (SMS) - A systematic and explicit

approach defining the activities by which safety management is
undertaken by an organisation in order to achieve acceptable or
tolerable
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safety. (ESARR 3).
 SMS Purpose and Methods

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Provides:
▪ A systematic way to identify and control risk.
▪ Assurance that risk controls remain effective.
▪ A formal means of meeting Statutory requirements
▪ The NCAA a means of evaluating an organization’s
safety management capability
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 THE IMPORTANCE OF A SAFETY

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MANAGEMENT SYSTEM

• Helps provide safe and stable consumer support

• Helps reduce insurance premiums, due to the

implementation of safety protocols

• Reduces the possibility of accidents/injuries

• Minimizes loss of life in hazardous working conditions

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 THE IMPORTANCE OF A SAFETY

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MANAGEMENT SYSTEM

• Improves employee satisfaction and morale

• Enhances productivity with improved health of the
employees
• Minimizes absenteeism
• Leads to a balanced interaction with the regulatory
authorities

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 NAHCO-SMSTS-03.00
Components
of SMS
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Discussion Questions

What are the components of

Safety?

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Safety Policy
A statement of the organisation’s fundamental
approach to achieve acceptable or tolerable
safety”.

The certificate holder’s documented commitment

to safety, which defines its safety objectives and
the accountabilities and responsibilities of its
employees in regard to safety.
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Safety Policy
• The foundation of the Safety Management System
(SMS)

• Safety policy confirms an organisation’s commitment

to safety and clearly indicate that safety is afforded
highest priority in the service provision.

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Safety Policy
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, namely

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Safety Policy
• Commitment to safety (safety priority)
• Safety responsibility (planning for safety)
• Safety management (Identification of Key
Safety Staff)
• Emergency Response Plan Coordination
safety standards,
• Safety Document

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Safety Policy Statement
A formal expression in a statement of the organisation’s
Safety Policy, which reflects the organisation’s philosophy of
safety management.

A declaration of the overall safety objective of the

organisation. It sets the general direction and aspirations for
improved safety performance.

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Safety Policy Statement

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Safety Policy Statement

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Employers
Responsibilities

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An employer has a 'duty of care'
to make sure, as far as possible,
the health, safety and welfare of
employee while they are at
work.

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Assess risks

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Employers have duties under health and safety law to assess risks in the
workplace. This means identifying work activities that could cause injury
or illness and taking action to eliminate the hazard, or if this isn’t
possible, control the risk.

Provide information about risks

Employers must give workers information about the risks in their
workplace and how they are protected, also instruct and train them on
how to deal with the risks.

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Consult employees

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Employers must consult employees on health and safety issues.
Consultation must be either direct or through a safety representative
that is either elected by the workforce or appointed by a trade union.

Provide health and safety information

Employers have a legal duty under the Health and Safety Information
for Employees Regulations (HSIER) to display the approved poster in a
prominent position in each workplace or to provide each worker with a
copy of the approved leaflet.

Health and safety law poster, free leaflet and pocket card

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▪ Provide a workplace free from serious recognized hazards and

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comply with standards, rules and regulations issued by
government
▪ Examine workplace conditions to make sure they conform to
applicable standards.
▪ Make sure employees have and use safe tools and equipment
and properly maintain this equipment.
▪ Warn employees of potential hazards.
▪ Establish or update operating procedures and communicate them
so that employees follow safety and health requirements
▪ Employers must provide safety training in a language and
vocabulary workers can understand.
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▪ Provide medical examinations and training

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▪ Report to the regulatory agencies all work-related fatalities within
48 hours
▪ Keep records of work-related injuries and illnesses.
▪ Provide employees, former employees and their representatives
access to the Log of Work-Related Injuries and Illnesses
▪ Provide access to employee medical records and exposure
records to employees or their authorized representatives.
▪ Not discriminate against employees who exercise their rights
under the Act. See our "Whistle-blower Protection" webpage.

