SMS

SAFETY MANAGEMENT SYSTEM COURSE

(SMS)

BASED ON ICAO SMS

ENG.: AHMED MOHAMED ALI ELTAWIEL
AME & Approved Instructor
Mobile phone: +249-912131435
E-Mail:eltawiel01@gmail.com
ICAO Safety Management Systems (SMS) Course
‫بسم هللا الرحمن الرحيم‬
 Objective

• To introduce ICAO course instructors and

participants

• To introduce the course goals, concept, contents

and structure.
 Outline

 Part I – Presentation of participants

 Part II– Course goals, concept, contents and

structure

 Part III – Administrative information

 Part IV – Evaluation procedures

 SMS course introduction

 Part I – Presentation of participants

 Part 1
Introduction of participants

• The 5 W’s
– Who are you ? What is your preferred name
in class?
– Where do you work?
– What is your job title, and
– What are your main responsibilities?
– Why are you attending this course?
• Please define your expectations
 SMS course introduction

 Part II – Course goals, concept,

contents and structure
 Part 2 - Course goals
• The goals of the ICAO Safety Management Systems (SMS)
Course are to:
– provide participants knowledge of safety management
concepts and ICAO Standards and Recommended
Practices (SARPs) on safety management in Annexes1, 6,
8, 11, 13 and 14, and related guidance material; and
– develop participants’ knowledge to accept and oversee
the key components of an SMS, including their
implementation, and the establishment of the State safety
programme (SSP) in compliance with relevant ICAO
SARPs.
 Course concept

Realistic
implementation
Safety
management

Performance
based

ICAO
Prescriptive SARPS
 Course contents
• Module 1 – SMS course introduction
• Module 2 – Basic safety concepts
• Module 3 – Introduction to safety management
• Module 4 – Hazards
• Module 5 – Risks
• Module 6 – SMS regulation
• Module 7 – Introduction to SMS
• Module 8 – SMS planning
• Module 9 – SMS operation
• Module 10 – Phased approach to SSP and SMS
implementation
 SMS course introduction

 Part III – Administrative information

 Course structure

Safety Module 10
Phased approach to
Management SSP and SMS
Implementation
System
Module 8 Module 9
SMS planning SMS operation

Module 5 Module 6 Module 7

Risks SMS regulation Introduction to SMS

Module 1 Module 2 Module 3

Introduction Module 4
SMS course Basic safety to safety Hazards
introduction concepts management
 Housekeeping

Punctuality Participation Data forms Documentation

Certificates No smoking Phones

 SMS course introduction

 Part IV – Evaluation procedures

 Evaluation procedures

1. Overall course evaluation

2. Evaluation of participants’

performance
 1. Overall course evaluation
• A form for course evaluation will be
provided the last day of the course.
• You will be asked to complete this form to
provide feedback on:
– All course’s activities
– The instructors
– Ways and means to improve the training.
 2. Evaluation of participants’
performance
• Daily progress evaluation
• A final evaluation test of one hour duration will be
administered on the last day of the course.
• Attendance: 25%
• Assignment: 25%
• Final Exam: 50%
• Total: 100%
• Exam Pass: 70 %
 2. Evaluation of participants’
performance
• Objectives of the final evaluation:
– verify that participants have understood the
planning, implementation and operation of safety
management systems, to be able to certify and
oversee the SMS of service providers;
– have understood the importance of its relationship
with the State safety programme (SSP);
– in accordance with ICAO requirements.
‫بسم هللا الرحمن الرحيم‬
 Building an SMS
Safety Module 10
Phased approach to
Management SSP and SMS
Implementation
System
Module 8 Module 9
SMS planning SMS operation

Module 5 Module 6 Module 7

Risks SMS regulation Introduction to SMS

Module 1 Module 2 Module 3

Introduction Module 4
SMS course Basic safety to safety Hazards
introduction concepts management
 Objective
• At the end of this module,
participants will be able to explain
the strengths and weaknesses of
traditional methods to manage
safety, and describe new
perspectives and methods for
managing safety.
 Outline
• Concept of safety
• The evolution of safety thinking
• A concept of accident causation – Reason model
• The organizational accident
• People, context and safety – SHEL(L) model
• Errors and violations
• Organizational culture
• Safety investigation
• Questions and answers
• Points to remember
 Concept of safety
• What is safety
• a) Zero accidents (or serious incidents).
• b) The freedom from danger or risks, i.e. those factors which cause or are
likely to cause harm;
• c) The attitude towards unsafe acts and conditions by employees (reflecting a
“safe” corporate culture);
• d) The degree to which the inherent risks in aviation are “acceptable”;
• e) The process of hazard identification and risk management; and
• f) The control of accidental loss (of persons and property, and damage to the
environment).
– Error avoidance
– Regulatory compliance?
 Concept of safety
• Consider (the weaknesses in the notion of perfection)
– The elimination of accidents (and serious incidents)
is unachievable
– Failures will occur, in spite of the most
accomplished prevention efforts
– No human activity or human-made system can be
guaranteed to be absolutely free from hazard and
operational errors
– Controlled risk and controlled error are acceptable
in an inherently safe system
 Concept of safety
(Document No.9859)
• Safety is the state in which the risk of harm to
persons or property damage is reduced to, and
maintained at or below, an acceptable level
through a continuing process of hazard
identification and risk management.
 First Fatal Crash – Commercial Jet
 Canadian Pacific Airlines - Comet 1A (CF-CUN) at
Karachi, Pakistan.

 Failed to become airborne

 Plunged into a dry canal
 Collided with an embankment
 Killed all 5 crew & 6 pax

 Attributed to pilot error.

 Engineering

This A340-600 never left the factory in Toulouse.

In fact, it never left the ground!
It was destroyed before its first flight
 Ground Handling

How did that engine get in MY way?

30
 Weight & Balance

Just a little out of balance!

 Cargo

I know this is supposed to go in SOMETHING?

 Security

A sight nobody will ever forget

 Safety
 Traditional approach – Preventing accidents
 Focus on outcomes (causes)
 Unsafe acts by operational personnel
 Attach blame/punish for failures to “perform safely”
 Address identified safety concern exclusively
 Regulatory compliance
Identifies:

WHAT? WHO? WHEN?

But not always discloses:

WHY? HOW?
 The evolution of safety
thinking
TECHNICAL FACTORS

HUMAN FACTORS

TODAY
ORGANIZATIONAL FACTORS

1950s 1970s 1990s 2000s

The evolution of safety
thinking
 A concept of accident causation
Organization Workplace People Defences Accident

Latent conditions trajectory

Source: James Reason

 The organizational accident
Organizational processes

Workplace Policy-making Latent

conditions Planning conditions
Communication
Allocation of resources
Active Supervision Defences
failures  ...

Activities over which any organization has a reasonable degree

of direct control
The organizational accident

Organizational processes

Workplace Latent
conditions conditions
Technology
Training
Active
Regulations Defences
failures

Resources to protect against the risks that organizations involved

in production activities generate and must control.
 The organizational accident

Organizational processes

Workplace  Inadequate hazard Latent

conditions identification and conditions
risk management
 Normalization of
Active deviance Defences
failures

Conditions present in the system before the accident, made evident

by triggering factors.
The organizational accident

Organizational processes

 Workforce stability
Workplace  Qualifications and Latent
conditions experience conditions

 Morale
 Credibility
Active
 Ergonomics Defences
failures
 ...

Factors that directly influence the efficiency of people in

aviation workplaces.
 The organizational accident

Organizational processes

Workplace Latent
conditions conditions

Errors
Active
failures
Violations Defences

Actions or inactions by people (pilots, controllers, maintenance

engineers, aerodrome staff, etc.) that have an immediate adverse
effect.
A human error is an action or decision which was not
intended, which involved a deviation from an accepted
standard.
Human errors occur frequently, but are generally only
considered to be problem if they lead to an undesirable
outcome.
Errors fall into three categories;
1- slips.
2- lapses.
3- mistakes.
 violations
Violations differ from errors in that errors are
unintended where as violations are deliberate.
Violations are any deliberate deviations from
rules, procedures, instructions and regulations.
Violations are shaped mainly by attitudes,
beliefs, group norms and safety culture.
Violations represent a significant threat to safety
as systems are designed assuming people will
follow the procedures.
 Human Errors
Human
Failure

Errors Violations

Skill-based Errors
Mistakes

Optimizing
Slips of Lapses of routine situational exceptional
action memory

Rule-
Knowledge based
based
mistakes
mistakes
» The failures caused by those in direct contact with the
system, i.e., pilot or technicians who are working on the
aircraft, are considered to be active failures..
These failures are errors or violations that have a
direct and immediate effect on system.

» Latent failures are those failures which derive form

decisions made by supervisors and managers who are
separated in both time and space from the physical
system.
 The perspective of the
organizational accident
• Organizational processes
Improve Identify
Monitor
Workplace Latent
conditions conditions

Reinforce
Contain

Active
Defences
failures
 People and safety
• Aviation workplaces involve
complex interrelationships
among its many components
• To understand operational
performance, we must
understand how it may be
affected by the
interrelationships among the
various components of the Source: Dedale

aviation work places

A

B
Processes and outcomes

Error:
causes and
consequences
are not linear in
their magnitude
 People and safety – SHELL model
• Understanding the relationship between people and
operational contexts
Software
S Hardware
Environment
H L L
Live ware
E Live ware, other
persons
 Operational performance and technology

• In production-intensive
industries like
contemporary aviation,
technology is essential
• As a result of the massive
introduction of
technology, the
operational consequences
of the interactions
between people and
technology are often
overlooked, leading to
human error
 Understanding operational errors

Human error is considered contributing

factor in most aviation occurrences
Even competent personnel commit errors
Errors must be accepted as a normal
component of any system where humans
and technology interact
Errors and safety – A non linear relationship

Statistically, millions of
operational errors are made
before a major safety
breakdown occurs
Accident investigation – Once in a million flights

Error Deviation Amplification Degradation /

breakdown
Safety management – On almost every flight

Error Deviation Amplification Normal flight

 Three strategies for the control of human error

• Error reduction
strategies intervene at
the source of the error
by reducing or
eliminating the
contributing factors
– Human-centred
design
– Ergonomic factors
– Training
–…
 Three strategies for the control of human error

• Error capturing
strategies intervene once
the error has already
been made, capturing the
error before it generates
adverse consequences
– Checklists
– Task cards
– Flight strips
–…
 Three strategies for the control of human error
• Error tolerance
strategies intervene to
increase the ability of a
system to accept errors
without serious
consequence
– System redundancies
– Structural inspections
–…
 Understanding violations – Are we ready?

