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SAFETY 1st

SMS DEVELOPMENT GUIDE

November 2013 © Safety 1st i

TABLE OF CONTENTS

Forward… ..................................................................................................................... v

HOW TO USE THIS GUIDE ............................................................................1

CHAPTER OVERVIEW .............................................................................................. 2

General Introduction to the Safety 1st Development Guide .................................. 2

Chapter 1: Introduction ......................................................................................... 2

Chapter 2: Safety Organization ............................................................................ 2

Chapter 3: Hazard Identification & Safety Reporting .......................................... 2

Chapter 4: Accident Prevention Program & Root Cause Analysis....................... 3

Chapter 5: Safety Risk Management (SRM) ........................................................ 3

Chapter 6: Human Factors .................................................................................... 3

Chapter 7: Safety Assurance ................................................................................. 3

Chapter 8: Emergency Preparedness .................................................................... 4

Your Customized Manual ..................................................................................... 4

Acronyms, Abbreviations, Definitions & Terminology ....................................... 5

CHAPTER 1: INTRODUCTION ....................................................................13

1. General Introduction ............................................................................................... 14

2. Core Components of a Safety Management System ............................................... 15

Safety Policy ....................................................................................................... 15

Safety Risk Management (SRM) ........................................................................ 16

Safety Assurance ................................................................................................ 17

Safety Promotion ................................................................................................ 18

3. SMS Development and Implementation ................................................................. 19

November 2013 © Safety 1st ii

4. The FAA and System Safety .................................................................................. 21

5. Summary ................................................................................................................. 22

6. The Dirty Dozen ..................................................................................................... 22

7. Document Revision and Control ............................................................................. 23

CHAPTER 2: SAFETY ORGANIZATION ....................................................25

1. Safety Management Organization........................................................................... 26

2. Roles & Responsibilities ......................................................................................... 28

Safety Manager / Director of Safety ................................................................... 28

3. Gap Analysis ........................................................................................................... 30

4. Safety Management Plan ........................................................................................ 31

5. SMS Documentation ............................................................................................... 33

6. Safety Training ....................................................................................................... 33

Management Safety Awareness and Training .................................................... 34

Safety Orientation ............................................................................................... 35

Recurrent Safety Training................................................................................... 36

CHAPTER 3: HAZARD IDENTIFICATION & SAFETY REPORTING .....37

Contents: ............................................................................................................. 37

1. Hazard Identification Process ................................................................................. 38

Hazard Identification and Controls ..................................................................... 39

2. Non-Punitive Hazard Reporting ............................................................................. 44

3. Accident / Incident Reporting ................................................................................. 45

4. Investigation............................................................................................................ 48

5. Safety Committee ................................................................................................... 49

6. Safety Communications .......................................................................................... 50

November 2013 © Safety 1st iii

CHAPTER 4: ACCIDENT PREVENTION PROGRAM & ROOT CAUSE

ANALYSIS ......................................................................................................53

1. Accident Prevention Program ................................................................................. 54

2. Safety Data management ........................................................................................ 55

3. Root Cause Analysis ............................................................................................... 55

CHAPTER 5: SAFETY RISK MANAGEMENT ...........................................56

The Safety Risk Management Process ........................................................................ 57

General................................................................................................................ 57

SRM Principles ................................................................................................... 58

Six Steps for SRM .............................................................................................. 59

Implementing the SRM Process ......................................................................... 60

Types of Risk Defined ........................................................................................ 61

Risk Identification .............................................................................................. 62

Acceptability of Risk .......................................................................................... 65

CHAPTER 6: HUMAN FACTORS ................................................................66

1. Human Factors - Overview ..................................................................................... 67

Introduction ........................................................................................................ 67

The Meaning of Human Factors ......................................................................... 67

The Aim of Human Factors in Aviation ............................................................. 68

Safety and Efficiency .......................................................................................... 69

Factors Affecting Workplace Performance ........................................................ 70

Personality vs. Attitude ....................................................................................... 72

Crew Resource Management (CRM) and Maintenance Resource Management

(MRM) ................................................................................................................ 73

2. Safety Culture ......................................................................................................... 75

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CHAPTER 7: SAFETY ASSURANCE ..........................................................77

1. Safety Oversight ..................................................................................................... 78

Reactive Process ................................................................................................. 79

Proactive Safety Assessment .............................................................................. 79

2. Safety Assurance Process ....................................................................................... 80

Safety Assessment .............................................................................................. 81

3. Safety Program Internal Review ............................................................................. 82

4. External Audit Procedures ...................................................................................... 83

5. Environmental Compliance .................................................................................... 86

CHAPTER 8: EMERGENCY PREPAREDNESS ..........................................87

1. Emergency Preparedness ........................................................................................ 88

General................................................................................................................ 88

What impact would an accident have on your company? .................................. 88

Role of Senior Management ............................................................................... 89

Coordination and Communications .................................................................... 90

Policies................................................................................................................ 90

Other Organizations and Individuals .................................................................. 91

Major Components of an Emergency Response Plan ......................................... 92

REFERENCES ................................................................................................97

Additional References ................................................................................................ 98

November 2013 © Safety 1st v

FORWARD

This guide has been adapted from material developed by: the Federal Aviation

Administration (FAA); Global Aviation Information Network (GAIN); Transport

Canada; and the International Civil Aviation Organization (ICAO) addressing the

fundamentals of safety management system structure and content. This guide

provides a means for each company to customize this program to company-

specific safety goals and objectives.

The “Participant Advisories” in the borders of this guide are for guidance

purposes only.

November 2013 © Safety 1st Page 1

HOW TO USE THIS GUIDE

The Safety 1st SMS Development Guide provides guidance and instruction for the

creation, implementation and use of a safety management system (SMS). This guide

reflects enhancements to the traditional SMS for the benefit of participating

companies, and addresses the activities commonly performed within air operator,

FBO and maintenance organizations.

This guide can be used to either develop and implement your own company-specific

safety management system; or enhance your current safety program with advanced

industry best practices.

For ease of use, this guide is organized into eight chapters that allow your safety

manager to develop your own customized SMS manual.


CHAPTER OVERVIEW

General Introduction to the Safety 1st SMS Development Guide

A safety management system is comprised of three main components: 1) The overall

management system, to include policies, procedures, duties, authorities, interfaces,

controls, measures, and responsibilities; 2) The training that will be provided to your

employees who must perform specific tasks using required (by regulation) and

industry accepted practices; and 3) a performance standard that describes how each

task will be performed. All three components comprise the elements that will provide

a quality standard for participating companies.

The following list is an overview of each chapter in this guide.

Chapter 1: Introduction

General Introduction

Core Components of a Safety Management System

SMS Development and Implementation

The FAA and System Safety

The Dirty Dozen

Chapter 2: Safety Organization

Safety Management Organization

Roles and Responsibilities

Gap Analysis

Safety Management Plan

SMS Documentation

Safety Training

Chapter 3: Hazard Identification & Safety Reporting

Hazard Identification Process


Accident/Incident Reporting

Non-Punitive Hazard Reporting

Investigation

Safety Committee

Safety Communications

Chapter 4: Accident Prevention Program & Root Cause Analysis

Accident Prevention Program

Safety Data Management

Root Cause Analysis

Chapter 5: Safety Risk Management (SRM)

Safety Risk Management Process

o SRM Principles

o Six Steps for SRM

o Implementing the SRM Process

o Types of Risk Defined

o Risk Identification

o Acceptability of Risk

Chapter 6: Human Factors

Human Factors Overview

Safety Culture

Chapter 7: Safety Assurance

Safety Oversight


Safety Assurance Process

Safety Program Internal Review

External Audit Procedures

Environmental Compliance

Chapter 8: Emergency Preparedness

What impact would an accident have on your company?

Role of Senior Management

Coordination and Communications

Policies

Other Organizations and Individuals

Major Components of an Emergency Response Plan

Your Customized Manual

Using the Safety 1st SMS Development Guide to create your company-

specific document.

o The Safety 1st guide as your quality standard for conducting all

technical functions associated with air, ground and maintenance

operations (as applicable).

o Developing your internal controlled manual system to assess

distribution, ensure timely revisions and track implementation.

o Incorporating updates from Safety 1st and the aviation industry,

and ensuring conformance.

o Establishing an internal quality assurance assessment of your

system‟s effectiveness.

o Audits.