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Safe Working
and Operating
Practises

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 Safe Work Practices

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and Procedures
Safe work practises and procedures
needs to be in place in order to ensure
workers are safe within the work
environment. Common area in the
aviation industry where policy and
practise would need to be established in
order to foster safe working
environment will include the following:
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 Aircraft Safety
Aircraft safety while it is parked on the

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apron, during movement on the airside is
very important in the aviation industries
Tools and Equipment
Workers need to have an understanding of
Lighting their selection of the appropriate tools or
equipment specific to their job task, being
The correct placement and use of Safe Work trained in the correct use and maintenance of
both natural and artificial lighting in relation
to workers and their environment. Lighting
Practices the equipment.

needs to allow workers to clearly see what and

bthey are doing while also not be Procedures
overpowering or create glare. Airport
Marking
Manual Handling
This relates to the movement of Visiblle and clear marking is important to help
objects of varying weights. prevent ground incidents. These markings
Workers need to be trained in serves as guide to all personnel working on
manual handling techniques the apron.
for scenario when working individually, in pairs or
in a team, as well as understanding of legal weight
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limits they should be lifting and equipment which
can support manual handling.
 NAHCO-SMSTS-03.00
Employees
Responsibilities

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 Taking reasonable care to protect the health and safety

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of yourself and other people in the workplace
 Not engaging in improper behaviour that will endanger
yourself or others
 Not being under the influence of drink or drugs in the
workplace
 Undergoing any reasonable medical assessment (or
other assessment) if requested by your employer
 Reporting any defects (faults) in equipment or the
workplace which might be a danger to health and safety

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 ICAO SMM, Doc. 9859, 4th Edition

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What is
just 2.2.2 c)

culture? Personnel are provided with information by the organization

that:

• describes the expected behaviours in

respect to the organizational processes and
procedures;
• describes what actions will be taken by the
organization in response to individual
behaviours;

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 Just culture – Human Behavior

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 Just culture – Human Behavior

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 Just culture – Human Behavior

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 Just culture – Human Behavior

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Questions

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 SAFETY RISK MANAGEMENT

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 SAFETY RISK MANAGEMENT

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Items to be considered: Highlights:

• Hazard identification Hazard reporting

− Information sources
− Tools, systems Risk management responsibility
with process owners
• Risk assessment
− Systematic Final decision on actions with AE
− Responsibilities
• Hazard identification
• Mitigation
− Decisions • Risk assessment and mitigation
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Evaluation of effectiveness
 SAFETY RISK MANAGEMENT

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• Hazard Identification and safety risk management (SRM)
are the core process in the management of safety.

• Hazard identification and safety risk management are

dogmatic components that underlie the comprehensive
concept of system safety.

DOGMATIC

a belief that people are expected to

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 Hazards and Risks

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Learning objectives
At the end of this module you should be able to:

• Identify and define hazards associated with aviation

• Differentiate between hazards, risks and
consequences
• Explain the difference between hazard and risk

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 Hazards

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Hazard

“Anything that has capacity to cause Harm”

“A hazard is a condition or an object with the potential

to cause or contribute to an aircraft incident or accident.”

ICAO Doc. 9859, 4th Edition

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 Hazard identification sources

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Reactive Proactive

• Analysis of past events • Hazard reporting (voluntary)

• Risk assessment
− Incident/accident reports • Audits (internal/external)
− Safety occurrence reports reports

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 Hazard Reporting

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Remember reporting barriers
(Module 2, Human factors)
• Do not insist on correct hazard
definitions
• Do not insist on ‘formal’ conformity
• Accept all inputs
• Give feedback, show appreciation (direct
or indirect)

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 Hazard Reporting

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Types of Reporting System
• Mandatory Reporting System
• Voluntary Reporting System
• Confidential Reporting System

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Discussion Questions

• What types of hazards could be

associated with the activities
involved in an Airport?

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 Hazards and consequences

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Hazard Consequences Impact

Manual handling • Hand impacted by machine squeeze, cut fingers

• Strain on back back injury

Working at height • Fall down bone fractures

Moving GSE/ • Hit aircraft Aircraft damage

Vehicle • Hit personnel Personnel injury

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 Discussion Questions

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In your groups discuss and select an activity in the
airport.
• Identify associated hazards for the selected activity
• Assign potential consequences to each hazard
• Assign potential impacts to each consequence
• Note the down in the table provided
• Select a group member to present your results

Time to complete: 10 min

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 Hazard identification - Items to be

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considered
• System description (manuals, job cards, …)
• Design factors (equipment, tasks)
• Human performance limitations
• Procedures and operating practices (documentation, checklists)
• Communication factors
• Organizational factors
• Performance monitoring systems (supervision)
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Man-machine interface
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What is

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As per ICAO (and

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IATA) risk is the
combination of the
predicted
Probability and
Severity,

Expressed as the
risk index.

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 Risk

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Probability Severity
The chance that a hazard The magnitude of a
results in a consequence potential impact, if a hazard
- Frequency per results in a consequence

• # Turnarounds − Damage
• # Operational hours • Aircraft, GSE, baggage, cargo,
• # Bags infrastructure
• T Cargo − Injury
• # Passengers • Personnel, crew, pax, bystanders
− Loss
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 Risk Management

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ICAO definition of safety:

“The state in which risks associated with aviation activities,

related to, or in direct support of the operation of aircraft, are
reduced and controlled to an acceptable level.”