Accident
High
Incident
System’s
production
objective(s)

Exceptional violation space

Risk

Violation space
Low
Minimum System output Maximum
 Culture
• Culture binds people together as members of
groups and provides clues as to how to behave in
both normal and unusual situations

• Culture influences the values, beliefs and

behaviours that people share with other members
of various social groups
Three cultures
National

Organizational

National
Professional
 Three distinct cultures
• National culture encompasses the value system
of particular nations
• Organizational/corporate culture differentiates
the values and behaviours of particular
organizations (e.g. government vs. private
organizations)
• Professional culture differentiates the values and
behaviours of particular professional groups (e.g.
pilots, air traffic controllers, maintenance
engineers, aerodrome staff, etc.)
• No human endeavour is culture-free
 Organizational/corporate culture
• Sets the boundaries for acceptable behaviour in
the workplace by establishing norms and limits
• Provides a frame work for managerial and
employee decision-making
– “This is how we do things here, and how we
talk about the way we do things here”
• Organizational/corporate culture shapes – among
many others – safety reporting procedures and
practices by operational personnel
 Safety culture
• A trendy notion with potential for misperceptions
and misunderstandings
– A construct, an abstraction
– It is the consequence of a series of
organizational processes (i.e., an outcome)
• Safety culture is not an end in itself, but a
means to achieve an essential safety
management prerequisite:
– Effective safety reporting
 Organizational Culture
Values
National Culture Professional Norms

Psychological

Laws/Regulations
Industry Standards

System/
Behavioral Outcomes
Environment

Industry Norms Practices

Business Relations
Markets
 Effective safety reporting – Five basic traits

Information Flexibility
People are knowledgeable about the human, technical and People can adapt reporting
when facing unusual
organizational factors that determine the safety of the circumstances, shifting
system as a whole. from the established mode
to a direct mode thus
Willingness allowing information to
quickly reach the
People are willing to appropriate decision-
report their errors and
Effective safety making level.
experiences. reporting
Learning
People have the
competence to draw
Accountability conclusions from safety
People are encouraged (and rewarded) for providing information systems and
essential safety-related information. However, there is a the will to implement major
clear line that differentiates between acceptable and reforms.
unacceptable behaviour.
 Three options
• Organizations and the management of
information
– Pathological – Hide the information

– Bureaucratic – Restraint the information

– Generative – Value the information

 Three possible organizational cultures
Source: Ron Westrum

Pathological Bureaucratic Generative

Information Hidden Ignored Sought

Messengers Shouted Tolerated Trained

Responsibilities Shirked Boxed Shared

Reports Discouraged Allowed Rewarded

Failures Covered up Merciful Scrutinized

New ideas Crushed Problematic Welcomed

Resulting Conflicted “Red tape” Reliable
organization organization organization organization
The organizational accident

Organizational processes

Workplace Latent
conditions conditions

Active
Defences
failures
 Points to remember
1. The organizational accident.

2. Operational contexts and human performance

3. Errors and violations.

4. Organizational culture and effective safety

reporting.

5. The management of safety information.

 Questions
• Q1: How is safety defined in document 9859?
• Q 2: Enumerate the five building blocks of the
organizational accident.
• Q 3: Explain the components of the SHEL(L) Model

• Q 4: Q: Enumerate three basic traits underlying effective

safety reporting

• Q 5: How can organizations be characterized, depending

upon their management of safety information?
 ‫بسم هللا الرحمن الرحيم‬

‫`‬
 Building an SMS
Safety Module 10
Phased approach to
Management SSP and SMS
Implementation
System
Module 8 Module 9
SMS planning SMS operation

Module 5 Module 6 Module 7

Risks SMS regulation Introduction to SMS

Module 1 Module 2 Module 3

Introduction Module 4
SMS course Basic safety to safety Hazards
introduction concepts management
 Objective

• At the end of this module, participants

will be able to explain the need for, the
strategies and the key features of safety
management.
 Outline
• The safety stereotype
• The management dilemma
• Need for safety management
• Strategies for safety management
• The imperative of change
• Safety management – Eight building blocks
• Four responsibilities for managing safety
• Points to remember
• Questions and answers
The safety stereotype
Is it?
Really?
What is the fundamental objective
of a business organization?
 Safety management – Rationale

• In order to achieve its production objectives, the

management of any aviation organization requires the
management of many business processes
• Managing safety is one such business process
• Safety management is a core business function just as
financial management, HR management, etc.
• There is no aviation organization that has been created to
deliver only safety
• This brings about a potential dilemma for management
 The management dilemma

Management levels

Resources Resources

Protection Production
The management dilemma

Resources +

Protection

Production

Catastrophe
 The management dilemma

+ Resources

Production

Protection

Bankruptcy
 Safety space

Bankruptcy
Protection

Catastrophe

Source: James Reason

Production
 The response to the dilemma
• Safety issues are a product of activities related to
production/services delivery.

• An analysis of an organization's resources

and goals allows for a balanced and realistic
allocation of resources between protection
and production goals, which supports the
needs of the organization.
• The product/service provided by any aviation
organization must be delivered safely (i.e. protecting
users and stakeholders).
 Why SM ? – The first ultra-safe
industrial system
Fragile system (1920’s -1970’s)
Individual risk management & intensive training
10-3 Accident investigation

Safe system (1970’s – mid 1990’s)

Technology and regulations
Incident investigation
10-5
Ultra-safe system (mid 1990’s onwards)
Business management approach to
safety (SMS)
Routine collection and analysis of
Less than one catastrophic operational data
10-6 breakdown per million
production cycles
 Why Safety Management? An imperfect system

System Baseline performance

design
“Practical drift”
Operational
deployment
 The essential is invisible to the eyes

Number of occurrences

1–5 Accidents

30 – 100 Serious incidents

100 – 1000 Incidents

1000 – 4000 Latent conditions

 “Navigating the drift”
Baseline performance
Practical drift

Organization

Navigational aids

Reactive Proactive Predictive

 Reactive safety management
• Investigation of accidents and serious incidents
– Based upon the notion of waiting until something breaks
to fix it
– Most appropriate for:
• situations involving failures in technology
• unusual events
– The contribution of reactive approaches to safety
management depends on the extent to which the
investigation goes beyond the triggering cause(s), and
includes contributory factors and findings as to risks
 Proactive safety management
• Mandatory and voluntary reporting
systems, safety audits and survey

– Based upon the notion that system

failures can be minimized by:

• identifying safety risks within the

system before it fails; and
• taking the necessary actions to reduce
such safety risks
 Predictive safety management
• Confidential reporting systems, flight
data analysis, normal operations
monitoring.
– Based upon the notion that safety
management is best accomplished by
looking for trouble, not waiting for it
– Aggressively seek information from a
variety of sources which may be
indicative of emerging safety risks
 Strategies – Summary
Reactive method
The reactive method
responds to the Proactive method
events that already The proactive
happened, such as method
looks actively for the Predictive method
incidents and
identification of The predictive
accidents safety risks method captures
through the analysis system performance
of the organization’s as it happens in
activities real-time normal
operations to
identify potential
future problems
 SMS - Strategies
– Levels of intervention and tools
Safety management levels

Baseline performance

“Practical drift”
Predictive Proactive Reactive Reactive

Organization
System Surveys Accident
Analysis Audits ASRS and incident
Design SDR reports
Performance
Assessment
Highly efficient VeryAssessment
efficient Efficient Insufficient

Desirable management
levels
 The imperative of change
• As global aviation activity and complexity
continues to grow, traditional methods for
managing safety risks to an acceptable level
become less effective and efficient
 The changing of the guard
• Traditional – Accident/serious incident investigation
– Aviation system performs most of the time as per
design specifications (base line performance)
– Compliance based
– Outcome oriented
• Evolving – Safety management
– Aviation system does not perform most of the time
as per design specifications (practical drift)
– Performance based
– Process oriented
 Safety management – Eight building blocks

Senior management’s commitment to the

management of safety

Effective safety reporting

Continuous monitoring through systems to
collect, analyse, and share safety-related
data arising from normal operations
 Safety management – Eight building blocks
 Investigation of safety occurrences with the
objective of identifying systemic safety
deficiencies rather than assigning blame

 Sharing safety lessons learned and best

practices through the active exchange of safety
information

 Integration of safety training for operational

personnel
 Safety management – Eight building blocks
Effective implementation of Standard
Operating Procedures (SOPs), including
the use of checklists and briefings
Continuous improvement of the overall
level of safety
The result of implementing the eight building blocks:
An organizational culture that fosters safe practices,
encourages effective safety communication, and
actively manages safety with the same attention to
results as financial management.
 Responsibilities for managing safety
• These responsibilities fall into four basic areas:

 Definition of policies and procedures

regarding safety

 Allocation of resources for safety

management activities

 Adoption of best industry practices

 Incorporating regulations governing civil
aviation safety
The safety management process at a glance

Identify
hazards

Collect
Re-evaluate additional
control Assess
hazard consequences
strategies data

Implement Safety Assess and

control management prioritize
strategies process risks

Approve Develop
Assign control elimination/
responsibilities mitigation
strategies strategies
 In summary
• Managing safety requires resources

• Allocation of resources is a managerial

function

• Management has the authority and the

responsibility to manage safety risks in the
organization
 In summary
• Safety management
– Includes the entire operation
– Focus on processes (Clear difference
between processes and outcomes)
– Data-driven (constant monitoring)
– Strictly documented
– Gradual improvement as opposed to
dramatic change
– Strategic planning as opposed to
piecemeal initiatives
 Points to remember
1. The dilemma of the two P’s.
2. The safety space
3. Why SM? An ultra-safe, yet imperfect system.
4. Safety management methods and their
effectiveness.
5. The changing of the guard.
6. The eight building blocks and the four basic
responsibilities for the management of safety.
 Questions
• Q 1: Explain the management dilemma regarding safety
management.
• Q 2: Explain the difference between reactive, proactive and
predictive safety strategies.
• Q 3: Explain the difference between the traditional and the
evolving approach to safety management
• Q 4: Enumerate at least four building blocks of safety
management.
• Q 5: Enumerate the four basic responsibilities for
managing safety.
‫بسم هللا الرحمن الرحيم‬
 Course structure
Safety Module 10
Phased approach to
SSP and SMS
Management Implementation

System Module 8 Module 9

SMS planning SMS operation

Module 5 Module 6 Module 7

Risks SMS regulation Introduction to SMS

Module 1 Module 2 Module 3

Introduction Module 4
SMS course Basic safety to safety Hazards
introduction concepts management
 Objective

• At the end of this module, participants will be

able to apply the fundamentals of hazard
identification and analysis through a case
study.
 Outline
• Two definitions
• First fundamental – Understanding hazards
• Second fundamental – Hazard identification
• Third fundamental – Hazard analysis
• Fourth fundamental – Documentation of
hazards
• Questions and answers
• Points to remember
 Two definitions
• Hazard – Condition or object with the potential of
causing injuries to personnel, damage to equipment
or structures, loss of material, or reduction of ability
to perform a prescribed function
• Consequence – Potential outcome(s) of the hazard
– A wind of 15 knots blowing directly across the
runway is a hazard
– A pilot may not be able to control the aircraft
during takeoff or landing is one of the
consequences of the hazard
First fundamental – Understanding hazards
• There is a natural tendency to describe hazards as
their consequence(s)
– “Unclear aerodrome signage” vs. “runway
incursion”
• Stating a hazard as consequence(s) :
– disguises the nature of the hazard
– interferes with identifying other important consequences.
• Well-named hazards :
– allow to infer the sources or mechanisms of the hazard
– allow to evaluate the loss outcome(s)
 First fundamental – Understanding hazards

• Types of hazards
– Natural

– Technical

– Economic
 Examples of natural hazards
• Severe weather or climatic
events:
– E.g.: hurricanes, major
winter storms, drought,
tornadoes, thunderstorms
lightning, and wind shear
• Adverse weather
conditions:
– E.g.: Icing, freezing
precipitation, heavy rain,
snow, winds, and
restrictions to visibility
 Examples of natural hazards
• Geophysical events:
– E.g.: earthquakes, volcanic
eruptions, tsunamis, floods
and landslides
• Geographical conditions:
– E.g.: adverse terrain or large
bodies of water
• Environmental events:
– E.g.: wildfires, wildlife activity,
and insect or pest infestation
• Public health events:
– E.g.: epidemics of influenza
or other diseases
 Examples of technical hazards
• Deficiencies
regarding:
– E.g.: aircraft and aircraft
components, systems,
subsystems and related
equipment
– E.g.: an organization’s
facilities, tools, and
related equipment
– E.g.: facilities, systems,
sub-systems and related
equipment that are
external to the
organization
Examples of economics hazards
• Major trends
related to:
– Growth
– Recession
– Cost of material or
equipment
– Etc.
 Examples of hazards
Automation events Unfamiliar phraseology