Acronyms, Abbreviations, Definitions & Terminology

A

Accident (ICAO Annex 13): “An occurrence associated with the operation of an

aircraft which takes place between the time any person boards the aircraft with the

intention of flight until such time as all such persons have disembarked, in which:

a. “A person is fatally or seriously injured as a result of:

Being in the aircraft, or

Direct contact with any part of an aircraft, including parts which have

become detached from the aircraft, or

Direct exposure to jet blast, except when the injuries are from natural causes,

self-inflicted or inflicted by other persons, or when the injuries are to

stowaways hiding outside the areas normally available to the passengers and

crew; or

b. “The aircraft sustains damage or structural failure which:

Adversely affect the structural strength, performance or flight characteristics

of the aircraft, and

Would normally require major repair or replacement of the affected

component, except for engine failure or damage, when the damage is limited

to the engine, its cowlings or accessories; or for damage limited to propellers,

wing tips, antennas, tires, brakes, fairings, small dents or puncture holes in

the aircraft skin; or

c. “An aircraft is missing, completely damaged, or inaccessible.”

Note: An injury resulting in death within 30 days of the accident is classified as fatal.

Accountability: The obligation or willingness to accept responsibility for the

execution or performance of an assigned function, duty, task or action; implies being

answerable (i.e., accountable) to a higher authority for ensuring such responsibility is

executed or performed.

Accountable Executive: Single, identifiable person who: (1) Is the final authority

over operations authorized to be conducted under the certificate holder‟s

certificate(s); (2) Controls the financial resources required for the operations to be

conducted under the certificate holder‟s certificate(s); (3) Controls the human

resources required for the operations authorized to be conducted under the certificate


holder‟s certificate(s); (4) Retains ultimate responsibility for the safety performance

of the operations conducted under the certificate holder‟s certificate.

Aircraft Accident (49 CFR Part 830): “An occurrence associated with the operation

of an aircraft, which takes place between the time any person boards the aircraft with

the intention of flight and all such persons have disembarked, and in which any

person suffers death or serious injury, or in which the aircraft receives substantial

damage.” (Also see “Substantial Damage.”)

Aircraft Operation: Operation of an aircraft with the intent of flight.

Aviation Safety Action Program (ASAP): A reporting program that allows

employees of participating air carriers and repair station certificate holders to identify

and report safety issues to management and to the FAA for resolution, without fear

that the FAA will use reports accepted under the program to take legal enforcement

action against them, or that companies will use such information to take disciplinary

action.

Assumptions: Characteristics or requirements of a system or system state that are not

verified.

Audit: The structured and objective assessment used to determine the level of

conformity to your company‟s operating manuals, safety program, technical

guidance, regulations, etc.

Aviation Safety Reporting System (ASRS): A voluntary program administered by

NASA that receives, processes, and analyzes reports of unsafe occurrences and

hazardous situations that are voluntarily submitted by pilots, air traffic controllers,

and others. Information collected by the ASRS is used to identify hazards and safety

discrepancies in the National Airspace System. It is also used to formulate policy and

to strengthen the foundation of aviation human factors safety research.

B

Best Practice: A strategy, process, approach, method, tool or technique that is

generally recognized as being effective in helping an operator achieve operational

objectives.

C

Causes: Actions, omissions, events, conditions, or a combination thereof, which led

to an accident or incident. Causes can occur by themselves or in combinations.


Control: Anything that mitigates the risk of a hazard‟s effects. A control can be a

key procedure, responsibility, or decision-making position within the organization,

department or functional area. (Note: Comprehensive evaluations focus on verifying

and testing the controls within flight, ground and maintenance operations.)

Comprehensive Evaluations: Periodic reviews of company operations performed by

the Safety Manager. The independence of these reviews is intended to improve the

ability of your company to verify that systems are effectively evolving with company

growth and to ensure that technical issues are adequately considered in strategic

decisions.

Comprehensive Fix: A fix in which all corrective measures have been completed to

the satisfaction of the company.

Concern: A conclusion by the auditor, supported by objective evidence, that does

not demonstrate a finding, but rather a condition that could become a finding.

Corrective Action: The action(s) taken to eliminate or mitigate the cause of or to

reduce the effects of a detected non-conformity or other undesirable situation.

Corrective Action Plan (CAP): The total plan to close all Findings through

implementation of comprehensive and permanent corrective action(s).

Corrective Action Record (CAR): A document that identifies the need for

corrective action based on a Finding, and provides a history of implementation and

verification of the corrective action.

D

Documented: A specification published in a company operating manual, handbook,

or other official company medium. It is distinct from records because it is the written

description of policies, processes, procedures, objectives, requirements, authorities,

responsibilities, or work instructions.

E

Effect: The potential outcome or harm of the hazard if it occurs in the defined system

state.

F


Finding: A condition, supported by objective evidence that demonstrates

nonconformance with a specific standard.

Flight Operations Quality Assurance (FOQA): The voluntary collection, analysis,

and sharing of routine flight operation data, obtained by analysis of flight data

recorder information.

G

Ground Incident: An occurrence not associated with the operation of an aircraft,

causing injury that does not require professional medical attention, or minor damage

to an aircraft or other equipment.

Ground Operations: The department, company or vendor responsible for all ground

(ramp) operations.

H

Hazard: Any real or potential condition that can cause injury, illness, or death to

people; damage to or loss of a system, equipment, or property; or damage to the

operating environment. A hazard is a condition that is a prerequisite to an accident or

incident.

Human Factors: Human factors involves gathering information about human

abilities, limitations, and other characteristics and applying it to tools, machines,

systems, tasks, jobs, and environments to produce safe, comfortable, and effective

human use. In aviation, human factors is the study and application to better

understand how humans can most safely and efficiently be integrated with the

technology. That understanding is then translated into design, training, policies, or

procedures to help humans perform better.

I

ICAO (International Civil Aviation Organization): A specialized agency of the

United Nations that sets standards and regulations necessary for aviation safety,

security, efficiency and regularity, and aviation environmental protection. The

Organization serves as the forum for cooperation in all fields of civil aviation among

its Member States.

ICAO Annex 6: Standards and recommended practices for the international

operation of aircraft. Annex 6, Part I is applicable to commercial air transport in


airplanes; Part II is applicable to general aviation operations in airplanes; and Part III

is applicable to both commercial air transport and general aviation operations in

helicopters.

ICAO Annex 13: The international recommended standard for aircraft accident and

incident investigation.

Incident (49 CFR Part 830): “An occurrence other than an accident, associated with

the operation of an aircraft, which affects or could affect the safety of operations.”

Investigation: A process conducted for the purpose of accident prevention, which

includes the gathering and analysis of information, the drawing of conclusions,

including the determination of causes and, when appropriate, the making of safety

recommendations.

Investigator-in-charge: A person, commission or other body charged, on the basis

of his/her/their qualifications, with the responsibility for the organization, conduct

and control of an investigation.

L

Likelihood: The estimated probability or frequency, in quantitative or qualitative

terms, of an occurrence related to a hazard. (Also see “Hazard.”)

N

Near Miss (Serious Incident): An incident involving circumstances indicating that

an accident nearly occurred. The difference between an accident and a serious

incident lies only in the result.

Non-Conformity: Non-fulfillment of specifications contained in the applied standard

as determined by the auditor in terms of having been documented and/or

implemented by the company.

O

Objective Evidence: Information, which can be proved to be true, based on facts

obtained through observation, measurement, test or other means.


Occupational Injury: An injury sustained by an employee on your payroll whether

they are labor, executive, hourly, salary, part-time, seasonal or migrant worker and

who sustain the work related injury, illness or death.

OSHA: Occupational Safety & Health Administration

OSHA 1910: That portion of the Occupational Safety and Health Act that pertains to

general industry regulations.

OSHA 300 Log: The OSHA-required form for maintaining occupational injury and

illness records.

P

PPE (Personal Protective Equipment): Equipment for protecting the eyes, face,

head, ears, extremities, protective clothing, respiratory devices and protective shields.

Q

Quality: The degree to which a system consistently meets specified requirements,

satisfies stated needs, or produces desired outcomes.

Quality Assurance: All those planned and systematic actions necessary to provide

adequate confidence that a product or service will satisfy given requirements for

quality.

Quality System: The organizational structure, responsibilities, procedures and

resources for implementing and maintaining the quality policy and objectives.

R

Recommended Best Practice: A strategy, process, approach, method, tool or

technique that is generally recognized as being effective in helping an operator to

achieve operational objectives.