ICAO Annex 19, 2nd Edition 2016

Risk reduction and control = Risk Management

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Risk

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 Risk Assessment Overview

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Process steps
1. Select operational activity (SOP)
2. Identify associated hazards PIX AHM 610 4.4

3. Define possible consequences

4. Probability analysis (chance or
likelihood) of the consequences to
occur
5. Severity analysis (possible impact) if a
consequence occurs
6. Check the risk tolerability
7. Risk acceptable = no action
8. Risk not acceptable = mitigation action
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10/11/2022

Can risks be
Eliminated?
• Not under ‘normal’ circumstances.
• Existing risks after all control and
• reduction activities are called

• Residual Risk

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 Risk probability

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Safety risk probability table ICAO Doc 9859, 4th Edition
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 Risk probability

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Safety risk probability table IATA AHM 610, 41st Edition
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 Risk probability

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Proposed to be adapted according to company specifications
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 Risk probability

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Hints and tips
✓ Data from own company records
✓ Data from authorities, if shared
✓ Industry data, if available
✓ Own judgement or memory, if no
data available
- Include experienced staff who know
the job
✓ Be realistic

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 Risk probability

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Proposed to be adapted according to company specifications
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 Risk Severity

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10/11/2022 Safety risk severity table ICAO Doc 9859, 4th Edition
 Risk Severity Safety risk severity table IATA AHM 610, 41st Edition

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 Risk Severity Safety risk severity table IATA AHM 610, 41st Edition

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 Risk Severity Safety risk severity table IATA AHM 610, 41st Edition

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 Risk Severity Safety risk severity table IATA AHM 610, 41st Edition

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Note: Each organization has to define their own definitions corresponding to their activity. Descriptors shown in
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this chart are for example only and aim to provide a guide to risk assessment users.
 Risk Severity

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Proposed to be adapted according to company specifications
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 Risk Severity

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Hints and tips
✓ Take worst foreseeable, but apply a
‘balanced approach’
✓ Data from own company records
✓ Data from authorities, if shared
✓ Industry data, if available
✓ Own memory, if no data available
− Include experienced staff who know
the job

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 Risk Assessment Matrix

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Risk assessment table IATA AHM, 41st Ed. 610, 4.5
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 Risk Assessment Matrix

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Safety risk assessment matrix ICAO Doc 9859, 4th Edition also proposed

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 Risk tolerability matrix

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Safety risk assessment matrix ICAO Doc 9859, 4th Edition also proposed
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 Discussion Questions

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What do you think about the ICAO, IATA
and Suggested probability table, severity
table and Risk Assessment Matrix?

Do you think you can work with any of

these table?
Time to complete: 5 min

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 Risk mitigation

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Principles and documentation
Mitigation action

Risk mitigation means keeping risks under control

• In any operations usually all tasks and procedures are controlled
• The controls are documented in policies, processes and SOPs
• Additional controls may be necessary, based on risk assessment
results
Recommendation
✓ Note down additional controls to reduce risks in the risk
assessment
✓ Document your existing controls as well (keywords)
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 Mitigation Action

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Mitigation actions can only Actions
work on either side in the risk To reduce probability:
assessment process ✓ (Re-) Design
− Process / procedure
• Reduce probability − Equipment / tools
− Training / education
• Reduce severity) − Supervision

To reduce severity
✓ Installation / provision
− Protectors, bumper
− Barriers
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 Risk Mapping

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Method to
• Provide overview of operational risks for management
• Keep focus on critical, important and sensitive safety relevant
processes

Contents
✓ Operational processes
✓ Possible consequences on unsafe execution of tasks (simplified)
✓ Impact on safety (categories)

Not a regulatory requirement

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 Risk Mapping

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Method to
• Provide overview of operational risks for management
• Keep focus on critical, important and sensitive safety relevant
processes

Contents
✓ Operational processes
✓ Possible consequences on unsafe execution of tasks (simplified)
✓ Impact on safety (categories)

Not a regulatory requirement

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 Risk Mapping Sample

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 Safety Action Plan

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Document all planned (mitigation/corrective) actions
resulting from risk assessments and/or investigations

Contents
✓ Planned actions
✓ Responsibilities (who, department, …)
✓ Timelines (start/end or deadlines)
✓ Expected results
✓ 10/11/2022
Review dates to evaluate effectiveness
 Safety Action Plan (Sample)

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Questions

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Performance
Monitoring

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 Learning objectives

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At the end of this module you should be able to:

• Identify information sources for performance monitoring

• Develop and implement safety performance indicators for
your organization
• Support the visualization of performance results for internal
company information and discussion

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 Discussion Questions

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What is performance?