ATC procedures
Weather

Similar call signs

Missed approaches
Terrain

Heavy traffic Flight diversions

Unfamiliar airports System

malfunctions
 Examples of hazards
LAHSO Missed approaches

Noise restrictions Communication failure

Runway inspections
Weather

Similar call signs

SIRO
Reduced separation
minima

Heavy traffic Airspace restrictions

Airspace
Runway crossings
reclassification

System malfunctions
 Examples of hazards
FO(D) Constructions

Vehicles in apron
Weather
Runway inspections

Security issues
Obstacles
Non standard
procedures
Heavy traffic
Noise restrictions

Built-up areas Runway crossings

Wildlife
 Second fundamental – Hazard identification
• In order to identify hazards, consider:
– Design factors, including equipment and task
design
– Procedures and operating practices,
including documentation and checklists
– Communications, including means,
terminology and language
–…
 Second fundamental – Hazard identification
• … consider:
– Organizational factors, such as company
policies for recruitment, training, remuneration
and allocation of resources
– Work environment factors, such as ambient
noise and vibration, temperature, lighting and
protective equipment and clothing
– ...
 Second fundamental – Hazard identification
• … consider:
– Regulatory factors, including the applicability
and enforceability of regulations; certification of
equipment, personnel and procedures; and the
adequacy of oversight
– Defences including detection and warning
systems, and the extent to which the equipment
is resilient against errors and failures
– Human performance, including medical
conditions and physical limitations
 Sources of hazard identification
• Internal
– Flight Data Analysis
– Company voluntary
reporting system
– Audits and surveys
• External
– Accident reports
– State mandatory
occurrence system
• As a reminder
– Predictive
– Proactive
– Reactive
 Hazard identification
• By whom?
– By anybody
– By designated personnel
• How?
– Through formal
processes
– Depends on the
organization
• When?
– Anytime
– Under specific conditions
Hazard identification
• Specific conditions
– Unexplained increase
in safety-related
events or infractions

– Major operational
changes are foreseen

– Periods of significant
organizational change
 Third fundamental – Hazard analysis
ABC of hazard analysis

State the generic

hazard Identify specific
components of Naturally leading
(Hazard statement)
the hazard to specific
 Airport construction  Construction
consequence(s)
equipment
 Aircraft colliding
 Closed taxiways with construction
 … equipment
 Aircraft taking wrong
taxiway
 …
 Third fundamental – Hazard analysis

• Efficient and safe operations or provision of service

require a constant balance between production goals...
– maintaining regular aerodrome operations during a
runway construction project
• ...and safety goals
– maintaining existing margins of safety in
aerodrome operations during runway construction
project.
• Aviation workplaces may contain hazards which may not
be cost-effective to address even when operations must
continue
(Cost-benefit analysis further discussed in Module 5)
 Fourth fundamental – Documentation of hazards
• Appropriate
documentation
management is important
as:
– It is a formal procedure
to translate operational
safety data into hazard-
related information
– It becomes the
“safety library” of an
organization
Fourth fundamental – Documentation of hazards

• Tracking and
analysis of hazards
is facilitated by
standardizing:
– Definitions
– Understanding
– Validation
– Reporting
– Measurement
– Management
 Fourth fundamental – Documentation of hazards

Method Identification Management Documentation Information

Reactive method Assess the Safety

• ASR consequences Assign management
and prioritize responsibilities information
• MOR
• Incident reports the risks
Hazards

• Accident reports Trend analysis

Proactive method
Develop control
• ASR Implement Safety
and mitigation
• Surveys strategies bulletins
strategies
• Audits
Hazards

Report
Predictive method distribution
• FDA Inform Re-evaluate
person(s) strategies
• Direct responsible for
observation implementing and Seminars and
systems strategies processes workshops

Feedback
The focus of hazard identification
Hazard identification is a
wasted effort if restricted to
Accidents
the aftermath of rare
1–5
occurrences where there is
Serious incidents
serious injury, or significant
30 – 100
damage.
Incidents
100 – 1000

Latent conditions
1000 – 4000 “Practical drift”
SMS
 Points to remember
1. Hazards have potential
consequences

2. Sources of hazard identification

3. ABC of hazard analysis

4. Hazard documentation: the “safety

library” of an organization
 Questions

• Q 1: Define the concept of hazard. ? .

• Q 2: Provide three examples of
areas/factors to consider when identifying
hazards ?
• Q 3: Name three specific circumstances
when hazard identification is essential. ? .
‫بسم هللا الرحمن الرحيم‬
 Course structure
Safety Module 10
Phased approach to
SSP and SMS
Management Implementation

System Module 8 Module 9

SMS planning SMS operation

Module 5 Module 6 Module 7

Risks SMS regulation Introduction to SMS

Module 1 Module 2 Module 3

Introduction Module 4
SMS course Basic safety to safety Hazards
introduction concepts management
 Objective

• At the end of this module, participants

will be able to apply the fundamentals of
risk management through a case study.
 Outline
• Definition of risk
• First fundamental – Risk management
• Second fundamental – Risk probability
• Third fundamental – Risk severity
• Fourth fundamental - Risk
index/tolerability
• Fifth fundamental – Risk control/mitigation
• Risk management warm-up exercises
• Points to remember
• Questions and answers
 Definition of risk
• Risk – The assessment, expressed in terms of
predicted probability and severity, of the
consequence(s) of a hazard taking as reference the
worst foreseeable situation
– A wind of 15 knots blowing directly across the
runway is a hazard
– A pilot may not be able to control the aircraft
during takeoff or landing is one of the
consequences of the hazard
– The assessment of the consequences of the
potential loss of control of the aircraft by the pilot
expressed in terms of probability and severity is
the risk
 First fundamental – Risk management
• What is it?
– The identification, analysis and elimination,
and/or mitigation to an acceptable level of risks
that threaten the capabilities of an organization
• What is the objective?
– Aims at a balanced allocation of resources to
address all risks and viable risk control and
mitigation
• Why is it important?
– A key component of safety management systems.
– Data-driven approach to safety resources
allocation, thus defensible and easier to explain
 Risk management

The risk is
Intolerable region
unacceptable
at any level

As The risk is
acceptable
Low based on
As Tolerable region mitigation.
Cost benefit
Reasonably analysis
Practicable is required.

Acceptable
region The risk is
acceptable as it
currently stands
 Cost-benefit analysis
• Direct costs
– The obvious costs, which are easily
determined. The high costs of exposure of
hazards can be reduced by insurance coverage
• Purchasing insurance only transfers monetary risk,
does not address the safety hazard

• Indirect costs
– The uninsured costs. An understanding of
uninsured costs (or indirect costs) is
fundamental to understand the economics
of safety
 Indirect costs
 Loss of use of equipment
 Loss of staff
• –Involved in accident issues
• –Lower productivity
• –Training for new hired
 Investigation & clean-up
 Legal claims
 Fines and citations
 Misplaced/stranded passengers
 Negative media exposure
 corrective action
 increased insurance premiums
 Risk cost
Event Direct cost Indirect cost

Catering truck hits airplane $17,000 $230,000

Jet way hits airplane $50,000 $600,000

Landing event $1,900,000 $4,800,000

Notice the reality that the indirect costs are

10-25 times the cost of the direct costs.
 Cost-benefit analysis
• Indirect costs may amount
to more than the direct
costs resulting from
exposure to hazards:
– Loss of business
– Damage to the reputation
– Loss of use of equipment
– Loss of staff productivity
– Legal actions and claims
– Fines and citations
– Insurance deductibles
 Second fundamental – Risk probability

• Definition
–Probability – The likelihood
that an unsafe event or
condition might occur
 Second fundamental – Risk probability

• Questions for assessing the probability of

an occurrence:
– Is there a history of occurrences like the one
being assessed, or is the occurrence an
isolated event?

– What other equipment, or similar type

components, might have similar defects?
 Second fundamental – Risk probability

• … questions such as:

– What number of operating or

maintenance personnel must follow the
procedure (s) in question?

– How frequently is the equipment or

procedure under assessment used?
 Second fundamental – Risk probability
Probability of occurrence
Qualitative
Meaning Value
definition

Frequent Likely to occur many times (has occurred frequently) 5

Occasional Likely to occur some times (has occurred infrequently) 4

Remote Unlikely, but possible to occur (has occurred rarely) 3

Improbable Very unlikely to occur (not known to have occurred) 2

Extremely
Almost inconceivable that the event will occur 1
improbable
 Third fundamental – Risk severity

• Definition
–Severity – The possible effects
of an unsafe event or condition,
taking as reference the worst
foreseeable situation
 Third fundamental – Risk severity
• Define the severity in terms of effects for:
– Property
– Finance
– Liability
– People
– Environment
– Image
– Public confidence
 Third fundamental – Risk severity
• Questions for assessing the severity of an
occurrence:
– How many lives may be lost?
• Employees
• Passengers
• General public
– What is the environmental impact?
• Spill of fuel or other hazardous product
• Physical disruption of natural habitat
 Third fundamental – Risk severity
• … questions such as:
– What is the severity of the property or
financial damage?
• Direct operator property loss
• Damage to aviation infrastructure
• Third party damage
• Financial impact and economic impact for the State
– Are there organizational, management or
regulatory implications that might generate
larger threats to public well-being?
– What are the likely political implications
and/or media interest?
 Third fundamental – Risk severity
Severity of occurrences
Aviation definition Meaning Value
Equipment destroyed.
Catastrophic Multiple deaths. A
A large reduction in safety margins, physical distress or a
workload such that the operators cannot be relied upon to
Hazardous perform their tasks accurately or completely. B
Serious injury.
Major equipment damage.
A significant reduction in safety margins, a reduction in the
ability of the operators to cope with adverse operating
conditions as a result of increase in workload, or as a result C
Major of conditions impairing their efficiency.
Serious incident.
Injury to persons.
Nuisance.
Minor Operating limitations.
Use of emergency procedures. D
Minor incident.
Negligible Little consequences E
Fourth fundamental – Risk index/tolerability
Fourth fundamental – Risk index/tolerability
 Likelihood - IATA
Category Description
1 Frequently

2 Likely

3 Occasionally

4 Seldom

5 Rarely

Likelihood is broken down into five groups.

While these can be qualitative judgments, some
users assign numeric values to the Likelihood /
Severity scale.
 Risk Severity - IATA

Severity and probability may be viewed in five

grades, which users can define by dollars, damage
or any other useful concept.
 IATA- Risk Factor
• Multiplying the Probability Risk Rating by
the Impact Risk Rating provides the overall
Risk Factor for that stage of the analysis.