Risk: The composite of predicted severity and likelihood of the potential effect of a

hazard in the worst credible system state. Types of risk include:

a. Identified risk: That risk that has been determined to exist using analytical

tools. The time and costs of analysis efforts, the quality of the risk management


program, and the state of the technology involved affect the amount of risk that

can be identified

b. Unidentified risk: That risk that has not yet been identified. Some risk is

not identifiable or measurable, but is no less important. Mishap investigations

may reveal some previously unidentified risks.

c. Total risk: The sum of identified and unidentified risk. Ideally, identified

risk will comprise the larger portion of the two.

d. Acceptable risk: The part of identified risk that is allowed to persist after

controls are applied. Risk can be determined acceptable when further efforts to

reduce it would cause degradation of the probability of success of the

operation, or when a point of diminishing returns has been reached.

e. Unacceptable risk: The portion of identified risk that cannot be tolerated,

but must be either eliminated or controlled.

f. Residual risk: The remaining safety risk that exists after all control

techniques have been implemented or exhausted, and all controls have been

verified. Only verified controls can be used for the assessment of residual

safety risk.

Root Cause Analysis: A systematic approach to identifying, investigating,

categorizing, and eliminating the root causes of safety related incidents.

S

Safety: A condition in which the risk of harm or damage is limited to an acceptable

level.

Safety Management System (SMS): A formal, top-down business-like approach to

managing safety risk. It includes systematic procedures, practices and policies for the

management of safety. It also includes safety risk management, safety policy, safety

assurance, and safety promotion. NOTE: The extent of the SMS documentation can

differ from one organization to another due to the size of the organization and type of

activities. The documentation can be in any form or type of medium.

Severity: The consequence or impact of a hazard in terms of degree of loss or harm.


Substantial Damage (49 CFR Part 830): “Damage or failure which adversely affects

the structural strength, performance or flight characteristics of the aircraft, and which

would normally require major repair or replacement of the affected component.

Engine failure or damage limited to an engine if only one engine fails or is damaged,

bent fairings or cowling, dented skin, small punctured holes in the skin or fabric,

ground damage to rotor or propeller blades, and damage to landing gear, wheels,

tires, flaps, engine accessories, brakes, or wingtips are not considered „substantial

damage‟ for the purpose of this Part.”

System: An integrated set of constituent elements that are combined in an

operational or support environment to accomplish a defined objective. These

elements include people, equipment, information, procedures, facilities, software, and

support services.

System Safety: The application of special technical and managerial skills in a

systematic, forward-looking manner to identify and control hazards throughout the

life cycle of a project, program, or activity.

System State: An expression of the various conditions, characterized by quantities or

qualities, in which a system can exist.

T

Top Management: The person or group of people who direct and control an

organization (ref: ISO 9000-2005 definition 3.2.7).

V

Validated: The act of determining factual evidence for a certain condition or

situation.

Verified: The ability to prove that something exists or is true, or to make certain that

something is correct.

W

Work Related Injury or Illness: An injury or illness that is caused by an event or

exposure in the work environment that either caused or contributed to the resulting

condition or significantly aggravated a pre-existing injury or illness. Work-

relatedness is presumed for injuries and illnesses resulting from events or exposures

occurring in the work environment.


CHAPTER 1: INTRODUCTION

Contents:

1. General Introduction

2. Core Components of a Safety Management System

Safety Policy

Safety Risk Management

Safety Assurance

Safety Promotion

3. SMS Development & Implementation

Level 1: Planning and Organization

Level 2: Reactive Processes

Level 3: Proactive and Predictive Processes

Level 4: Safety Assurance and Continuous Improvement

4. The FAA and System Safety

5. Summary

6. The Dirty Dozen

7. Document Revision and Control


1. GENERAL INTRODUCTION

This guide outlines the foundation of SMS, and provides guidance on tailoring SMS

to your company‟s operations. To ensure this program works as effectively as

possible in your organization, every employee must be empowered to achieve the

highest levels of safety. Every employee must be responsible and appropriately

accountable for safety during aircraft flight, ground and maintenance operations.

This guide will define all the applicable components of a Safety Management System

(SMS). The SMS components outlined in this guide serve as an operational guide for

the daily management of all safety activities.

SMS is a systematic, comprehensive process for the management of safety risks that

integrates operations and technical systems with financial and human resource

management, for all activities related to flight, ground and maintenance operations.

SMS is a data driven, business-like approach to safety management. In common with

all other management systems, the SMS provides for goal setting, planning, and

performance measurement. It concerns itself with organizational safety, rather than

conventional health and safety issues at work. The SMS defines how your company

intends the management of safety to be conducted as an integral part of its business

management activities.

As with many aspects of managing a company, the approach and strategy for the

SMS is based on the “3 P” model illustrated below. Each part of your strategy must

connect and rely on each other to ensure the model will always be strong.

In the “3 P” model of safety management:

Participant Advisory:

SMS can be adapted to both

large and small organizations.

Managers that desire to make

a positive impact on their

safety performance will find

SMS achieves results, by

raising awareness at every

level of the organization,

building in responsibility and

providing a logical, data

driven approach to managing

risk.


There is a Policy approved and supported at the highest level.

Processes that make up the safety management system are documented,

implemented and used to manage the company‟s activities.

People (staff) managing and running the business have been trained on the

SMS and are expected to follow approved policy and processes.

The elements of the SMS outlined in this guide conform to FAA Advisory Circular

(AC) 120-92A, Safety Management Systems for Aviation Service Providers, and the

International Civil Aviation Organization (ICAO) SMS Framework.

The information in this guide outlines the principles of safety management and its

application to flight, maintenance and ground operations.

The documented elements contained in this guide are the individual building blocks

of the system, and should be introduced in a well thought out, managed process

supported by top management.

The implementation of the SMS and its components should be phased to ensure the

success of each element. Aspects of some of the elements may already be in place in

your company, but might need to be modified in order to conform to the requirements

of the safety management system your company ultimately develops.

2. CORE COMPONENTS OF A SAFETY MANAGEMENT SYSTEM

SMS is an integrated collection of processes, procedures and programs that ensure a

formal and proactive approach to system safety through risk management. The

following describes the four main components of an SMS:

Safety Policy

All management systems must define policies, procedures and organizational

structures to accomplish their goals.

Under Safety Policy, the following activities take place:

Top management defines the organization‟s safety policy and conveys its

expectations, objectives, commitments and accountabilities to its

employees.


The organization defines documents and communicates the safety roles,

responsibilities and authorities throughout its organization.

The organization appoints a management representative to manage,

monitor and coordinate the SMS processes.

The organization develops and implements procedures that it will follow in

the event of an accident or incident or operational emergency to mitigate

the effects of these events.

The organization establishes documented safety policies, objectives,

procedures, a document/record management process and a safety

management plan that meet organizational safety expectations and

objectives.

Safety Risk Management (SRM)

A formal system of hazard identification and safety risk management (SRM) is

essential to controlling risk to acceptable levels. Under Safety Risk Management,

the organization:

Develops and maintains a process that ensures that hazards in operations

are identified. Hazards are identified from the analysis of critical design

and performance factors, processes and activities in sufficient detail to

determine associated level of risk and risk acceptability.

Analyzes its systems, operations and operational environment to gain an

understanding of critical design and performance factors, processes and

activities to identify hazards.

Identifies and documents the hazards in its operations that are likely to

cause death, serious physical harm, or damage to equipment or property in

sufficient detail to determine associated level of risk and risk acceptability.

Develops and maintains a process that ensures analysis, assessment and

control of the safety risks in system operations.

Determines and analyzes the severity and likelihood of potential events

associated with identified hazards, and will identify risk factors associated

with unacceptable levels of severity or likelihood.


Assesses risk associated with each identified hazard and defines risk

acceptance procedures and levels of management that can make safety risk

acceptance decisions.

Designs and implements a risk control for each identified hazard for which

there is unacceptable risk, to reduce risk to acceptable levels. The potential

for residual risk and substitute risk is analyzed before implementing any

risk controls.

Safety Assurance

Once SRM controls are identified and operational, the company must ensure the

controls continue to be effective in a changing environment. The safety assurance

(SA) function provides for this, using system safety and quality management

concepts and processes.

Under Safety Assurance, the organization:

Monitors, measures, and evaluates the performance and effectiveness of risk

controls.

Develops and maintains a means to monitor, measure and verify the safety

performance of the organization, and to validate the effectiveness of safety

risk controls.