What does monitoring mean to you?

Time to complete: 4 min

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Safety objectives, SPIs and SPTs

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 Definitions

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Safety Performance Indicator (SPI)
A data-based parameter used for monitoring and assessing safety
performance.

Safety Performance Target (SPT)

The planned or intended objective for safety performance
indicator(s) over a given period of time

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- ICAO Annex 19
 Safety objectives, SPIs and SPTs

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Safety objectives must be aligned to SPIs and SPTs to facilitate
monitoring and verify achievement
• Safety Objective:
[Airline] will minimize incidents of cabin smoke

• Safety Performance Indicator/s:

1) 0.90 oven smoke incidents per 1,000 departures
2) 1.3 reports of foreign objects in ovens per 1,000 departures

• Safety Performance Target/s:

1) Reduce oven smoke incidents to 0.65 per 1,000 departures within 1 year
2) Reduce number of foreign objects discovered in ovens to less than 1 per
1,000 departures
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 Performance Monitoring
Information sources

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Audits and inspections
✓ Findings, period, type and number
✓ Non-conformities, period, type and number

Reports
✓ Accident / incident reports, period, type/category and number
✓ Occurrence (all other) reports, period, type/category and number
✓ Production, period, manhours, turnarounds (per aircraft type),…
✓ Financial,
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 Discussion Questions

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Identify key safety concerns
• identify four current Airport safety risks and
concerns which you might want to measure
through SPIs.
• Identify and state a safety objective for each.
• Prioritize them and present to the rest of the
group.

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 Performance Monitoring

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Monitoring the performance of an organization:
• Elements or subjects
− Finance, safety, findings,…

• Performance indicators
• Performance targets
• Monitoring intervals
− Annually, quarterly, monthly, weekly, daily

These include all specifications of safety objectives – Safety

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Policy
 Lagging SPIs – Concept

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Monitor safety events that have already taken
place
High severity Low severity
Low probability High probability
• Accidents • Safety events that did
• Serious incidents not manifest in serious
incidents or accidents

Lagging SPIs should be action oriented, e.g. “Reduce oven

smoke incidents due to foreign objects”
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 Leading SPIs– Concept

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Monitor information on prevailing situations and/or
conditions that may affect safety performance
They may be Or Positive
Negative
• Monitor conditions • Monitor conditions
with potential to which contribute to
contribute to a safety
negative outcome

Leading SPIs should be activity oriented e.g. “safety

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briefing completion, seat belt checks etc.”
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Safety Performance
Target
• Realistic
• Measurable
• Timescale
• Acceptable level of risk

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 What data might be needed?

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• Number of flights, departures
• Number of passengers carried
• Size of fleet
• Safety reports
• Training records
• Specific aircraft number/registration?
• Other airline accidents/incidents

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 Performance monitoring

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Executive Operational All Employees
Management Management
Monthly Monthly Intervals to be
defined

Management meeting Safety meeting Internal publications

(standard agenda) − Supervisor,
- coordinator
Report /presentation Report /presentation Tailor made (no
From SM From SM sensitive data!)

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 Managing results

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Gather data Report results
Analyze data
• From where? • To whom?
• How often?
• How often? • How often?
• By whom?
• In what format? • In what format?

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 Acting on Results

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Lagging SPIs Leading SPIs

• Targets not achieved • Indicate good result, but

• Identify reasons lagging SPI does not
• Do not wait for poor • Reconsider leading SPI
results • There may be a
disconnect between the
two

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 Evaluating and refining SPIs and SPTs

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• Ongoing relevance to operation
Check • Ongoing reliability of data
• Are they precise enough to identify and recognize changes?

• To address changing conditions such as new services,

Update product, procedures etc.

• When SPIs are no longer relevant

Delete • When improvements result in stable conditions and
performance

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Incident/Accident
Investigation

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 Learning objectives

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At the end of this module you should be able to:

• Assist or manage incident/accident investigations in your

organization
• Identify relevant contributing factors during an
investigation
• Determine the root cause of accidents/incidents and
suggest necessary corrective action(s)

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 Accidents and Incidents

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An accident is an unplanned, uncontrolled event which resulted in
or could have led to loss of life, injury, damage to aircrafts,
damage to equipment and damage to facility.
.