• ie: Risk Factor = PRR x IRR

• Risk Factor Values range from 1 To 25

Source: PL Bates Syd Uni 2006

161
 IATA- Risk assessment

Risk severity
Risk Factor Assessment
Catastrophic Hazardous Major Minor Negligible
Risk
probability 5 4 3 2 1

5 – Frequent 25 20 15 10 5

4 – Occasional 20 16 12 8 4

3 – Remote 15 12 9 6 3

2 – Improbable 10 8 6 4 2

1 – Extremely
improbable
5 4 3 2 1

Source ICAO 162

IATA- Risk assessment
 IATA- Risk assessment

Consequence

Insignificant Minor Moderate Major Catastrophic

Likelihood (1) (2) (3) (4) (5)

Almost Certain
(A)
Significant Significant High High High

Likely
(B)
Medium Significant Significant High High

Possible
(C)
Low Medium Significant High High

Unlikely
(D)
Low Low Medium Significant High

Rare
(E)
Low Low Medium Significant Significant

Risk Rating Matrix

 IATA- Risk assessment

Assessment risk index Suggested criteria

Risk Tolerability
(Risk Factor)

Unacceptable under the existing

Greater than 15 circumstances

Risk control/mitigation requires

Between 15 & 8 management decision

Acceptable after
Between 8 & 4 review of the operation

Less than 4 Acceptable

Source ICAO
165
 Fifth fundamental – Risk control/mitigation
• Definition
–Mitigation – Measures to address
the potential hazard or to reduce the
risk probability or severity
• Risk mitigation = Risk control
(Mitigate – To make milder, less
severe or less harsh)
 Fifth fundamental – Risk control/mitigation
• Strategies
– Avoidance – The operation or activity is
cancelled because risks exceed the
benefits of continuing the operation or
activity
• Operations into an aerodrome
surrounded by complex geography and
without the necessary aids are
cancelled
 Fifth fundamental – Risk control/mitigation
• Strategies
– Reduction –The operation or activity is
subject to limitations, or action is taken to
reduce the magnitude of the
consequences of the accepted risks
• Operations into an aerodrome
surrounded by complex geography and
without the necessary aids are limited
to day-time, visual conditions
 Fifth fundamental – Risk control/mitigation
• Strategies
– Segregation of exposure – Action is taken to
isolate the effects of the consequences of the
hazard or build-in redundancy to protect against
it
• Non RVSM equipped aircraft not allowed to operate
into RVSM airspace
• Operations into an aerodrome surrounded by
complex geography are limited to aircraft with
specific/performance navigation capabilities
 Safety risk management at a glance
Hazard
Equipment, procedures, organization, etc.
identification

Analyse the likelihood of the consequence Risk analysis

occurring Probability

Evaluate the seriousness of the consequence if it Risk analysis

does occur Severity

Is the assessed risk(s) acceptable and within the Risk assessment

organization’s safety performance criteria and tolerability

No, take action to Risk control

Yes, accept the risk(s) reduce the risk(s) to an
acceptable level /mitigation
 Risk mitigation – Defences
• Recalling the three
basic defences in
aviation:
– Technology

– Training

– Regulations
 Risk mitigation – Defences
• As part of the risk mitigation, determine:
– Do defences to protect against such risk (s)
exist?
– Do defences function as intended?
– Are the defences practical for use under actual
working conditions?
– Is staff involved aware of the risks and the
defences in place?
– Are additional risk mitigation measures required?
 Risk mitigation at a glance
Hazard/consequence Assessment of the Control and Accepting the
identification defences within the mitigation of the mitigation of the
and risk assessment safety system risk(s) risk(s)

H H H H Does it address the

Intolerable region risk(s)?
Is it effective?
Each Is it appropriate?
consequence
Is additional or
Tolerable region different mitigation
R R R R warranted?
Do the mitigation
Acceptable
region
strategies generates
additional risk(s)
Each Risk

Feedback (Safety assurance)

 As a reminder
• There is no such thing as absolute safety – In
aviation it is not possible to eliminate all risks
• Risks can be managed to a level “as low as
reasonably practicable” (ALARP)
• Risk mitigation must be balanced against:
– time
– cost
– difficulty of taking measures to reduce or eliminate
the risk (i.e. managed).
• Effective risk management seeks to maximize the
benefits of accepting a risk (a reduction in time and
cost) while minimizing the risk itself
• Communicate the rationale for risk decisions to gain
acceptance by stakeholders affected by them
 Risk management process at a glance
Feedback and
record the hazard A safety concern is perceived
identification and
assessment and Identify hazards/consequences
risk mitigation and assess risks
Define the level Define the level
of probability of severity
Define the risk index and
tolerability
Take action
and continue YES Is the risk index acceptable? NO
the operation

Take action
and continue YES Can the risk be eliminated? NO
the operation

YES Can the risk be mitigated?

Take action Can the residual risk be Cancel the

and continue YES accepted? (if any) NO
the operation operation
 Hazards and risks – Closing the loop
• Hazard – Condition or object with the potential of causing
injuries to personnel, damage to equipment or structures, loss
of material, or reduction of ability to perform a prescribed
function
• Consequence – Potential outcome(s) of the hazard
• Risk – The assessment, expressed in terms of predicted
probability and severity, of the consequence(s) of a hazard
taking as reference the worst foreseeable situation
– A wind of 15 knots blowing directly across the runway is a
hazard.
– A pilot may not be able to control the aircraft during takeoff
or landing is one of the consequences of the hazard
– The assessment of the consequences of the potential loss
of control of the aircraft by the pilot expressed in terms of
probability and severity is the risk
 Points to remember
1. The risk index/tolerability
2. The risk assessment criteria
table
3. Risk mitigation: avoid, reduce,
segregate
 Questions

• Q 1: Define risk management? .

• Q 2: What are the five designations for
risk probability ?
• Q 3: What are the five designations for
risk severity? .
• Q 4: Describe the three basic risk
mitigation strategies? .
‫بسم هللا الرحمن الرحيم‬
 Course structure
Safety Module 10
Phased approach to
SSP and SMS
Management Implementation

System Module 8 Module 9

SMS planning SMS operation

Module 5 Module 6 Module 7

Risks SMS regulation Introduction to SMS

Module 1 Module 2 Module 3

Introduction Module 4
SMS course Basic safety to safety Hazards
introduction concepts management
 Objective
• At the end of this module participants will
be able to describe the safety management
requirements included in Annexes 1, 6, 8,
11, 13 and 14, including the relationship
between a State safety programme (SSP)
and an SMS
 Outline
• SSP and SMS requirements
• What is an SSP?
• What is an SMS?
• Acceptable level of safety (ALoS) –
Implementation, scope and legal considerations
• Safety performance of the service provider’s
SMS
• Performance-based regulatory environment
• Questions and answers
• Points to remember
 The big picture
• Two audience groups
– States
– Service providers
• Three distinct requirements
– State safety programme (SSP)
• Acceptable level of safety (ALoS)
– Safety management System (SMS)
• Safety performance of the SMS
– Management accountability
 Basic safety management SARPs – Part I

• States shall establish a State safety

programme (SSP), in order to achieve
an acceptable level of safety in civil
aviation.

• The ICAO SSP framework (Module 10)

 What is an SSP?
• An integrated set of regulations and activities
aimed at improving safety.
• States are responsible for establishing an SSP,
encompassing the following responsibilities:
Safety regulation
Accident/incident investigation
Safety assurance
Mandatory/voluntary reporting
systems
Safety data analysis and
exchange
Safety promotion
Further discussed in Module 10
Basic safety management SARPs
• The acceptable level of safety (ALoS) to be achieved
shall be established by the State

• When establishing ALoS, consideration must be given to

– The level of safety risk that applies

– The safety risk tolerance

– The cost/benefits of improvements to the aviation
system

– The public expectations in civil aviation system

 Safety indicators and safety targets
• Safety indicators
– Fatal airline accidents/serious incidents
– Runway excursion events/ground collision events
– Development/absence of primary aviation legislation
– Development/absence of operating regulations
– Level of regulatory compliance
–…
• Safety targets
– Reduction in fatal airline accident/serious incidents
– Reduction in runway excursion events/ground collision
events
– Number of inspections completed quarterly
–…
 Values of safety indicators and safety targets –
Examples
Value of safety indicators Value of safety targets
1. [Rate/number] Fatal 1. [Reduction by/maximum]
airline accidents per fatal airline accidents per
[number] operations [number] operations
2. [Rate/number] Runway 2. [Reduction by/maximum]
excursion events per runway excursion events
[number] operations per [number] operations
3. [Rate/number] Ground 3. [Reduction by /maximum]
collision events per ground collision events
[number] operations per [number] operations
4. [Number] inspections to 4. [Minimum number] of
operators completed inspections completed
[timeframe] ... [timeframe]…
 Delivering ALoS – Safety action plans
• Tools and means to deliver the safety
targets of an SSP:
– Operational procedures
– Technology
– Systems
– Training programmes
 ALoS – Example
1. Reduce by/maximum] A controlled flight into terrain (CFIT) and
Values of
approach and landing accidents per [number] departures
safety
2. [Minimum number] inspections to operators completed quarterly
targets
3. ...
1. CFIT training package distributed to industry and supported by training
Action courses
plans 2. Revision and if necessary update of hiring policy. Inspection manual
updated
3. ...
1. Number] CFIT and approach and landing accidents per [number]
Values of
departures
safety
2. [Number] inspection to operators completed quarterly
indicators
3. ...

State Will comply all applicable international standards.

 ALoS of an SSP
• Legal considerations
– Establishing ALoS for the SSP does not
replace legal, regulatory, or other already
established requirements, but it must support
compliance with them
– Establishing ALoS for the SSP leaves
unaffected the obligations of States, and does
not relieve States from compliance with SARPs
 A fundamental differentiation
• Safety measurement
– Quantification of the outcomes of high-level or
high-consequence events
• Accident rates
• Serious incident rates
– Quantification of high-level State functions
• Development/absence of primary aviation legislation
• Development/absence of operating regulations
• Level of regulatory compliance
 A fundamental differentiation
• Safety performance measurement
– Quantification of the outcomes of low-level, low
consequences processes
• Number of FOD events per number of ramp OPS
• Number of ground vehicle events in taxiways per
number of airport OPS
– Provide a measure of the actual performance of
an individual SSP or SMS (Beyond accident
rates and regulatory compliance)
 A fundamental differentiation
• Safety measurement
– Not a continuous process.
– A spot check.
– Conducted following pre-specified timeframes.
• Safety performance measurement
– Continuous process.
– Monitoring and measurement of selected
operational activities necessary for the
provision of services.
 Basic safety management SARPs – Part II
• States shall require, as part of their State safety
programme (SSP), that a [service provider] implements a
safety management system (SMS) acceptable to the
State that, as a minimum:
a) identifies safety hazards;
b) ensures that remedial action necessary to maintain
safety performance is implemented;
c) provides for continuous monitoring and regular
assessment of the safety performance; and
d) aims at a continuous improvement of the overall
performance of the SMS.
 Service providers
1. Approved training organizations that are exposed
to safety risks during the provision of their
services
2. Aircraft operators
3. Approved maintenance organizations
4. Organizations responsible for design and/or
manufacture of aircraft
5. Air traffic services providers
6. Certified aerodromes
• The ICAO SMS framework (Module 8)
 What is an SMS?
• A systematic approach to
managing safety, including the
necessary organizational
structures, accountabilities,
policies and procedures
• Service providers are
responsible for establishing an
SMS
• States are responsible, under the
SSP, for the acceptance and
oversight of organizations’
SMS
 Safety performance of services provider’s SMS
• Expresses the safety objectives of a service provider.
• Provides measurable reference for measuring the safety
performance of an SMS
• Within each State, the safety performance of each SMS
will separately be agreed between the State oversight
authority and individual aviation organizations
• Agreed safety performance should be commensurate to
the:
– complexity of individual service provider specific
operational context; and
– availability of service provider resources to address
them
 Safety performance of an SMS
• The safety performance of an SMS represents safety
performance measurement exclusively
• The safety performance of an SMS is expressed in
practical terms by two measures or metrics:

– Safety performance indicators

– Safety performance targets
• It is delivered through various tools and means:
– Safety requirements
 Safety performance of an SMS
• Safety performance indicators
– Short-term, tactical, measurable objectives reflecting the
safety performance of an SMS
– They include safety performance measurement
exclusively
– Expressed in numerical terms
• Safety performance targets
– Long-term, strategic, measurable objectives reflecting the
safety performance of an SMS
– They include safety performance measurement
exclusively.
– Expressed in numerical terms
 Safety performance of an SMS
Legal considerations
 Establishing safety performance for the SMS leaves
unaffected the obligations of services providers and
other related parties, and it does not relieve the
services providers and other related parties from
compliance with SARPs and/or national regulations, as
applicable
 Safety performance of an SMS
1. Maintain no more than 20 events of unauthorized vehicles on the taxiways per
Safety 10,000 operations.
performance
2. By January 2010 reduce to 8 FOD events on the apron per 10,000 operations.
targets
3. …

1. Training course for drivers / installation of specific signage.

Action Plans 2. daily walk-in ramp inspection programme.
3. …

Safety 1. 20 events of unauthorized vehicles on the taxiways per 10,000 operations.

performance 2. 15 FOD events on the apron per 10,000 operations.
indicators 3. ...