Continuously monitors operational data, including products and services

received from contractors, to identify hazards, measure the effectiveness of

safety risk controls, and assess system performance.

Performs regularly scheduled internal audits of its operational processes,

including those performed by contractors, to verify safety performance and

evaluate the effectiveness of safety risk controls.

Conducts internal evaluations of the SMS and operational processes at

planned intervals, to determine that the SMS conforms to its objectives and

expectations.

Includes the results of assessments performed by oversight (FAA) and other

organizations in its analysis of data.


Establishes procedures to collect data and investigate incidents, accidents,

and instances of potential regulatory noncompliance to identify potential new

hazards and risk control failures.

Establishes and maintains a confidential employee safety reporting and

feedback system. Data obtained from this system is monitored to identify

emerging hazards and to assess performance of risk controls in the

operational systems.

Analyzes the data collected in this Section to assess the performance and

effectiveness of risk controls in the organization‟s operational processes and

the SMS, and to identify root causes of non-conformances and potential new

hazards.

Performs an assessment of the safety performance and effectiveness of risk

controls, conformance to SMS expectations and the objectives of the safety

policy.

Develops and maintains a process to identify changes within the organization

or its operational environment that may affect established processes and

services and to describe the arrangements to assure safety performance

before implementing changes.

Develops and maintains a process to identify the causes of sub-standard

safety performance, determine the implications of sub-standard safety

performance and eliminate or mitigate such causes.

Takes corrective and preventive action to eliminate the causes, or potential

causes of nonconformance identified during analysis, to prevent recurrence.

Conducts regular reviews of the SMS to assess the performance and

effectiveness of the organization‟s operational processes and the need for

improvements.

Safety Promotion

The company must promote safety as a core value with processes that support a

sound safety culture. Under Safety Promotion, the organization:

Promotes the growth of a positive safety culture and communicates it

throughout the organization.


Ensures that personnel are trained and competent to perform the SMS duties.

The scope of safety training is commensurate with the individual‟s

involvement in the SMS.

Documents competency requirements for safety-related positions and key

safety personnel and ensures those requirements are met.

Develops, documents, delivers and regularly evaluates training necessary to

meet competency requirements.

Communicates the outputs of its SMS to all employees, and provides its

oversight organization access to SMS outputs in accordance with established

agreements and disclosure programs.

3. SMS DEVELOPMENT AND IMPLEMENTATION

There are four levels of SMS implementation, which provide for a progressive

system development:

Level 1: Planning and Organization;

Level 2: Reactive Processes;

Level 3: Proactive and Predictive Processes;

Level 4: Safety Assurance and Continuous Improvement.

Each level involves the following activities:

Level 1: Planning and Organization

The organization will:

Establish a statement of commitment, signed by the CEO / Accountable

Executive, to the development and implementation of the SMS.

Designate a management official responsible for SMS implementation.

Define safety-related positions for those who will participate in SMS

development and implementation.

Conduct a documented gap analysis between the organization‟s existing

system and SMS guidelines.


Develop a comprehensive SMS implementation plan for the entire

organization based on the results of the gap analysis.

Develop an SMS training plan for all employees.

Level 2: Reactive Processes

The organization will:

Document and implement a voluntary non-punitive employee reporting

program.

Document policies and procedures to conduct a reactive analysis and

assessment of hazards, and to implement corrective actions to mitigate future

risk.

Apply SMS processes and procedures to at least one existing hazard, and

initiate the risk mitigation process.

Conduct SMS training for the staff directly involved in the SMS on reactive

processes.

Update the SMS implementation and training plans for the entire

organization.

Level 3: Proactive and Predictive Processes

During Level 3, the organization will demonstrate that, in addition to the components

already developed and implemented during Level 2, it also has a process for the

proactive identification of hazards and associated methods of collecting, storing and

distributing data and a risk management process. The organization will:

Document all processes and procedures for operating the SMS, from

information gathering through Safety Risk Management and mitigation.

Conduct hazard analyses on all current operating processes.

As appropriate, revise documented SMS implementation plan for the entire

organization.

As appropriate, revise documented policies and procedures.


Level 4: Safety Assurance and Continuous Improvement

During Level 4, the organization will demonstrate that, in addition to the components

developed and implemented during Levels 2 and 3, it has also developed and

implemented processes for:

Recurrent training

Quality management

Emergency preparedness

As appropriate, revise documented safety management plan

As appropriate, revise documented policies and procedures

The safety assurance process should include a method for validation of control,

evaluation of results, and development of any necessary changes to the SMS.

A safety management system is progressive in its development. The expectation is to

strive for, and realize, continuous improvement.

4. THE FAA AND SYSTEM SAFETY

In 2006, the FAA issued Order 8000.1, which established a policy of managing

safety through a process-oriented system or “system safety process.” This process

applies to all FAA management activities and its safety oversight relationship with

the aviation industry.

In October 2010, the FAA released Advisory Circular (AC) 120-92A, “Safety

Management Systems for Aviation Service Providers.” The purpose of the AC is to

encourage any organization providing aviation services, e.g., airlines, air charter

operators, corporate flight departments, maintenance repair organizations, pilot

schools, repair stations, etc., to develop and implement an SMS. The material in this

guide conforms to the requirements of AC120-92A and the ICAO standards for SMS.

Safety Risk Management (SRM) and Safety Assurance (SA) Processes


5. SUMMARY

The following is a summary of the benefits that SMS provides for your company:

A comprehensive, systematic approach to the management of flight, ground

and maintenance safety, including the interfaces between the company,

customers, and vendors.

A focus on flight, ground and maintenance operations; hazard identification,

management and the effects on activities critical to safety.

The full integration of flight, ground and maintenance safety considerations,

via the application of management controls to all aspects of operations

critical to safety.

The use of active monitoring and audit processes to validate that the controls

identified in the hazard management process are in place, and to ensure an

active commitment to safety.

The use of quality management principles, including improvement and

feedback mechanisms.

6. THE DIRTY DOZEN


The Federal Aviation Administration (FAA) has identified 12 main causes of human

error leading or contributing to accidents, often referred to as “the dirty dozen:”

Lack of Communication;

Complacency;

Lack of Knowledge;

Distraction;

Lack of Teamwork;

Fatigue;

Lack of Resources,

Pressure;

Lack of Assertiveness;

Stress;

Lack of Situational Awareness; and

Norms (behavior that is not required, but expected at the workplace).

Your company, in cooperation with the Safety 1st Team, strives to eliminate these

causal contributors by aggressively supporting the principles outlined in this industry

specific safety management system.

The organizational structures and activities that make up your company‟s SMS are

designed to enhance safety throughout the organization.

Every employee in every department contributes to the safety of the organization.

The system must be integrated into a safety culture or “the way things are done”

throughout the company. This will be achieved by the implementation and continuing

support of a documented safety program based on a coherent policy, which leads to

well designed and maintained procedures.

7. DOCUMENT REVISION AND CONTROL

The SMS documentation that your company develops as part of this program shall

have a method of revision and control, to provide accurate and timely updates to all

employees. The revision status shall be identified by the revision date on each page

of your SMS documentation.

No revision service for this guide is provided. The most current version of the guide

will be maintained on the Safety 1st

Website.


This guide is not a regulatory-approved document and does not supersede any

requirements mandated by local, state or federal authorities, nor does it

supersede or amend any manufacturer's guidance, manuals, or any other

approved documentation. This document is provided for guidance purposes

only. Safety 1st

does not accept any liability for incidents arising from the use

of the guidance materials contained in this document.

November 2013 © Safety 1

st Management System Page 25

CHAPTER 2: SAFETY

ORGANIZATION

Contents:

1. Safety Management Organization

2. Duties & Responsibilities

3. Safety 1st Shared Responsibilities

4. Gap Analysis

5. Safety Management Plan

6. SMS Documentation

7. Training


1. SAFETY MANAGEMENT ORGANIZATION

SafetyManager

SafetyCommittee

FlightOperations

MaintenanceDepartment

LineService

Scheduling &Flight Following

Accountable Executive / Top Managment

Safety Organization: To be effective, the Safety Manager should report directly

to the highest level within the management structure.

While this section outlines individual roles and responsibilities, it‟s important to

emphasize that everyone has a responsibility for safety.

By implementing SMS, your company is committing to achieving and maintaining

the highest levels of safety within the aviation services industry and to providing the

resources necessary to ensure that all strategic safety objectives established in this

guide are achieved.

The authority and responsibility to implement SMS in your company rests with Top

Management.