A near miss is an unplanned event that did not result in injury,

illness, or damage – but had the potential to do so. Only a
fortunate break in the chain of events prevented an injury,
fatality or damage
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 Accidents and Incidents

NAHCO-SMSTS-03.00
IATA AHM, Appendix B – definition
ACCIDENT (Aircraft) An occurrence associated with the operation of an aircraft
that takes place between the time any person boards the aircraft with the
intention of flight an all such persons have disembarked, and in which any
person suffers death or serious injury, or in which the aircraft receives
substantial damage, or the aircraft is missing or completely inaccessible.

INCIDENT An occurrence (i.e. aircraft damage, injury, equipment damage,

loading event/irregularities, aircraft servicing issues) other than an accident
associated with the handling of the aircraft.
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 Accidents and incidents

NAHCO-SMSTS-03.00
ICAO Annex 13 definition
• Accident always aircraft related
a) person fatally or seriously injured
b) aircraft sustains damage or structural failure
c) aircraft missing or inaccessible

• Serious incident
- occurrence with high probability of an accident

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 Accidents and incidents (Cont)

NAHCO-SMSTS-03.00
• Serious injury
a) hospitalization >48 hrs
b) fractures
c) hemorrhage, nerve, muscle, tendon damage
d) internal organ
e) burns (2nd/3rd degree)
f) infectious substances / radiation

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 Investigation responsibility

NAHCO-SMSTS-03.00
• Accident investigation authority
• Designated by state
• Usually CAA or subsection

They take the lead for all investigations under ICAO definition
and may accept airline or manufacturers involved to join

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 Discussion Questions

NAHCO-SMSTS-03.00
What is your (company) definition of
accident/incident?

5 Minutes

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 Investigations

NAHCO-SMSTS-03.00
Accidents/serious incidents All other safety issues

• Under authority lead • Internal naming irrelevant

• Occurrence reporting (suggested “Incidents”)
mandatory
• Investigation as per company
• Might ask for support of
process/procedure
service provider
• Right to retrieve necessary − Lead OM/SM
documentation (W&B, PAX- − Severity level limit
list, …)

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 NAHCO-SMSTS-03.00
Investigation
Process

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 Fact Finding

NAHCO-SMSTS-03.00
Incident/accident report Other information

• Date, time, location • Photos

• Meteo (dry/wet, day/night, …) • Sketches/drawings
• Type of event (damage, injury,
From interviews
near miss, …) • Statements staff involved
• Aircraft (type, reg, flt-no.) • Statements witnesses
• GSE (type, reg.) • From research (documentation)
• Phase of operation (ARR/DEP, • Maintenance records (PM status,
• loading, positioning, removal) failure reports, …)
• Personnel (operator, supervisor, • Maintenance procedures
• Staff records (qualification, rest time,
other staff) history, …)
• Procedures involved (Ops, panning,
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 Analysis

NAHCO-SMSTS-03.00
Contributing factors Tools

• Work in small teams • IT systems (Safety Management)

• Review all facts gathered • Hardcopy lists
• Discuss and identify issues • •Visualization (fishbone)
showing weaknesses or gaps
• Look for ‘links’ between
identified issues (multiple links
usually show contributing factors)

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 Fishbone Practical Example

NAHCO-SMSTS-03.00
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 Analysis

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Root cause(s) Tools

• Work in small teams • Discussions

• List identified contributing factors • Records
• Ask question(s): “If this specific − Previous occurrences
contributing factor would not have − Individual failures
been present, would the incident/
accident have happened?”
• Answer “No” it is usually not the
root cause
• Answer “Yes” it remains as a
contributing factor

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 Past Investigation Activities

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Corrective action Tools

• Actions to be elaborated to eliminate • Discussions

root cause(s) • Records
• Actions may be elaborated to avoid − Previous occurrences
contributing factors − Individual failures
• Review and approval of actions by
management
• Implementation of actions
• Monitor OPS to evaluate

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 Investigation Report

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External receivers/purpose Contents

• Authorities • Description of occurrence

− Compliance • Investigation team / lead
• Investigation thread
• Customers
− Information
• Findings
− Insurance − Contributing factors
− Compensation − Root cause
• Immediate action taken
• Corrective / preventive
• action plan

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 Investigation Report (cont)

NAHCO-SMSTS-03.00
Internal receivers/purpose Contents

• Insurance • Description of occurrence

− Claim compensation • Investigation team / lead
• Management
• Investigation thread
− Information • Findings
− Contributing factors
• Database − Root cause
− Structured data • Immediate action taken
• Corrective / preventive
• action plan

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 Discussion Questions

NAHCO-SMSTS-03.00
In your groups discuss the scenario provided
in the exercise document
− Fill in the requested information
− Select a group member to present
your results

90 Minutes

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