Service
Will comply all applicable national and international standards.
provider
 Basic safety management SARPs – Part III

• A safety management system (SMS) shall

clearly define lines of safety accountability
throughout a service provider organization,
including a direct accountability for safety
on the part of senior management

(Accountability – Obligation or willingness to

account for one’s actions)
 SSP – SMS relationship
Protection Production
Objective: State
Safety risk
management Safety
Programme

State
(SSP)
Performance-based
Acceptance oversight
Compliance
oversight
Objective:

Services provider
Objective: Organization’s Support
Safety risk production
management Safety Service delivery goals and
Management customer
system (SMS) satisfaction
Safety assurance
 In summary
State Service provider

States shall establish a Identify safety hazards.

State safety programme Ensure ensures remedial
(SSP), in order to achieve action to maintain safety
an acceptable level of safety performance.
(ALoS) in civil aviation. Provides continuing
monitoring and regular
The acceptable level of
safety (ALoS) to be assessment of the safety
performance.
achieved shall be
Aims at a continuous
established by the State.
improvement of the overall
performance of the SMS.
 The objective (Remember Module 1?)

Realistic
implementation
Safety
management

Performance
based

ICAO
Prescriptive SARPS
 In summary
Prescription Performance
2.1 Safety requirements for service providers 2.2 Agreement on service providers’ safety
SMS performance
The State has agreed with individual service
The State has established the controls which providers on the safety performance of their
govern how service providers will identify SMS.
hazards and manage safety risks. 3.2 Safety data collection, analysis and
3.1 Safety oversight exchange
The State has established mechanisms to
The State has established mechanisms to ensure the capture and storage of data on
ensure an effective monitoring of the eight hazards and safety risks at both an individual
critical elements of the safety oversight and aggregate State’s level.
function. 3.3 Safety data driven targeting of oversight on
areas of greater concern or need
The State has established procedures to
prioritize inspections, audits and surveys
towards those areas of greater safety concern
or need, as identified by the analysis of data
on hazards, their consequences in operations,
and the assessed safety risks.
 In summary
1. Maintain no more than 20 events of unauthorized vehicles on the taxiways per
Safety 10,000 operations.
performance
2. By January 2009 reduce to 8 FOD events on the apron per 10,000 operations.
targets
3. …

1. Training course for drivers / installation of specific signage.

Action plans 2. Daily walk-in ramp inspection programme.
3. …

Safety 1. 20 events of unauthorized vehicles on the taxiways per 10,000 operations.

performance 2. 15 FOD events on the apron per 10,000 operations.
indicators 3. ...

Service
Will comply all applicable national and international standards.
provider
 ICAO SAFETY MANAGEMENT MANUAL

• Guidance on safety
management systems is
contained in the ICAO
Safety Management
Manual (Doc 9859).
• SUCAR Part 19, safety
management.
• National safety programme
(NSP).
 SUCAR 19
– Safety Management
• SUCAR 19, of Sudan civil aviation sets the
standard and recommended practices for service
providers to develop a safety management system
in order to comply with ICAO requirement for
Sudan state.
• SMS established by the service providers shall
achieve an acceptable level of safety performance
(ALoSP) defined by the Sudan Civil Aviation
Authority.
 SUCAR 19
– Safety Management

• The Republic of Sudan has established a National

Safety Programme (NSP) that has been approved
in accordance to the Sudan Civil Aviation Act and
sets the requirements for service provider’s safety
management system (SMS) and the development
and promulgation of this SUCAR dealing with
Standards and requirements for safety
management in compliance with Annex 19 – Safety
Management to the Convention on International
Civil Aviation.
•
 National Safety
Programmed (NSP)
• SMS, As of the first July 2016, implementation
becomes mandatory and no services provider
can exercise the privileges of their activities
for certification, licensing, permits or
authorization issued by the SCAA unless they
established and implement a SMS that caters
for the type and level of their operation
acceptable to the authority SCAA.
 Points to remember
1.SSP
2.SMS
3.Acceptable of level of safety (ALoS)
4.Safety performance of the SMS
5.Management accountability
6.Prescription vs. Performance
 Questions

• Q 1: What are the main

responsibilities in a State safety
programme (SSP)?.
• Q 2: What is a safety
management system (SMS)?
‫بسم هللا الرحمن الرحيم‬
 Course structure
Safety Module 10
Phased approach to
SSP and SMS
Management Implementation

System Module 8 Module 9

SMS planning SMS operation

Module 5 Module 6 Module 7

Risks SMS regulation Introduction to SMS

Module 1 Module 2 Module 3

Introduction Module 4
SMS course Basic safety to safety Hazards
introduction concepts management
 Objective
• At the end of this module, participants will
be able to describe the features of an SMS,
explain the importance of system
description and gap analysis, and the
relationship between SMS and QMS
 Outline
• ICAO requirements
• SMS – Introductory concepts
• SMS features
• First fundamental – System description
• Second fundamental – Gap analysis
• Third fundamental – SMS and QMS
• Clarifying terms
• Questions and answers
• Points to remember
 ICAO requirements
• Compliance with all
relevant regulations and
ICAO standards, other
than those specifically
SMS-related, is a key
component of an SMS
• Many of these regulations
and ICAO standards,
include operational
provisions that will be part
of an SMS
 SMS – Introductory concepts
• A toolbox
– The scope of SMS
encompasses most of the
activities of the organization
– SMS must start from senior
management, and safety
must be considered at all
levels of the organization
– SMS aims to make
continuous improvement to
the overall level of safety.
– All aviation stakeholders
have a role to play in SMS
Identifying aviation system stakeholders
• Aviation professionals
• Aircraft owners and operators
• Manufacturers
• Aviation regulatory authorities
• Industry trade associations
• Regional air traffic service providers
• Professional associations and federations
• International aviation organizations
• Investigative agencies
• The flying public
 Identifying aviation system stakeholders
• Why is it important to
identify aviation system
stakeholders? Aviation
system
– To ensure that stakeholders

stakeholders inputs and

knowledge relevant to
safety risk(s) decisions
are taken into
consideration before the
decisions are taken
 SMS features
• Systematic – Safety management activities
are in accordance with a pre-determined
plan, and applied in a consistent manner
throughout the organization
• Proactive – An approach that emphasizes
hazard identification and risk control and
mitigation, before events that affect safety
occur
• Explicit – All safety management activities
are documented and visible
 First fundamental – System description
• System description
– Most hazards are generated by operational
interactions among different system
components

– It is therefore essential to describe the system

in terms of its components as one of the first
activities when planning an SMS
 System description
1) The system interactions with other systems in the
air transportation system
2) The system functions
3) Required human performance considerations of
the system operation
4) Hardware components of the system
5) Software components of the system
6) Related procedures that define guidance for the
operation and use of the system
7) Operational environment
8) Contracted and purchased products and services
 Second fundamental – Gap analysis
• An analysis of safety arrangements
existing within the organization
– The basic organizational structures necessary
to start developing an SMS may exist in the
organization

– Various activities related to an SMS may be in

place and working

– SMS development should build upon existing

organizational structures
 Second fundamental – Gap analysis
• Conduct the gap
analysis against the
components and
elements of the SMS
(Presented in Module 8)

• Once completed and

documented the gap
analysis forms the basis
of the SMS
implementation plan
 Third fundamental – SMS and QMS
• SMS differs from QMS in
that:
– SMS focuses on the
safety, human and
organizational aspects of
an organization
• i.e. safety satisfaction
– QMS focuses on the
product(s) and service(s)
of an organization
• i.e. customer satisfaction
SMS and QMS – Striking a balance
• SMS builds partly upon
QMS principles

• SMS should include both

safety and quality policies

• The coverage of quality

policies – insofar as SMS
is concerned – should be
limited to quality in
support of the
management of safety
 Quality in support and partnership with safety
• The safety risk management component of an SMS
– based on risk management principles – results
in the design and implementation of organizational
processes and procedures to identify safety hazards
and control/mitigate safety risks in aviation
operation
• The safety assurance component of an SMS –
based on quality principles – provides a structured
approach to monitor that processes and procedures
to identify safety hazards and control/mitigate safety
risks in aviation operations function as intended
and, when they do not, to improve them
 Systems integration
• There is a tendency in civil aviation to
integrate the different systems of
management:
– Quality management system (QMS)
– Environment management system (EMS)
– Occupational health and safety management
system (OHSMS)
– Safety management system (SMS)
– Security management system
 Systems integration benefits
• Reduce duplication and therefore costs

• Reduce risks and increase profitability

• Balance potentially conflicting objectives

• Eliminate potentially conflicting

responsibilities and relationships

• Defuse the power system

 Systems integration considerations
• There are different ways to integrate a safety
management system in the operation of the
organization

• Aviation organizations should be encouraged to

integrate their management system for quality,
safety, security, occupational health and safety,
and environmental protection management

• This integration, however, is presently beyond

the scope of the harmonized ICAO safety
management requirements and of this training
course
 Clarifying the use of terms
• Safety oversight
– Is what the CAA performs with regard to the
service providers SMS
– Safety assurance
– Is what the service providers do with regard to
safety performance monitoring and measurement
• Safety audit
– Is what the CAA performs with regard to its safety
programme and the service providers perform
with regard to the SMS
 SMS – Nothing new?
• Rounding up the usual suspects
– In aviation, safety is first
– Safety is everybody’s responsibility
– If isn't broke, why fix it?
– If you believe safety is expensive, try an
accident
– 70% accidents are due to human error
 Points to remember
1. SMS main features

2. The importance of system description

3. The importance of gap analysis

4. The relationship between SMS and QMS

 Questions

• Q 1: Why is it important to SMS development to

involve stakeholders?
• Q 2: Explain the importance of gap analysis
• Q 3: Explain the difference between SMS and
QMS.
‫بسم هللا الرحمن الرحيم‬
 Course structure
Safety Module 10
Phased approach to
SSP and SMS
Management Implementation