Note: Top Management is defined as, “the person or group of people who direct or

control an organization.” Top management makes decisions that affect everyone in

the organization, and is held responsible for the success or failure of the company. In

large organizations, this can be the Chief Executive Officer (CEO), president or

board of directors. In smaller organizations, it might be the company owner.

The responsibility for maintaining the SMS normally rests with the Safety Manager.

However, every employee has specific accountabilities. After orientation and safety

training, all employees will be assigned duties and responsibilities to ensure your

company‟s safety management system is as effective as possible.


Whether your organization is a

one-location operation or has a

highly centralized corporate

structure with numerous

outlying facilities, it‟s

important to ensure that the

safety communication

structure touches all facilities

and operations.

Safety is not a “corporate

only” function, but one that

must be visible in the field on

a daily basis.

Safety is not the sole

responsibility of the Safety

Manager, but the responsibility

of managers, supervisors, and

every employee.

The Safety Manager must be

empowered by your company

to facilitate, assist and guide

your company to establish and

maintain a robust safety

program.


The following list of activities demonstrates top management‟s active commitment to

the SMS:

Including safety matters on the agenda of meetings from the Board of

Directors level down

Being actively involved in safety activities and reviews at both home office

and base locations (as applicable)

Allocating the necessary resources, such as time and funding, to safety

matters

Setting personal examples in day-to-day work

Receiving and acting on safety reports submitted by employees

Promoting safety topics in company publications

“Walk the Walk – Talk the Talk” - Safety First.

The Accountable Executive is responsible: to ensure the company achieves

its business and quality objectives, for the safety and efficiency of company

operations, and for authorizing budgets accordingly.

The Accountable Executive will assess safety resource needs requested by

the Safety Manager.

The Accountable Executive is responsible for managing all components of

the SMS. The Accountable Executive may direct the Safety Manager to

produce an annual aviation safety report that will be authorized by the

Accountable Executive.

The Accountable Executive will act, or appoint a management representative,

as Chair of the Safety Committee.

The Safety Manager reports to the Accountable Executive and is responsible

for proposing safety policy, monitoring its implementation and providing an

independent overview of company activities in so far as they affect safety;

maintenance, review and revision of the safety program; timely advice and

assistance on safety matters to managers at all levels; and a reporting system

for hazards.

All managers are committed to support the safety management system, and

share the overall commitment to safety as expressed by the Accountable

Executive.


The Safety Manager‟s

reporting structure:

Industry best practice

recommends that the Safety

Manager position report to the

highest level in the

organization, such as the

CEO/President.

The Safety Manager should

not report directly to

“Operations,” as this reporting

relationship can be hindered

by the need to “get the job

done” at the expense of doing

it safely.

It‟s vital to the effectiveness of

this program that safety

communication is not hindered

in any way.


2. ROLES & RESPONSIBILITIES

Your organization shall document and define the roles and responsibilities of all

personnel in the safety management system, especially the following positions (as

applicable): Director of Operations, Director of Maintenance, Chief Pilot, and

operational employee groups such as pilots, dispatchers/schedulers, mechanics, line

service and customer service representatives. This should include a statement that

everyone is both responsible and accountable for safety.

Top management‟s dedication and involvement to safety should be clearly visible.

It‟s important that top management is viewed as providing strong and active

leadership in the safety management system. This includes a commitment to provide

the resources necessary to attain strategic safety objectives established by the

organization.

Safety Manager / Director of Safety

The Safety Manager is responsible for ensuring that the safety and health

management process is established, communicated, implemented, audited, measured

and continuously improved for your company and its customers. This should be

accomplished in the following duties and responsibilities:

Prepare and maintaining your company‟s SMS.

Serve as a safety and health (if applicable) resource for operational

departments and employees.

Assist in the organization/development of documented workplace safety

business plans.

Assist in the operational and safety planning processes, e.g., safety

performance goals.

Maintain company safety management information data.

Provide human factors guidance and program development.

Provide guidance or secure guidance on regulatory compliance issues.

Provide regular safety communication through various means.

Provide or make available industrial hygiene services (if applicable).

Establish and maintain the chemical safety management process (MSDS) (if

applicable).


Support continuous safety improvement programs and abide by Company

SMS audit policies and procedures.

Conduct hazard assessments and audits, and perform frequent observations

of all aspects of employee and technical operations.

Provide hazard control recommendations to top management for review.

Report safety resource management needs to top management.

Conduct and/or coordinate all safety training and ensure all applicable

employees train in accordance with your SMS.

Facilitate environmental compliance (if applicable).

Conduct and/or coordinate emergency response exercises.

Review reports of safety-related events.

Represent the company with government agencies and professional

associations on safety and environmental matters.

Serve as recorder of safety committee meetings.

Provide emergency management tools and services.

To enhance the level of safety professionalism and effectiveness at your company,

the safety manager can be more effective by participating in formal safety education.

Participation in industry safety meetings, conferences or schools is an essential part

of the continuing education of the safety manager.

Training should include areas such as:

Corporate Safety Culture

Safety/Internal Evaluation Philosophy

Safety/Internal Data Collection and Analysis Programs

Operational Risk Management

Root Cause Analysis

Incident/Accident Prevention and Investigation

Human Factors

The safety manager should have extensive operational experience and professional

qualifications in aviation. This would include knowledge and understanding of:

Aviation Safety/Audit Programs

Aviation Safety Standards


Safe Aviation Operating Practices

OSHA Regulations (as applicable)

The Safety Manager should also receive advanced training in safety management by

attending an accredited safety management course. A list of institutions offering

these courses is provided in the “References” section of this guide.

Documentation of Roles and Responsibilities of Other Key SMS Personnel

The following highlight the areas that should be documented for key SMS personnel:

The safety responsibilities for each position and task.

The competencies required for each position.

The line of responsibility for ensuring all staff are competent and trained for

their duties, and for ensuring that training takes place.

The responsibilities of the manager responsible for externally supplied

services, such as training, maintenance, etc. All contracting companies

should meet the SMS standards equivalent to those established by your

company.

3. GAP ANALYSIS

The next step in the SMS process is to develop an implementation plan for the entire

organization. But, where do you begin? A good place to start is a comparison of your

current safety program with the four SMS components. This comparison or “gap

analysis” helps identify areas of your safety program that need further development

in order to have a fully operational SMS in your company.

Safety 1st provides two separate gap analysis tools. The first is the FAA Air Carrier

Detailed Gap Analysis Tool (to download click here), designed for FAR 135 air

charter operators, and reviews the following activities (as applicable):

Flight operations

Dispatch/flight following

Maintenance and inspection

Cabin safety

Ground handling and servicing

Cargo handling

http://www.nata.aero/data/files/sms/web/faa%20air%20carrier%20detailed%20gap%20analysis%20rev%203.xls


Training

The second tool is the SMS Gap Analysis Survey (to download click here), and is

designed for FBOs. Both gap analysis tools review a company‟s adherence to the

SMS components outlined in FAA Advisory Circular (AC) 120-92A.

4. SAFETY MANAGEMENT PLAN

In order for your company to implement an effective SMS, it‟s important to define

the organization‟s safety objectives, what form the safety system will take and who

will assume responsibility for the safety system. This involves defining the

organization‟s overall approach to integrating safety as a primary business function.

The Safety 1st SMS contains three principle objectives:

Define a clear corporate safety policy.

Define roles, responsibilities, and organizational reporting structures for all

personnel involved in safety.

A description of the SMS components.

Your company‟s safety policy should clearly state the company‟s intentions,

management system, and objectives to achieve continuous improvements in safety.

This can be accomplished through documented policies describing what

organizational processes and structures it will use to achieve the SMS. This should

also contain a statement outlining the company‟s objectives and the outcomes it

hopes to achieve through its SMS. Other elements should include:

Establishing safety as a core value.

Setting safety goals that will be revised annually based on performance.

Measuring safety performance.

An effective safety policy must clearly communicate top management‟s commitment.

This commitment should explain how the company will devote appropriate time,

resources, and attention to organizational safety. (A sample company safety

commitment policy can be accessed by clicking here.)

Top management‟s commitment should be documented in a manner that expresses

clear direction. The safety policy should allocate responsibilities and hold employees

accountable for meeting safety performance goals.

http://www.nata.aero/data/files/sms/web/sms%20gap%20analysis.xls

http://www.nata.aero/data/files/sms/web/company%20safety%20commitment%20november%202013.doc


The safety policy should include top management‟s commitment to:

Implement and maintain the SMS.

