Safety Management Systems (SMS) Course

Module N° 10 – Phased
approach to SMS
implementation

Revision N° 11 ICAO Safety Management Systems (SMS) Course 01/01/08

 Building an SMS

Safety Module 10
Phased approach to
Management 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

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

Module N° 10 ICAO Safety Management Systems (SMS) Course 2

 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’s safety programme.

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 Outline
❖Why a phased approach to SMS?
❖The four phases
❖The State’s safety programme
❖CAAs – Four steps to support SMS implementation
❖Points to remember
❖Exercise 10/01 – Model of SMS regulation – Outline of an
SMS Standard
❖Exercise 10/02 – Collision between two aircraft at Milano-
Linate International Airport (See Handout N° 6)

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 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.

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 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.

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 Phase 1 – Planning
1. Identify the accountable executive and the safety
accountabilities of managers.
Elements 1.1 and 1.2
2. Identify the person (or planning group) within the
organization responsible for implementing the SMS.
Element 1.3
3. Describe the system (Air operator, ATC services provider,
approved maintenance organization, certified aerodrome)
Element 1.4

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 Phase 1 – Planning
4. Conduct a gap analysis of the organization’s existing
resources compared with the national and international
requirements for establishing an SMS.
Element 1.4
5. Develop an SMS implementation plan that explains how
the organization will implement the SMS on the basis of
national requirements and international SARPs, the
system description and the results of the gap analysis.
Element 1.4
6. Develop documentation relevant to safety policy and
objectives
Element 1.6
7. Develop and establish means for safety communication
Element 4.2
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 Phase 2 – Reactive processes
1. Puts into practice those elements of the SMS
implementation plan that refer to the safety risk
management component – reactive processes.
Elements 2.1 and 2.2
2. Training relevant to reactive processes:
➢ The SMS implementation plan components.
➢ The safety risk management component.
Element 4.1
3. Documentation relevant to reactive processes :
➢ The SMS implementation plan components.
➢ The safety risk management component.
Elements 1.4 and 1.6
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 Phase 3 – Proactive and predictive processes
1. Puts into practice those elements of the SMS
implementation plan that refer to the safety risk
management component – proactive and predictive
processes.
Elements 2.1 and 2.2
2. Training relevant to proactive and predictive processes.
Element 4.1
3. Documentation relevant to proactive and predictive
processes.
Elements 1.4 and 1.6

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 Phase 4 – Operational safety assurance
1. Development of acceptable level (s) of safety
2. Development of safety indicators and targets
3. SMS continuous improvement
Elements 3.1, 3.2 and 3.3
4. Training relevant to operational safety assurance
Element 4.1
5. Documentation relevant to operational safety assurance
Element 1.6

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 The bridge

Civil Service
Aviation Providers
Authority SMS

State’s safety programme

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 State’s safety programme
❖ Definition
➢ An integrated set of regulations and activities aimed at
improving safety.

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 State’s safety programme
❖Implementation
➢Develop the State’s safety programme around the
following four components:
1. State’s safety policy and objectives
2. State’s safety risk management
3. State’s safety assurance
4. State’s safety promotion

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 State’s safety programme components
1. State’s safety policy and objectives
❖ How the CAA will oversee the management of safety in
the State.
➢ A definition of CAA requirements, responsibilities and
accountabilities regarding the State’s safety
programme.
➢ Similar to the equivalent SMS component.

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 State’s safety programme components
2. State’s safety risk management
❖ Establishment of controls which govern how service
providers SMS will operate:
➢ Standards/requirements for service providers SMS
➢ Same processes as SMS
▪ Hazard identification and risk management
➢ Different outputs
▪ New/modified rules and/or regulations (i.e.,
controls) which govern how service providers SMS
operate.
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 State’s safety programme components
3. State’s safety assurance
❖ Ensuring that the operation of service providers SMS
follows established controls (standards / requirements)
➢ Oversight, inspections and audits
➢ Data tracking and analysis
▪ Data driven targeting of oversight on areas of
greater concern/need.