System Module 8 Module 9

SMS planning SMS operation

Module 5 Module 6 Module 7

Risks SMS regulation Introduction to SMS

Module 1 Module 2 Module 3

Introduction Module 4
SMS course Basic safety to safety Hazards
introduction concepts management
 Objective
• When completing the module the
participants will be able to describe the
requirements associated to the planning of
an SMS, and explain the structure of an
SMS implementation plan and the contents
of the safety management system manual
(SMSM)
 Outline
• The components of SMS
• The elements of SMS
• Safety policy and objectives
• Questions and answers
• Points to remember
 The components of SMS
Safety policy and objectives
Safety risk management
Safety assurance
Safety promotion
 The elements of SMS
Safety policy and objectives
1.1 – Management commitment and responsibility
1.2 – Safety accountabilities
1.3 – Appointment of key safety personnel
1.4 – Coordination of emergency response
planning
1.5 – SMS documentation
Safety risk management
2.1 – Hazard identification
2.2 – Risk assessment and mitigation
 The elements of SMS
Safety assurance
3.1 – Safety performance monitoring and
measurement
3.2 – The management of change
3.3 – Continuous improvement of the SMS
Safety promotion
4.1 – Training and education
4.2 – Safety communication
 ICAO SMS framework
 Safety policy and objectives
1.1 – Management commitment and responsibility
1.2 – Safety accountabilities
1.3 – Appointment of key safety personnel
1.4 – Coordination of emergency response planning
1.5 – SMS documentation
 Safety risk management
2.1 – Hazard identification
2.2 – Risk assessment and mitigation
 Safety assurance
3.1 – Safety performance monitoring and measurement
3.2 – The management of change
3.3 – Continuous improvement of the SMS
 Safety promotion
4.1 – Training and education
4.2 – Safety communication
 Safety policy and objectives
1.1 – Management commitment and responsibility
• The service provider shall define the safety policy of
the organization which shall:
1) Be in accordance with international and
national requirements;
2) Be signed by the Accountable executive of the
organization;
3) Reflect organizational commitments regarding
safety;
4) Include a clear statement about the provision of
the necessary resources for the implementation
of the safety policy; ...
 Safety policy and objectives
1.1 – Management commitment and responsibility
• ... safety policy of the organization shall
(cont’d):
5) Be communicated, with visible endorsement,
throughout the organization;
6) Include the safety reporting procedures;
7) Clearly indicate which types of operational
behaviours are unacceptable;
8) Include the conditions under which exemptions
from disciplinary action would be applicable; ...
 Safety policy and objectives
1.1 – Management commitment and responsibility
• ... safety policy of the organization shall
(cont’d):
9) Be periodically reviewed to ensure it remains relevant
and appropriate to the organization;
10) Ensure the implementation of remedial action necessary
to maintain agreed safety performance;
11) Provide for continuous monitoring and regular
assessment of the safety performance;
12) Aim at a continuous improvement to the overall
performance of the SMS
 ICAO SMS framework
 Safety policy and objectives
1.1 – Management commitment and responsibility
1.2 – Safety accountabilities
1.3 – Appointment of key safety personnel
1.4 – Coordination of emergency response planning
1.5 – SMS documentation
 Safety risk management
2.1 – Hazard identification
2.2 – Risk assessment and mitigation
 Safety assurance
3.1 – Safety performance monitoring and measurement
3.2 – The management of change
3.3 – Continuous improvement of the SMS
 Safety promotion
4.1 – Training and education
4.2 – Safety communication
 Safety policy and objectives
1.2 – Safety accountabilities

• The organization shall identify:

– the Accountable Executive who, irrespective
of other functions, shall have ultimate
responsibility and accountability, on behalf
of the organization, for the implementation
and maintenance of the SMS
– the accountabilities of all members of
management, irrespective of other functions,
as well as of employees, with respect to the
safety performance of the SMS
 Safety policy and objectives
1.2 – Safety accountabilities

• The Accountable Executive shall:

– Be a single and identifiable person
• CEO/Chairman Board of Directors
• A partner
• The proprietor
• ...
 Safety policy and objectives
1.2 – Safety accountabilities

• The Accountable Executive must have:

– full authority for human resources issues
– authority for major financial issues
– direct responsibility for the conduct of the
organization’s affairs
– final authority over operations under
certificate
– final responsibility for all safety issues
 Safety policy and objectives
1.2 – Safety accountabilities

• Safety responsibilities, accountabilities and

authorities shall:
– be documented

– be communicated throughout the organization

– include a definition of the levels of management

with authority to make decisions regarding
safety risks tolerability
 Safety policy and objectives
1.2 – Safety accountabilities

• The job description of each senior

manager (departmental head or responsible
for a functional unit) should include, to the
appropriate extent, and in addition to the
specific responsibilities for the
department/functional unit operation:
– the safety accountabilities
– the responsibilities regarding the operation of
the SMS
 Safety responsibilities – An example
Safety Accountable Executive
Review
Board (SRB)

Head of Head of Heads of

operations maintenance other areas

Operations Maintenance
safety officer safety officer

Safety Action
Safety Services
Group(s)
(SAG) Office
 ICAO SMS framework
 Safety policy and objectives
1.1 – Management commitment and responsibility
1.2 – Safety accountabilities
1.3 – Appointment of key safety personnel
1.4 – Coordination of emergency response planning
1.5 – SMS documentation
 Safety risk management
2.1 – Hazard identification
2.2 – Risk assessment and mitigation
 Safety assurance
3.1 – Safety performance monitoring and measurement
3.2 – The management of change
3.3 – Continuous improvement of the SMS
 Safety promotion
4.1 – Training and education
4.2 – Safety communication
 Safety policy and objectives
1.3 – Appointment of key safety personnel

• The organization shall identify a safety

manager to be the responsible individual
and focal point for the implementation and
maintenance of an effective SMS
 Safety responsibilities
Safety Accountable Executive
Review
Board (SRB)

Head of Head of Heads of

operations maintenance other areas

Operations Maintenance
safety officer safety officer

Safety Action
Safety Services
Group(s)
(SAG) Office
 Safety policy and objectives
1.3 – Appointment of key safety personnel

• The Safety services office – Corporate

functions
– Advising senior management on safety matters

– Assisting line managers

– Overseeing hazard identification systems

 Safety policy and objectives
1.3 – Appointment of key safety personnel
• The safety manager – Functions
– Manages the SMS implementation plan on
behalf of the accountable executive
– Facilitates hazard identification and risk
analysis and management
– Monitors corrective actions to ensure their
accomplishment
– Provides periodic reports on safety
performance
– Maintains safety documentation
– Plans and organizes staff safety training
– Provides independent advice on safety matters
 Safety policy and objectives
1.3 – Appointment of key safety personnel
• The safety manager – Selection criteria
– Operational management experience and
technical background to understand the
systems that support operations
– People skills
– Analytical and problem-solving skills
– Project management skills
– Oral and written communications skills
 Safety responsibilities
Safety Accountable Executive
Review
Board (SRB)

Head of Head of Heads of

operations maintenance other areas

Operations Maintenance
safety officer safety officer

Safety Action
Safety Services
Group(s)
(SAG) Office
 Safety policy and objectives
1.3 – Appointment of key safety personnel
• The Safety Review Board (SRB):
– High level committee
– Strategic safety functions
• Chaired by the accountable executive
• It may include the Board of Directors

• Composed of heads of functional areas

 Safety policy and objectives
1.3 – Appointment of key safety personnel
• SRB monitors:
– safety performance against the safety policy and
objectives
– effectiveness of the SMS implementation plan
– effectiveness of the safety supervision of sub-contracted
operations
• SRB ensures that appropriate resources are allocated to
achieve the established safety performance
• SRB gives strategic direction to the SAG
 Safety responsibilities
Safety Accountable Executive
Review
Board (SRB)

Head of Head of Heads of

operations maintenance other areas

Operations Maintenance
safety officer safety officer

Safety Action
Safety Services
Group(s)
(SAG) Office
 Safety policy and objectives
1.3 – Appointment of key safety personnel

• Safety Action Group(s) (SAG):

– Reports to SRB and takes strategic direction
from SRB.

– Members
• Managers and supervisors from functional areas

• Front-line personnel
Safety policy and objectives
1.3 – Appointment of key safety personnel
• SAG:
– Oversees operational safety within the functional area.
– Resolves identified risks
– Assesses the impact on safety of operational changes.
– Implements corrective action plans
– Ensures that corrective action is taken in a timely
manner
– Review the effectiveness of previous safety
recommendations
– Safety promotion
 ICAO SMS framework
 Safety policy and objectives
1.1 – Management commitment and responsibility
1.2 – Safety accountabilities
1.3 – Appointment of key safety personnel
1.4 – Coordination of emergency response planning
1.5 – SMS documentation
 Safety risk management
2.1 – Hazard identification
2.2 – Risk assessment and mitigation
 Safety assurance
3.1 – Safety performance monitoring and measurement
3.2 – The management of change
3.3 – Continuous improvement of the SMS
 Safety promotion
4.1 – Training and education
4.2 – Safety communication
 Safety policy and objectives
1.4 – Coordination of emergency response planning

• The organization shall ensure that an emergency

response plan that provides for the orderly and
efficient transition from normal to emergency
operations, and the return to normal operations
is properly coordinated with the emergency
response plans of those organizations it must
interface with during the provision of its services
 Safety policy and objectives
1.4 – Coordination of emergency
response planning
• Emergency response planning
outlines in writing what should be
done after an accident, and who is
responsible for each action.
– Airport Emergency Plan (AEP)
– Contingency Plans (ATC)
– Emergency Response Plan
(Operators)
• The coordination of the different
plans should be described in the
SMS Manual
 ICAO SMS framework
 Safety policy and objectives
1.1 – Management commitment and responsibility
1.2 – Safety accountabilities
1.3 – Appointment of key safety personnel
1.4 – Coordination of emergency response planning
1.5 – SMS documentation
 Safety risk management
2.1 – Hazard identification
2.2 – Risk assessment and mitigation
 Safety assurance
3.1 – Safety performance monitoring and measurement
3.2 – The management of change
3.3 – Continuous improvement of the SMS
 Safety promotion
4.1 – Training and education
4.2 – Safety communication
 Safety policy and objectives
1.5 – SMS documentation

• The organization shall develop and maintain

SMS documentation to describe:
– the safety policy and objectives
– the SMS requirements
– the SMS processes and procedures
– the accountabilities, responsibilities and
authorities for processes and procedures
– the SMS outputs
 Safety policy and objectives
1.5 – SMS documentation
• As part of the SMS documentation, the organization
shall:
1) develop an SMS implementation plan, endorsed
by senior management of the organization that
defines the organization’s approach to the
management of safety in a manner that meets the
organization’s safety objectives
2) develop and maintain a safety management
system manual (SMSM), to communicate its
approach to the management of safety throughout
the organization
 Safety policy and objectives
1.5.1 – SMS implementation plan
• Developed by a planning group, which:
– comprises an appropriate experience base
– meets regularly with senior management
– receives resources (including time for meetings)
• A realistic strategy for the implementation of an SMS
that will meet the organization’s safety performance
needs
• A definition of the approach the organization will
adopt for managing safety.
 Safety policy and objectives
1.5.1 – SMS implementation plan
• Senior management endorses the plan.
• Typical implementation time frame will be
one to four years ahead
– See Module 10 – Phased approach to SSP and
SMS implementation.
 Safety policy and objectives
1.5.1 – SMS implementation plan – Contents
1) Safety policy and objectives
2) System description
3) Gap analysis
4) SMS components
5) Safety roles and responsibilities
6) Safety reporting policy
7) Means of employee involvement
8) Safety performance measurement
9) Safety training
10)Safety communication
11)Management review (of safety performance)
 Safety policy and objectives
1.5.2 – Safety Management
System Manual (SMSM)
• Key instrument for
communicating the organization’s
approach to safety to the whole
organization
• Documents all aspects of the
SMS, including the safety policy,
objectives, procedures and
individual safety responsibilities
and accountabilities
 Safety policy and objectives
1.5.2 – SMSM contents 7. Hazard identification
1. Scope of the safety and risk
management system management
2. The safety policy and schemes
objectives 8. Safety assurance.
3. Safety accountabilities 9. Safety performance
4. Key safety personnel monitoring
5. Documentation control 10.Safety auditing
procedures 11.Management of
6. Coordination of the change.
emergency response 12.Safety promotion
planning 13.Contracted activities
 Conclusion
• The successful management of safety is a
functional responsibility that requires the
participation of all operational personnel and
the supervision of the organization
(Systematic)

• This principle must be reflected in the

structure of the organization (Explicit)
 Conclusion
• The organization must define, document and
communicate individual lines of responsibility and
authority in regard to the management of
operational safety (Explicit)

• The means to manage safety within the

organization include hazard identification, risk
management, safety assurance and safety
promotion (Proactive)
 Points to remember
1. The four components of an SMS