Continuously improve the level of safety.

Manage safety risk.

Comply with applicable regulatory requirements.

Encourage employees to report safety issues without reprisal.

The safety policy should:

Establish clear standards for acceptable behavior for all employees.

Provide management guidance for setting safety objectives.

Be documented.

Be communicated with visible management endorsement to all employees

and responsible parties.

Be reviewed periodically to ensure it remains relevant and appropriate to the

organization.

Identify responsibility and accountability of management and employees

with respect to safety performance

The table below is an example of how to develop safety objectives.

OBJECTIVE SAFETY PERFORMANCE

MEASURES

Business Objectives:

Reduce Costs

Reduction in insurance rates

Safety Objectives:

Decrease the number and

severity of hangar rash incidents

Your company‟s specific

objectives

Total number of events

Number of damage-only events

Number of near-miss accidents

Lessons learned from event

analyses

Number of corrective action

plans developed and

implemented.


5. SMS DOCUMENTATION

The SMS that your company ultimately develops must document the following

program elements:

Company Safety Policy and Objectives

Duties and Responsibilities

Safety Focal Point

Hazard Identification

Accident/Incident Reporting

Self-Disclosure

Safety Investigation

Safety Committee

Safety Communications

Accident Prevention

Safety Data Management

Quality System Oversight

Each SMS program element should address the following three documentation

requirements:

The identification of applicable health and safety and industry regulations,

standards, and accepted practices.

Consolidated documentation describing the systems for each component of

the SMS.

The implementation of changes required by changes to health, safety,

industry regulations, standards, and recommended practices.

Note: A sample SMS implementation timeline can be accessed by clicking here.

6. SAFETY TRAINING

Training is fundamental to effective job performance. Effective performance means

compliance with the requirements of safety, profitability and quality.

To meet this training need, it‟s important to establish a program that ensures:

http://www.nata.aero/data/files/sms/web/sms%20implementation%20plan.doc


A systematic analysis, to identify the training needs of each job function

The establishment of training plans to meet the identified needs

The training is assessed and is effective, in that each training session has

been understood and the training program is relevant

Training involves the review of all occupations; analysis and observation of critical

activities, accident and incident analysis and statutory requirements. The objective of

all training is to provide employees with the skills and knowledge to carry out their

duties safely and effectively.

All appropriate training methods including the additional training provided for Safety

1st participants should be used. Additionally, there is no substitute for practical on-

the-job instruction in some occupations. Whatever training techniques are adopted,

it‟s important that the effectiveness of the training is assessed and that training

records are maintained. Periodic reviews of the training program are required to

ensure that it remains relevant and effective.

Management Safety Awareness and Training

For the successful operation of any management system, it‟s essential that the

management team understand the principles on which the system is based. Effective

training of management ensures this objective. Training should provide everyone

with supervisory responsibility the necessary skills to implement and maintain the

SMS.

The training of managers and supervisors should include:

Initial training, soon after appointment to a supervisory position, to acquaint

new managers and supervisors with the principles of the SMS, their

responsibilities and accountability for safety and statutory requirements.

Detailed training in the SMS, to include the background and rationale behind

each element.

Skills training in relevant areas such as communications and safety auditing.

Conducting group meetings.

Learning how to focus on safety - no matter what the task.

Regular update and refresher training as applicable.

Training courses should be tailored to ensure that managers and supervisors are

familiar with the principles of your company‟s SMS and their responsibilities and


accountabilities for safety. On-site training ensures that all staff are acquainted with

the relevant information appropriate to their function.

For successful SMS implementation, it‟s also important that the safety manager

receive training early-on. The safety manager needs to understand the details of the

SMS, and techniques for implementing its elements. As the focal point for the

system, the safety manager should be thoroughly conversant with the program and

safety management principles.

Safety Orientation

Safety orientation in the work place begins on the first day of employment or job

reassignment. The plan for conducting initial safety orientation of an employee

should include:

A thorough review of your company‟s SMS.

The employee‟s supervisor should assist the employee regarding the general

content of the safety program. Emphasis should be placed on employee

specific rules, policies and procedures that will directly affect the employee

in the performance of his/her duties.

Each employee should be advised by his/her direct supervisor that

compliance with rules and policies of the SMS is a condition of employment.

Every employee will have job-specific training and trained by his/her supervisor on

the proper performance of his/her duties to ensure these duties are carried out in a

safe and proper manner.

Job-specific training can be accomplished by computer-based, and/or on-the-

job training.

The safety manager should, based on job hazard analyses of the employee‟s

job, determine and schedule required safety training.

The following steps should be completed before releasing an employee to carry out a

specific job function unsupervised:

The supervisor should carefully review with the employee all general and

specific rules, policies, and procedures to ensure the safety of company

operations and compliance with appropriate labor statutes.


Employees should be given verbal instruction and specific directions on the

proper performance of work practices.

As required, employees should be given a demonstration of job tasks.

Employees should be observed performing actual work previously

demonstrated. As necessary, remedial instruction will be provided to correct

training deficiencies prior to final release of an employee to perform

unsupervised work.

Employees and supervisors should be given safe operating instructions, if

available, from an authorized equipment vendor prior to the use and

operation of new equipment or processes.

Supervisors should review safe work practice options with employees prior

to permitting any new, non-routine, or specialized procedures in the

workplace.

Recurrent Safety Training

The Safety 1st SMS Guide

Applicable continuing education

Local operational safety issues

Seasonal or event safety issues

Industry trends and best practices

Lessons learned

Locally developed training should be included in the employee-training record, to

include course contents, and a syllabus should be maintained at each location or

accessible on your company‟s network.

In order for employees to comply with all safety requirements, they need the

appropriate information, skills, and training. The training should include initial,

recurrent and any updates specific to the SMS.

Employee participation in recurrent safety training should be documented in their

permanent employee training record.


CHAPTER 3: HAZARD

IDENTIFICATION & SAFETY

REPORTING

Contents:

1. Hazard Identification Process

2. Non-Punitive Hazard Reporting

3. Accident/Incident Reporting

4. Investigation

5. Safety Committee

6. Safety Communication


1. HAZARD IDENTIFICATION PROCESS

This section provides guidance to develop your company‟s hazard identification

process.

A hazard is any real or potential condition that can cause injury, illness, or death to

people; damage to or loss of a system, equipment, or property; or damage to the

operating environment.

The safety manager should involve all operational and technical departments, such as

flight operations, maintenance, dispatch, line service and customer service, and any

other departments as appropriate (e.g., risk management, human resources) in the

hazard identification process. Involving these groups or personnel will help minimize

errors and omissions, ensure a quality analysis, and encourage employee “buy in” to

the process.

The hazard identification process consists of four steps:

Step One: Review the company‟s incident/accident history with all operational and

applicable administrative departments, e.g., risk management, human resources, etc.

The review should focus on indicators of existing hazards and associated controls (if

any) and determine whether the hazards were correctly identified and/or the

associated controls were adequate.

Step Two: Conduct a preliminary job assessment, such as a job hazard analysis (see

page 40). The safety manager should review with all operational employees the

hazards they know currently exist in each work area, job assignment, and within the

airport environment. Brainstorming should be encouraged during these discussions to

foster new ideas to either eliminate or control hazards.

It‟s important to understand all the steps or tasks associated with each job. One

method of understanding job tasks is to observe employees performing the job and

list each step as it‟s accomplished. Record enough information without making it too

lengthy. Obtain input from the employee performing the job. Review the recorded

job steps or tasks with the employee to ensure nothing important is omitted.

Note: Reassure the employee being observed that the intent of this exercise is to

evaluate the job itself, not the employee‟s performance.

If any hazards are identified that pose an immediate danger to employees, customers,

aircraft, equipment or facilities, the safety manager should take immediate preventive

action. Do not wait to complete a job hazard analysis.


Step Three: List, rank, and set priorities for the identified hazards. List jobs with

hazards that present unacceptable risks, based on those most likely to occur and with

the most severe consequences.

Step Four: Identify effective controls to reduce or better manage the hazards

associated with the task or job.

Hazard Identification and Controls

There are many ways of identifying hazards and quantifying risks, but success

requires thinking by people who are unencumbered by past ideas and experiences.

Some hazards might be obvious, such as a lack of training, or they might be subtle,

such as the insidious effects of long-term fatigue from long duty or work days.