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 State’s safety programme components
4. State’s safety promotion
❖ Support the integration of the State safety programme
with the operation of service providers SMS
➢Training, communication and dissemination of safety
information
➢Dual-track promotion
▪ Within the CAA
▪ Among service providers it oversees

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 STATE SAFETY OVERSIGHT SYSTEM

❖1. Primary aviation legislation;

❖2. Specific operating regulations;
❖3. State system and functions;
❖4. Qualified technical personnel;
❖5. Technical guidance, tools and provision of safety-critical
information;
❖6. Licensing, certification, authorization and/or approval
obligations;
❖7. Surveillance obligations;
❖8. Resolution of safety issues.
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 State’s safety programme framework
1. State’s safety policy and objectives
1.1 CAA safety standards
1.2 CAA safety responsibilities and accountabilities
1.3 Accident and incident investigation
1.4 Enforcement policy
2. State’s safety risk management
2.1 Safety requirements for service providers SMS
2.2 Approval of service providers acceptable levels of safety
3. State’s 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’s safety promotion
4.1 Internal training, communication and dissemination of safety information
4.2 External training, communication and dissemination of safety information
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 CAAs – Four steps to support SMS
implementation
STEP 1 – State’s safety programme gap analysis:
❖ Conduct a gap analysis vis-à-vis the current status in the State of the following:
1. State’s safety policy and objectives
1.1 CAA safety standards
1.2 CAA safety responsibilities and accountabilities
1.3 Accident and incident investigation
1.4 Enforcement policy
2. State’s safety risk management
2.1 Safety requirements for service providers SMS
2.2 Approval of service providers acceptable levels of safety
3. State’s safety assurance
3.1 Safety oversight
3.3 Safety data driven targeting of oversight on areas of greater concern or need
4. State’s safety promotion
4.1 Internal training, communication and dissemination of safety information
4.2 External training, communication and dissemination of safety information

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 CAAs – Four steps to support SMS
implementation
STEP 2 – CAA training programme:
❖ Develop a training programme for CAA officers to:
➢provide knowledge of safety management concepts
and ICAO SARPs on safety management in Annexes 6,
11 and 14, and related guidance material; and
➢develop knowledge to certify and oversee the
implementation of key components of an SMS, in
compliance with the national regulations and relevant
ICAO SARPs.

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 CAAs – Four steps to support SMS
implementation
STEP 3 – Implementation SMS SARPs:

❖ Develop SMS regulations for operators/service providers.

➢ Refer to the SMS components and elements as per the

ICAO SMS training course.

❖ Prepare guidance material for the implementation of SMS.

➢ Refer to ICAO Doc 9859 and the ICAO SMS training

course.

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 CAAs – Four steps to support SMS
implementation
STEP 4 – CAA enforcement policy:

❖ As part of the State’s safety programme, revise the CAA’s

enforcement policy.

➢ Operators/service providers allowed to deal with

deviations/minor violations internally, within the context
of the SMS, to the satisfaction of the authority.

➢ Gross negligence, wilful deviation and so forth to be

dealt through established enforcement procedures.

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 A vision of the future – Integration
State’s safety programme + Service providers SMS =
Integrated safety system
Protection Production

Objective: State
Public safety
safety programme

Acceptance Oversight
Oversight
Objective:
Organization’s Achieve
Objective:
Organization’s commercial
safety production
Manage and goals and
management processes
control customer
safety risk
system (SMS) satisfaction
Risk management
Safety assurance
Module N° 10 ICAO Safety Management Systems (SMS) Course 25
 Points to remember
1. Reduce a complex task to 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’s safety programme

5. The CAAs four steps to support SMS implementation.

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 Phased approach to SMS implementation

Exercise 10/01 – Model of SMS

regulation – Outline of a SMS standard

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 Model of SMS regulation – Outline of a SMS
Standard
❖Group activity:

➢A facilitator will be appointed, who will coordinate the

discussion.

➢A summary of the discussion will be written on flip

charts, and a member of the group will brief on their
findings in a plenary session.