2. The elements of an SMS

3. The importance of documenting safety

responsibilities

4. SRB, SAG and the safety services office

5. The SMS implementation plan

6. The SMSM
 Questions

• Q 1: What kind of authority, responsibilities

and accountabilities are required for the
accountable executive?
• Q 2: What is the safety manager selection
criteria?
• Q 3: List five subjects that should be included
in the contents of the Safety Management
System Manual (SMSM).
‫بسم هللا الرحمن الرحيم‬
 Course structure
Safety Module 10
Phased approach to
SSP and SMS
Management Implementation

System Module 8 Module 9

SMS planning SMS operation

Module 5 Module 6 Module 7

Risks SMS regulation Introduction to SMS

Module 1 Module 2 Module 3

Introduction Module 4
SMS course Basic safety to safety Hazards
introduction concepts management
 Objective
• When completing the module the
participants will be able to describe the
requirements associated with the operation
of an SMS
 Outline
• Safety risk management
• Safety assurance
• Safety promotion
• Questions and answers
• Points to remember
 ICAO SMS framework
 Safety policy and objectives
1.1 – Management commitment and responsibility
1.2 – Safety accountabilities
1.3 – Appointment of key safety personnel
1.4 – Coordination of emergency response planning
1.5 – SMS documentation
 Safety risk management
2.1 – Hazard identification
2.2 – Risk assessment and mitigation
 Safety assurance
3.1 – Safety performance monitoring and measurement
3.2 – The management of change
3.3 – Continuous improvement of the SMS
 Safety promotion
4.1 – Training and education
4.2 – Safety communication
 Safety risk management
2.1 – Hazard identification (Module 4)
• The organization shall develop and maintain
a formal process that ensures that hazards
in operations are identified
• Hazard identification shall be based on a
combination of reactive, proactive and
predictive methods of safety data collection.
 Safety risk management
2.1 – Hazard identification
• Safety reporting systems – A special
mention
– Nobody knows better actual system
performance than operational personnel
• Mandatory reporting system
• Voluntary reporting systems
• Confidential reporting systems
– The requirements of safety reporting systems
may vary among States
 Safety risk management
2.1 – Hazard identification
• Reporting systems
– People are reluctant to report
– Why?
• Retaliation
• Self-incrimination
• Embarrassment
 Protecting sources of safety information
• Legal guidance in Annex 13, Attachment E
• Safety information must not be used for purposes other than
the purposes for which it was collected
– Introduction and definitions
– General principles
– Principles of protection
– Principles of exceptions
– Responsibilities of the custodian of safety information
– Protection of recorded information
 Safety risk management
2.1 – Hazard identification

• Typical qualities of successful safety

reporting systems:
– Reports easy to make

– No disciplinary actions as result of reports

– Reports are confidential

– Feedback is rapid, accessible and informative

 Safety risk management
2.1 – Hazard identification
• Four steps for action:
1. Reporting hazards, events or safety concerns
2. Collecting and storing the data
3. Analyzing reports
4. Distributing the information distilled from the
analysis
 ICAO SMS framework
 Safety policy and objectives
1.1 – Management commitment and responsibility
1.2 – Safety accountabilities
1.3 – Appointment of key safety personnel
1.4 – Coordination of emergency response planning
1.5 – SMS documentation
 Safety risk management
2.1 – Hazard identification
2.2 – Risk assessment and mitigation
 Safety assurance
3.1 – Safety performance monitoring and measurement
3.2 – The management of change
3.3 – Continuous improvement of the SMS
 Safety promotion
4.1 – Training and education
4.2 – Safety communication
 Safety risk management
2.2 – Risk assessment and
mitigation (Module 5)
• The organization shall develop
and maintain a formal process
Intolerable region
that ensures:
– analysis (probability and
A
severity of occurrence) L
A
– assessment (tolerability) R
Tolerable region
P
– control (mitigation) of the
Acceptable
safety risks assessed to the region

consequences of hazards in
operations to ALARP
 ICAO SMS framework
 Safety policy and objectives
1.1 – Management commitment and responsibility
1.2 – Safety accountabilities
1.3 – Appointment of key safety personnel
1.4 – Coordination of emergency response planning
1.5 – SMS documentation
 Safety risk management
2.1 – Hazard identification
2.2 – Risk assessment and mitigation
 Safety assurance
3.1 – Safety performance monitoring and measurement
3.2 – The management of change
3.3 – Continuous improvement of the SMS
 Safety promotion
4.1 – Training and education
4.2 – Safety communication
 Safety assurance
3.1 – Safety 1. Training course for drivers / installation of specific
signage.
performance Safety
requirements 2. Thrice-daily walk-in ramp inspection programme.

monitoring and 3. …

measurement 1. Maintain no more than 20 events of unauthorized

vehicles on the taxiways per 10,000 operations.
Safety

• The organization shall performance

targets
2. By January 2009 reduce to 8 FOD events on the apron
per 10,000 operations.
3. …
develop and maintain the
means to verify the 1. 20 events of unauthorized vehicles on the taxiways per
Safety 10,000 operations.
safety performance of performance
2. 15 FOD events on the apron per 10,000 operations.
indicators
the organization, and to 3. ...

validate the effectiveness

Will comply all applicable national and international
of safety risks controls Service provider
standards.
 Safety assurance
3.1 – Safety performance monitoring and
measurement
• The safety performance of the organization is
verified throughout the following tools:
– Safety reporting systems
– Safety studies
– Safety reviews
– Safety audits
– Safety surveys
– Internal safety investigations
–…
 Safety assurance
3.1 – Safety performance monitoring and
measurement
• Safety audits are used to ensure that the
structure of the SMS is sound in terms of:
– Levels of staff
– Compliance with approved procedures and
instructions
– Level of competency and training to:
• operate equipment and facilities
• maintain their levels of performance
 Safety assurance
3.1 – Safety performance monitoring and measurement

• Safety surveys examine particular elements or processes

of a specific operation

– Problem areas or bottlenecks in daily operations

– Perceptions and opinions of operational personnel

– Areas of dissent or confusion

 Safety assurance
3.1 – Safety performance monitoring and
measurement
• Safety surveys may involve the use of:
– Checklists
– Questionnaires
– Informal confidential interviews
• Since surveys information is subjective,
verification may be needed before
corrective action
• Surveys may provide an inexpensive source
of significant safety information
 Safety assurance
3.1 – Safety performance monitoring and
measurement
• Internal safety investigations include
occurrences or events that are not required
to be investigated or reported to State
– In-flight turbulence (flight operations)
– Frequency congestion (ATC)
– Material failure (maintenance)
– Ramp vehicle operations (aerodrome)
 ICAO SMS framework
 Safety policy and objectives
1.1 – Management commitment and responsibility
1.2 – Safety accountabilities
1.3 – Appointment of key safety personnel
1.4 – Coordination of emergency response planning
1.5 – SMS documentation
 Safety risk management
2.1 – Hazard identification
2.2 – Risk assessment and mitigation
 Safety assurance
3.1 – Safety performance monitoring and measurement
3.2 – The management of change
3.3 – Continuous improvement of the SMS
 Safety promotion
4.1 – Training and education
4.2 – Safety communication
 Safety assurance
3.2 – The management of change
• The organization shall develop and maintain a
formal process to identify changes within the
organization which may affect established
processes and services, in order to:
– describe the arrangements to ensure safety
performance before implementing changes
– to eliminate or modify safety risk controls that
are no longer needed or effective due to
changes in the operational environment
 Safety assurance
3.2 – The management of change
• Aviation organizations experience permanent
changes due to expansion, introduction of
new equipment or procedures.
• Changes can:
– Introduce new hazards
– Impact the appropriateness of risk mitigation
– Impact the effectiveness of risk mitigation
 Safety assurance
3.2 – The management of change
• External changes
– Change of regulatory requirements
– Security
– Reorganization of air traffic control
–…
• Internal changes
– Management changes
– New equipment
– New procedures
–…
 ICAO SMS framework
 Safety policy and objectives
1.1 – Management commitment and responsibility
1.2 – Safety accountabilities
1.3 – Appointment of key safety personnel
1.4 – Coordination of emergency response planning
1.5 – SMS documentation
 Safety risk management
2.1 – Hazard identification
2.2 – Risk assessment and mitigation
 Safety assurance
3.1 – Safety performance monitoring and measurement
3.2 – The management of change
3.3 – Continuous improvement of the SMS
 Safety promotion
4.1 – Training and education
4.2 – Safety communication
 Safety assurance
3.3 – Continuous improvement of the SMS
• The organization shall:
– develop and maintain a formal process to
identify the causes of sub-standard
performance of the SMS
– determine the implications of sub-standard
performance of the SMS in operations
– eliminate or mitigate such causes
 Safety assurance
3.3 – Continuous improvement of the SMS
• Continuing improvement is achieved
through:
– Proactive evaluation of facilities, equipment,
documentation and procedures through safety
studies, reviews, audits and surveys
– Proactive evaluation of the individuals’
performance, to verify the fulfilment of their
safety responsibilities and accountabilities
 Safety assurance
3.3 – Continuous improvement of the SMS

• Continuing improvement is achieved

through:
– Reactive evaluations in order to verify the
effectiveness of the system for control and
mitigation of risks, for example through
information obtained from:
• Accidents, incidents and major events investigations
Safety Risk Management (SRM) and Safety
Assurance (SA) – Summary
Design Operation
SRM SA
System
description/gap System operation Description
analysis and context

Safety performance
Hazard identification monitoring and Specific
measurement information

Safety risks Continuous

assessment improvement Analysis

Safety Mgt. of
risks change Assessment

Safety risks mitigation Corrective action Problem

resolution
 ICAO SMS framework
 Safety policy and objectives
1.1 – Management commitment and responsibility
1.2 – Safety accountabilities
1.3 – Appointment of key safety personnel
1.4 – Coordination of emergency response planning
1.5 – SMS documentation
 Safety risk management
2.1 – Hazard identification
2.2 – Risk assessment and mitigation
 Safety assurance
3.1 – Safety performance monitoring and measurement
3.2 – The management of change
3.3 – Continuous improvement of the SMS
 Safety promotion
4.1 – Training and education
4.2 – Safety communication
 ICAO SMS framework
 Safety policy and objectives
1.1 – Management commitment and responsibility
1.2 – Safety accountabilities
1.3 – Appointment of key safety personnel
1.4 – Coordination of emergency response planning
1.5 – SMS documentation
 Safety risk management
2.1 – Hazard identification
2.2 – Risk assessment and mitigation
 Safety assurance
3.1 – Safety performance monitoring and measurement
3.2 – The management of change
3.3 – Continuous improvement of the SMS
 Safety promotion
4.1 – Training and education
4.2 – Safety communication
 Safety promotion
4.1 – Training and education
• The organization shall develop and maintain
a safety training programme that ensures that
personnel are trained and competent to
perform the SMS duties
• The scope of the safety training shall be
appropriate to each individual’s involvement
in the SMS
 Safety promotion
4.1 – Training and education

• The safety manager should, in conjunction

with the personnel department, review the
job descriptions of all staff, and identify
those positions that have safety
responsibilities
 Safety promotion
4.1 – Training and education

Who? Why? How much?