Depending on the size and complexity of your operation, there are several useful

methods of identifying hazards:

Brainstorming - small discussion groups meet to generate ideas in a non-

judgmental way.

Formal review of standards, procedures and systems.

Staff surveys or questionnaires.

One person standing back from the operation and critically observing.

Internally or externally conducted safety assessments.

Confidential reporting systems.

An effective tool for identifying hazards is the job hazard analysis. A job hazard

analysis (JHA) is an exercise in safety detective work. The safety manager should

provide the following guidance to all operational and technical departments and

affected employees in identifying hazards to allow them to better complete a JHA.

The goal is to identify hazards by asking:

What can go wrong?

What are the consequences?

How could it arise?

How likely is it that the hazard will occur?

Documenting the answers to the previous questions in a consistent manner will help

identify hazards and implement hazard controls.


A good hazard scenario describes:

Where it is happening (environment)?

Who or what it is happening to (exposure)?

What precipitates the hazard (trigger)?

The outcome that would result should it occur (consequence)?

Any other contributing factors?

Note: Rarely is a hazard a simple case of one singular cause resulting in one singular

effect. Often, many contributing factors line up a certain way to create the hazard.

Job Hazard Analysis

Date:

Job Title/Task: Aircraft Fueling

Department: Line Service

JHA No.: Line Service 1

Personal Protective Equipment: Vest, Eye & Hearing Protection, Gloves

Basic Job Steps Hazards Hazard Control

1. Drive fuel truck to aircraft. 1. Truck unsafe to operate.

Consequences:

Damage to property

Injuries

Fuel Spill

1. Inspect the truck at the

start of each shift.

2. Train each driver on

inspection procedures.

3. Perform scheduled

maintenance/inspections.

4. Remove truck from

service if unsafe to use.

Audited By / Date: Approved By:

NOTE: A sample Job Hazard Analysis form can be accessed by clicking here.

Alternative Hazard Identification Techniques

One example of a system to proactively identify hazards is to establish groups to

identify safety hazards by the following steps:

http://www.nata.aero/data/files/sms/web/job%20hazard%20analysis%20form%20november%202013.doc


Identify potential operational hazards that could threaten the safety of

employees, customers, passengers, company facilities, company assets, or

customer property

Rank the severity of the hazards

Identify current defenses

Evaluate the effectiveness of each defense

Identify additional defenses.

Assess the Hazards

The next step in the process is to critically assess the hazards and rank risks. Factors

to consider are: the likelihood of the occurrence and the severity of the consequences.

For example, an in-flight fire might be a rare occurrence, but could be catastrophic. It

would rank above a bird strike which, although much more likely to occur, is

normally less severe. There are various ways of conducting this assessment. Further

information is provided in Chapter 5, Safety Risk Management.

Identify the Defenses

Once the hazards are identified and their risks approximately ranked, defenses

(controls) to protect against the hazards should be identified. Examples include:

Ensuring that operating procedures are properly documented and

implemented. For example, a defense against an unoccupied vehicle rolling

into an aircraft would be a policy requiring that all vehicles be “chocked,”

with the parking brake set and in “park.”

Implementing automated caution and warning systems.

Installing protective guards and shields.

Requiring the use of personal protective equipment.

Assess the Defenses (Hazard Controls)

The appropriateness of hazard controls should be assessed. How effective are the

hazard controls? Would they prevent the occurrence (i.e., do they remove the hazard

and eliminate or minimize the risk), or do they minimize the likelihood or the

consequences? If the controls minimize the hazard and likelihood of occurrence, how

effective are they? An example of determining the effectiveness of a hazard control is

to ask questions. For example, are employees trained on the use of the fire

extinguishers, and are the extinguishers inspected and maintained?


Identify the Need for Hazard Elimination and Avoidance, or for Further

Defenses

Each hazard and its control should be critically examined to determine whether the

risk is appropriately managed or controlled. If the risk is properly managed or

controlled, the operation can continue. If not, steps should be taken to either improve

the hazard control or to remove/avoid the hazard. For example, the company provides

recurrent training for all employees in the correct use of fire extinguishers.

In some instances, a range of solutions to a risk may be available. Some are typically

engineering solutions (e.g., redesign), which are generally the most effective, but

may be expensive. Others involve control (e.g., operating procedures) and personnel

(e.g., training) and may be less costly. In practice, a balance needs to be found

between the cost and practicality of the various solutions.

The safety manager should recommend change or action to top management.

Whether or not the recommendation is acted upon needs to be monitored, and a

further cycle of risk management performed.

System Risks

A system is defined as “an integrated set of constituent elements that are combined in

an operational or support environment to accomplish a specific mission or objective.”

System elements can include people, hardware, software, procedures, facilities,

services, etc.

Systems can have extensive human interaction, complicated machines and

environmental exposures. Humans must monitor systems (e.g., pilot, aircraft, etc.),

and conduct design, maintenance, assembly and installation efforts. The automation

can be comprised of extensive hardware, software and firmware. If automation is not

appropriately designed, potentially unacceptable system risks or system accidents can

result. Environmental considerations can be extreme: harsh climates, noise, radiation,

etc.

Hazard Prevention

In order to prevent hazards, information obtained from a JHA can be used to

implement hazard control measures recommended in the analysis for each job. The

safety manager should provide recommendations for hazard control to top

management for review. Except for hazards requiring immediate attention, top

management should provide feedback to the safety manager within five business days

after initial receipt of the recommendations.

The following is the order of precedence and effectiveness when implementing

hazard controls:


Engineering Control

Administrative Control

Personal Protective Equipment

1. Engineering controls include:

Eliminate/minimize the hazard: Design the facility, equipment, or process to

remove the hazard, or substitute processes, equipment, materials or other

factors to reduce the hazard.

Enclose the hazard, such as enclosures for noisy equipment.

Isolate the hazard with inter-locks, guards or other means.

Remove or redirect the hazard, such as with local and exhaust ventilation/jet

blast.

2. Administrative controls include:

Documented standard operating procedures and safe work practices.

Exposure time limitations.

Monitoring the use of hazardous materials.

Alarms, signs, whistles, and warnings.

Buddy system

Training

3. Personal Protective Equipment (PPE) includes items, such as respirators, hearing

protection, protective clothing, reflective clothing and safety glasses. These may be

acceptable as a control method in the following circumstances:

When engineering controls are not feasible or do not totally eliminate the

hazard.

While engineering controls are being developed.

When safe work practices do not provide sufficient additional protection.

During emergencies when engineering controls may not be feasible.

The use of one hazard control method over another higher in the control precedence

may be appropriate for providing interim protection until the hazard is either

minimized or eliminated permanently. If the hazard cannot be eliminated entirely, the

adopted control measures will likely be a combination of all three items instituted

simultaneously.


2. NON-PUNITIVE HAZARD REPORTING

History has shown that successful companies in safety-critical industries have

implemented an SMS to produce significant and permanent improvements in safety.

Your company recognizes that, to ensure safety awareness remains constant, the

safety culture must encourage openness and trust between management and

employees. Everyone should feel free to report incidents and events without the fear

of retribution. Reporting situations, events and practices that compromise safety

should be a priority for all employees.

A near miss that goes unreported due to the fear of retribution could lead to a serious

accident.

For your SMS to be effective, the organization must have a positive safety culture.

Maintaining the safety of flight, ground, and maintenance operations are your

company‟s most important commitment. To ensure that commitment, it‟s imperative

that you have uninhibited reporting of all incidents and occurrences that compromise

the safety of your operations.

Each employee should accept the responsibility to communicate any information that

may affect the integrity of company safety. Employees must be assured that this

communication will never result in reprisal, thus allowing a timely, uninhibited flow

of information to occur.

All employees should be advised that your company will not initiate disciplinary

actions against an employee who discloses an incident or occurrence involving

safety. This policy cannot apply to criminal or willful infractions. (A sample non-

punitive reporting policy can be accessed by clicking here.)

The Hazard Reporting Form should be used by all employees for reporting

information concerning company safety. The forms are designed to protect the

identity of the employee providing the information, and should be readily available in

all work areas. All employees should be encouraged to use this program to help your

company provide your customers and employees with the highest level of safety. The

Hazard Reporting Form can be accessed by clicking here.

Hazard Report Processing Procedures

All hazard reports should be forwarded to the safety manager for initial

processing.

http://www.nata.aero/data/files/sms/web/non%20punitive%20hazard%20reporting%20policy%20november%202013.doc

http://www.nata.aero/data/files/sms/web/hazard%20reporting%20form%20november%202013.doc


The safety manager should notify the individual submitting the report,

usually by email, and inform them that the report was received.