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 Model of SMS regulation – Outline of a SMS
Standard
❖Group assignment:
➢ On the basis of what was presented and discussed in
modules 6 to 9, develop a model of SMS regulation,
that addresses the following three general areas:
1. Scope and application
2. Main definitions (Do not develop)
3. General contents (Only headlines) of the SMS
regulation

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 Phased approach to SMS implementation

Exercise 10/02 – Collision between two

aircraft at Milano-Linate International
Airport (Handout N° 6)
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 Milano-Linate International Airport accident
❖Group activity:
➢A facilitator will be appointed, who will coordinate the
discussion.
➢A summary of the discussion will be written on flip
charts, and a member of the group will brief on their
findings in a plenary session.

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 Milano-Linate International Airport accident
❖ Scenario
➢ An MD-87 taxied to the holding point for runway 36R.
Heavy fog had delayed the flight by more than one
hour. While the visibility was improving, RVR was still
only 225 metres.
➢ A Cessna Citation parked at the West Apron was
cleared to taxi via taxiway Romeo 5 and to report
reaching the first holding point. The crew read the
clearance back correctly, but entered taxiway
Romeo 6.

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 Milano-Linate International Airport accident
❖ ... Scenario
➢ The Cessna Citation’s crew called for clearance to
proceed from the Romeo 5 holding point though it was
in fact at the Romeo 6 holding point.
➢ The MD-87 was cleared for take-off.
➢ The Cessna Citation crossed the holding point for
runway 36R-18L.
➢ The two aircraft collided.
➢ The MD-87 skidded off the runway into a baggage
hangar adjacent to the passenger terminal.
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 Milano-Linate International Airport accident

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 Milano-Linate International Airport accident

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 Milano-Linate International Airport accident

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 Milano-Linate International Airport accident

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 Milano-Linate International Airport accident
❖After analysis of evidence available and information
gathered, it can be assumed that the immediate cause for
the accident has been the runway incursion in the active
runway by the Cessna.

❖The obvious consideration is that the human performance

issues related to the Cessna crew – during low visibility
conditions – must be weighted against the scenario that
allowed the course of events that led to the fatal collision.

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 Milano-Linate International Airport accident
❖Equally it can be stated that the system in place at
Milano-Linate aerodrome was not geared to trap
misunderstandings, inadequate procedures, human errors
and faulty airport layout.
❖The aerodrome standard did not comply with ICAO
Annex 14.
❖No functional Safety Management System (SMS) was in
operation.

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 Milano-Linate International Airport accident
❖Group assignment – Task Nº 1
➢List the type of operation or activity.
➢State the generic hazard(s)
➢State the specific components of the hazard(s).
➢State the hazard-related consequences and assess the
risk(s).
➢Assess existing defences to control the risk(s) and
resulting risk index.
➢Propose further action to reduce the risk(s) and resulting
risk index.
➢Establish individual responsibility to implement the risk
mitigation
➢Complete the following Table 10/01.
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 Table 10/01 – Hazard identification and risk
management
Type of Specific Existing defences Further action to
Generic Hazard-related
Nº operation hazard
components to control risk(s) reduce risk(s) and Responsible
of the hazard consequences person
or activity and risk index resulting risk index

1 Risk index: Risk index:

Risk tolerability: Risk tolerability:

2 Risk index: Risk index:

Risk tolerability: Risk tolerability:

3 Risk index: Risk index:

Risk tolerability: Risk tolerability:

4 Risk index: Risk index:

Risk tolerability: Risk tolerability:

5 Risk index: Risk index:

Risk tolerability: Risk tolerability:

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 Milano-Linate International Airport accident
❖Group assignment – Task Nº 2
➢ The accident investigation has identified that no
functional Safety Management System (SMS) was in
operation at Milano-Linate International Airport.
➢ Therefore you should:
▪ Develop a SMS implementation plan for Milano-
Linate International Airport
▪ Complete the Gantt the following Table 10/02 – SMS
implementation plan.
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 Table 10/02 – SMS implementation plan
Nº Component/element Date: Date: Date: Date:

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 Milano-Linate actual aerodrome layout

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 Safety Management Systems (SMS) Course

Module N° 10 – Phased approach

to SMS implementation

Revision N° 11 ICAO Safety Management Systems (SMS) Course 01/01/08