Operational  To ensure that  Appropriate to the
personnel personnel are individual’s
Managers and trained and involvement in the
supervisors competent to SMS
Senior managers perform the SMS
Accountable duties
executive
 Safety promotion
4.1 – Training and education – A building block approach

Operational Managers and

Senior managers
personnel supervisors

1) Organization 3) The safety 6) Organizational

safety policy process safety standards
2) SMS 4) Hazard and national
fundamentals identification and regulations
and overview risk management 7) Safety assurance
5) The
management of
change
 Safety promotion
4.1 – Training and education
• Accountable executive – A special mention
– A briefing on:
• Safety policy and objectives
• SMS roles and responsibilities
• Safety risk management
• Safety assurance
– Somewhere between two hours and half a day
 ICAO SMS framework
 Safety policy and objectives
1.1 – Management commitment and responsibility
1.2 – Safety accountabilities
1.3 – Appointment of key safety personnel
1.4 – Coordination of emergency response planning
1.5 – SMS documentation
 Safety risk management
2.1 – Hazard identification
2.2 – Risk assessment and mitigation
 Safety assurance
3.1 – Safety performance monitoring and measurement
3.2 – The management of change
3.3 – Continuous improvement of the SMS
 Safety promotion
4.1 – Training and education
4.2 – Safety communication
 Safety promotion
4.2 – Safety communication
• The organization shall develop and maintain
formal means for safety communication
that:
– ensures that all personnel are fully aware of the
SMS
– conveys safety critical information
– explains why particular safety actions are taken
– explains why safety procedures are introduced
or changed
 Safety promotion
4.2 – Safety communication
• The means to communicate may include:
– Safety policies and procedures
– News letters
– Bulletins
– Website
• Safety communication is an essential
foundation for the development and
maintenance of an SMS
 SMS

Safety

Safety policy Safety risk

and objectives management

Safety Management Safety

promotion assurance
commitment

Effectiveness Efficiency
Aviation
community
stakeholders
 Points to remember
1. Key ingredients for successful reporting

2. The importance of a formal management of

change

3. Safety training – Who, why and how much

4. Safety communication
 Questions

• Q 1: Name four qualities of successful

confidential reporting systems.
• Q 2: What are the tools used for the safety
performance monitoring and measurement?
• Q 3: What is the objective of a formal
management of change process?
‫بسم هللا الرحمن الرحيم‬
 Course structure
Safety Module 10
Phased approach to
SSP and SMS
Management Implementation

System Module 8 Module 9

SMS planning SMS operation

Module 5 Module 6 Module 7

Risks SMS regulation Introduction to SMS

Module 1 Module 2 Module 3

Introduction Module 4
SMS course Basic safety to safety Hazards
introduction concepts management
 Objective
• At the end of this module participants will be
able to develop a proposal for an SMS
standard, based upon a phased
implementation, and explain the
organization of a State safety programme
(SSP)
 Outline
• Why a phased approach to SMS?
• The four phases
• The State safety programme (SSP)
• SSP initial steps in support of SMS
implementation
• A vision of the future – Integration
• Points to remember
 Why a phased approach to SMS?
• To provide a manageable series of steps to
follow in implementing an SMS
• To effectively manage the workload
associated with SMS implementation
• To pre-empt a “ticking boxes” exercise
• Four implementation phases are proposed
• Each phase is based upon the introduction
of specific SMS elements
 Phase 1 – Planning
• Provides:

– a blueprint on how the SMS requirements will

be met and integrated to the organization’s
work activities, and

– an accountability framework for the

implementation of the SMS
 Phase 1 – Planning
1. Identify the Accountable Executive and the safety Elements
1.1 and 1.2
accountabilities of managers (Module 8)

2. Identify the person (or planning group) within the Element 1.3
organization responsible for implementing the SMS (Module 8)

3. Describe the system (ATOs that are exposed to safety

risks during the provision of their services, aircraft Element 1.5
operators, AMOs, organizations responsible for type
design and/or manufacture of aircraft, air traffic (Module 8)
services providers and certified aerodromes)
4. Conduct a gap analysis of the organization’s existing
Element 1.5
resources compared with the national and international
(Module 8)
requirements for establishing an SMS
 Phase 1 – Planning
5. Develop an SMS implementation plan that explains
how the organization will implement the SMS on the Element 1.5
basis of national requirements and international
SARPs, the system description and the results of the (Module 8)
gap analysis

6. Coordinate emergency response planning with similar Element 1.4

planning of interfacing organizations (Module 8)

7. Develop documentation relevant to safety policy and Element 1.5

objectives (Module 8)

8. Develop and establish means for safety Element 4.2

communication (Module 9)
 Phase 2 – Reactive processes
1. Implement those elements of the SMS implementation Elements
plan that refer to the safety risk management 2.1 and 2.2
component – reactive processes (Module 9)

2. Training relevant to reactive processes:

Element 4.1
SMS implementation plan components.
(Module 9)
Safety risk management component

3. Documentation relevant to reactive processes:

Element 1.5
SMS implementation plan components.
(Module 8)
Safety risk management component
 Phase 3 – Proactive and predictive processes

1. Implement those elements of the SMS implementation

Elements
plan that refer to the safety risk management
2.1 and 2.2
component – proactive and predictive processes (Module 9)

Element 4.1
2. Training relevant to proactive and predictive processes (Module 9)

3. Documentation relevant to proactive and predictive Element 1.5

processes (Module 8)
 Phase 4 – Operational safety assurance

1. Development and agreement on safety performance Element 1.1

indicators and safety performance targets (Module 8)

2. Initiate safety performance monitoring and Elements

measurement, including the management of change 3.1, 3.2 and 3.3
and the continuous improvement of the SMS (Module 9)

Element 4.1
3. Training relevant to operational safety assurance
(Module 9)

4. Documentation relevant to operational safety Element 1.5

assurance (Module 8)
SMS implementation phases – Summary
Timeline
PHASE I
PHASE II
PHASE III
PHASE IV
Planning SMS Implementation of
reactive safety Implementation of
Elements: proactive and Implementation of
1.1; 1.2; 1.3 and management predictive safety operational safety
1.5 ; [and 1.4] processes management assurance
Elements: processes Elements:
2.1 and 2.2 Elements:
2.1 and 2.2 1.1; 3.1; 3.2 ;3.3
4.1 and 4.5

Develop documentation – Element 1.5

Develop and establish means for safety communication – Element 4.2

Develop and deliver training – Element 4.1

 The bridge

Service
State
providers

SSP SMS
 STATE SAFETY PROGRAMME (SSP)

• 1- An SSP is a management system for the

regulation and administration of safety by the
State. The implementation of an SSP is
commensurate with the size and complexity of
the State’s civil aviation system and requires
coordination among multiple authorities
responsible for the aviation functions of the
State. The objectives of the SSP are to:
• a) ensure that a State has the minimum
required regulatory framework in place;
 STATE SAFETY PROGRAMME (SSP)

• b) ensure harmonization amongst the State’s

regulatory and administrative organizations in
their respective safety risk management roles;
• c) facilitate monitoring and measurement of
the aggregate safety performance of the
State’s aviation industry;
• d) coordinate and continuously improve the
State’s safety management functions; and
• e) support effective implementation and
interaction with the service provider’s SMS.
 STATE SAFETY PROGRAMME (SSP)

• 2- Safety management principles provide a

platform for parallel development of the SSP
by the State and the SMS by its service
providers. In developing the State safety
legislative framework, the State promulgates
SMS requirements requiring service
providers to implement their safety
management capabilities allowing for the
effective identification of systemic safety
deficiencies and the resolution of safety
concerns.
 STATE SAFETY PROGRAMME (SSP)

• 3- The service provider’s SMS requires

effective regulatory oversight. Additionally,
SMS is a largely performance-based system
requiring the appropriate exchange of safety
information with internal and external
stakeholders. The State, through its SSP
functions, both provides the oversight
functions and facilitates implementation of
appropriate data aggregation and
information-sharing initiatives.
 SSP FRAMEWORK
• There are four components that form the fundamentals of
an SSP. Each component is subdivided into elements that
comprise the processes or activities undertaken by the State
to manage safety. These eleven elements combine
prescriptive and performance-based approaches and
support the implementation of SMS by service providers.
The four components and eleven elements of an SSP
framework are:
• 1. State safety policy and objectives
• 1.1 State safety legislative framework
• 1.2 State safety responsibilities and accountabilities
• 1.3 Accident and incident investigation
• 1.4 Enforcement policy
 SSP FRAMEWORK
• 2. State safety risk management
• 2.1 Safety requirements for the service provider’s SMS
• 2.2 Agreement on the service provider’s safety performance
• 3. State safety assurance
• 3.1 Safety oversight
• 3.2 Safety data collection, analysis and exchange
• 3.3 Safety-data-driven targeting of oversight of areas of greater
concern or need
• 4. State safety promotion
• 4.1 Internal training, communication and dissemination of safety
information
• 4.2 External training, communication and dissemination of safety
information.
 State safety programme
• Definition
– An integrated set of regulations and activities
aimed at improving safety.

• Requirement
– States shall establish a State safety
programme (SSP), in order to achieve an
acceptable level of safety in civil aviation.
 State safety programme
• Implementation
– Develop the State safety programme (SSP)
around the following four components:
1. State safety policy and objectives
2. State safety risk management
3. State safety assurance
4. State safety promotion
 ICAO SSP framework
1. State safety policy and objectives
1.1 State safety legislative framework
1.2 Safety responsibilities and accountabilities
1.3 Accident and incident investigation
1.4 Enforcement policy
2. State safety risk management
2.1 Safety requirements for service providers SMS
2.2 Agreement on service providers’ safety performance
3. State safety assurance
3.1 Safety oversight
3.2 Safety data collection, analysis and exchange
3.3 Safety data driven targeting of oversight on areas of greater concern or
need
4. State safety promotion
4.1 Internal training, communication and dissemination of safety information
4.2 External training, communication and dissemination of safety information
SSP initial steps in support of SMS implementation
STEP 1
Conduct a gap STEP 2
analysis of the
SSP, in order to Develop an STEP 3
ascertain the
SMS training
status of Develop SMS
maturity and programme for STEP 4
the State safety regulations for
existence within
oversight service Revise the
the State of the
elements of an authority staff. providers. State
SSP. Prepare enforcement
guidance policy.
material for the
implementation
of SMS.
 SSP initial steps in support of SMS implementation
• The service providers’ SMS cannot effectively
perform either in a regulatory vacuum, or in an
exclusively compliance-oriented environment.
• In such environments, service providers will only
implement and demonstrate, and the State
authorities will only assess, the tokens of an
SMS
• In such environments, service providers will not be
able to implement, or the State authorities will be
not able to assess, effectively performing SMS
SSP initial steps in support of SMS implementation

• Effectively performing SMS by

service providers can only flourish
under the enabling umbrella
provided by an SSP
• The SSP is therefore a fundamental
enabler for the implementation of
effective SMS by service providers
 The bridge

Service
State
Safety
providers
ALoS performance

SSP SMS
 A vision of the future – Integration
State safety programme (SSP) + Service providers SMS =
Integrated safety system (ISS)
Protection Production
Objective: State
Safety risk Safety
management
Programme

State
(SSP) Performance-based
Acceptance oversight
Compliance
oversight

Services provider
Organization’s Objective:
Objective: Support
Safety risk Safety production
management Service delivery
Management goals and
system (SMS) customer
satisfaction
Safety assurance
• Air Transat has a 72% decrease in irregular
operating costs (over $1m per month saved)
• Improved employee morale at Air Transat
• Benefits in reduced incidents and increased
awareness of operation
• Applies equally to other sectors of industry

International Civil Aviation

Organization
International Civil Aviation
Organization
 TRANSFORMATION TO SMS

Past/Current New
Prescriptive regulations Performance-based regulations
Focus on areas of greatest risk
Highly specialized and technically
trained staff System auditors and analysts

Significant resource requirements More efficient use of resources

to manage growth areas.
Industry responds to regulatory
requirements Industry becomes partner in
safety

International Civil Aviation

Organization
 Points to remember
1. Reduce a complex task to a series of
manageable steps

2. Avoid a bureaucratic exercise (“Ticking boxes”)

3. Element allocation under a particular phase

may slightly vary depending upon the specific
Annex

4. The State safety programme (SSP) framework

5. SSP initial steps in support of SMS

implementation
 SAFETY YOU
YOUR FAMILY