The safety manager should enter the report information into a confidential

database.

After reviewing the report, the safety manager should task the responsible

department(s) to address the issue(s) identified, usually within 15 days. (This

can be accomplished either by a corrective action to correct the issue, or by a

corrective action plan with a timeline on when the issue will be corrected.)

Depending on the nature of the problem, and with the approval of top management,

more time can be allotted. If a corrective action plan is provided, and the issues are

not time critical, the follow-up date can be adjusted to reflect the completion date of

the corrective action plan.

The safety manager should enter the report information into its tracking system and:

Track the report as open. The safety manager monitors the progress of the

report to ensure the report is answered in the time allotted.

Enter all corrective actions in the tracking system and close the report.

Notify the report submitter of the report status if the follow-up date is

changed and of the corrective action taken when the report is closed.

3. ACCIDENT / INCIDENT REPORTING

All accidents and incidents involving any employee or asset should be immediately

reported to the safety manager or designated senior manager. The safety manager or

designated senior manager should be reachable on a 24-hour basis via an emergency

communication listing provided by your company. A written account of the accident

or incident should be submitted as soon as possible, normally within 24 hours after

the occurrence.

To officially report an accident as required by Part 830 of the National Transportation

Safety Board‟s Regulations, NTSB Form 6120.1, Pilot/Operator Aircraft Accident

Report should be completed and can be accessed by clicking here.

A plain document can be used if the recommended form is not available. All reports

should be faxed or emailed to the appropriate personnel within your organization.

http://www.nata.aero/data/files/sms/web/ntsb%206120.1.pdf


The appropriate supervisor/manager should forward the report to the safety manager

and all other applicable departments.

Pictures and witness statements should be taken immediately, if possible.

To the extent possible, the following information should be included in the initial

report of an accident or incident, as applicable:

Description of the occurrence (include weather conditions, etc.)

Time of occurrence

Location of the occurrence

Number of persons involved

Number and description of injuries (all persons)

If an aircraft is involved:

a. Type, nationality, and registration of the aircraft;

b. Name of the owner, and operator of the aircraft;

c. Name of the Pilot in Command;

d. Date and time of the accident;

e. Last point of departure and point of intended landing of the aircraft;

f. Position of the aircraft with reference to some easily defined

geographical point;

g. Number of persons onboard, number fatally injured, and number

seriously injured;

h. Nature of the accident, the weather and the extent of damage to the

aircraft, so far as is known;

i. A description of any explosives, radioactive materials, or other

dangerous articles carried.

Other property or equipment damage

Description of hazardous material/restricted articles that may be involved

Employee names and names of others involved

Description of actions taken to secure damaged equipment and cargo

Details of any investigation performed by the airport authority, or other

agency

Name and phone number of the person reporting the occurrence

Name and phone number of witnesses


Name of hospital and doctors treating the injured

Accident/Incident Investigation Process

All accident/incident and injury reports should be submitted to the safety manager.

This should be accomplished within 24 hours of the occurrence.

The safety manager, based on the severity of the accident/incident and all other

factors will determine the appropriate category of accident/incident (i.e., hangar,

ramp, equipment, etc.) in order to facilitate the data collection process.

Safety 1st provides two reporting forms that can be used by your company: an

Air Safety Report that can be accessed by clicking here, and a Ground Event

Reporting Form that can be accessed by clicking here.

Upon receipt of report conclusions, the safety manager will report to the

safety committee, which will recommend corrective action(s) and the safety

manager will monitor the corrective action plan.

The safety manager will notify the individual that originally submitted the

report of the corrective action taken in response to the report.

If there is any doubt, a report should be filed for any of the following:

Inadvertent violation of FARs, company policies and/or procedures.

System defect occurs that adversely affects the handling characteristics of

ground support equipment or aircraft and renders it unfit for the intended use

An emergency is declared

Safety equipment or procedures are defective or inadequate

Deficiencies exist in operating procedures, manuals or instructions

Incorrect loading of fuel, cargo or dangerous goods

Ground damage occurs

A runway or taxiway excursion/incursion occurs

Significant handling difficulties are experienced

Communications fail or are impaired

Serious loss of braking, aircraft or ground equipment

Any part of an aircraft or ground equipment is sabotaged or vandalized

Security procedures are breached

Foreign Object Damage (FOD) occurs

http://www.nata.aero/data/files/sms/web/air%20safety%20report%20november%202013.doc

http://www.nata.aero/data/files/sms/web/ground%20event%20reporting%20form%20november%202013.doc


A co-worker improperly performs their job or puts personnel and/or

equipment at risk

Equipment abuse

Any other event considered to have serious safety implications

The aim is to reveal problems and shortcomings that could lead to accidents.

Typically such shortcomings can be inadequate equipment or procedures, lack of

effective training, or the use of inappropriate materials. The outcome should be

action to reduce and control risks.

4. INVESTIGATION

ACCIDENT / INCIDENT INVESTIGATION PROCESS

If an event or occurrence is determined to be an accident (see definitions section), the

procedures listed in the Accident/Incident Investigation Process (Appendix D) and/or

your company procedures should be followed.

Incident investigations are to be initially performed by the safety manager as soon as

possible after an occurrence classified as an incident or accident. The location and

details of an occurrence should be carefully analyzed, and all witnesses interviewed,

to identify potential contributing factors. This must be accomplished as soon as

possible so that corrective measures can be quickly implemented to prevent similar

situations from reoccurring.

The safety manager should investigate all employee incidents and file an

accident/incident or injury report to top management that specifies the corrective

action(s) or interim measures taken to prevent a recurrence. If recommendations are

included with the report, top management or the safety manager should consider

immediate action on those recommendations. When applicable, the safety manager

should perform a root cause analysis. A Root Cause Tutorial can be viewed by

clicking here.

Applicable occurrences resulting in lost time must also be reported to the Human

Resources Department who will, in turn, report the occurrence to the Department of

Labor (DOL) on the applicable DOL form. Any accident resulting in the death of a

worker must be reported immediately to the Human Resources and Safety

Departments.

Safety 1st has provided an Accident Investigation Process guide that can be accessed

by clicking here.

http://www.nata.aero/data/files/sms/web/root%20cause%20tutorial%20april%202013.ppt

http://www.nata.aero/data/files/sms/web/accident%20investigation%20procedure%20april%202013.doc


5. SAFETY COMMITTEE

The safety committee should meet at least quarterly, and should accomplish the

following:

Review status of current accidents and incidents and corrective action(s)

Review status of hazard reports and corrective action(s)

Review safety audit reports and corrective action(s)

Review and resolution of any safety matters brought before the committee.

Duties and Responsibilities

The safety committee serves as liaison between all company employees and

top management.

The safety committee approves, rejects or recommends action on any safety

related matter brought before them.

The safety committee chair signs the meeting minutes, thereby allowing the

minutes to be implemented.

The safety committee monitors the company‟s safety training and awareness

programs.

It is recommended that the CEO or a designated manager serve as chair of the safety

committee. The chair will appoint the committee membership. The safety manager

will serve as recorder and will prepare meeting agendas and minutes.

Safety Committee Management

Safety committee management is a function of the safety manager. The following

outlines safety committee management protocols:

Safety committee meeting schedules should be provided to membership at

least one week prior to meeting.

The safety committee meeting agenda should be developed and completed

prior to publishing meeting schedules.

The safety committee meeting agenda should be distributed to each member

in conjunction with the meeting schedule.

Every effort should be made to resolve each agenda item.

After the conclusion of the safety meeting, a draft of the meeting minutes

should be prepared and distributed to attendees with a request for revisions,

additions or clarifications.


Final safety committee meeting minutes should be signed by the committee

chair.

The final meeting minutes should then be distributed to all committee

members for implementation.

Follow up on any open item(s) to ensure corrective actions are in compliance

with the action(s) required and within the time period allotted.

Safety Committee Chair Responsibilities

The following describes the safety committee chair‟s responsibilities:

Obtain group consensus on all issues discussed.

Ensure adherence to meeting schedule.

Dispute resolution and control of the committee.

Safety committee records should be maintained by the safety manager. Agendas and

minutes should be retained for a minimum of two years or as prescribed by your

company‟s document retention policy.

6. SAFETY COMMUNICATIONS

Safety communications should heighten safety awareness among all employees. They

include the following:

1. The safety manager should distribute, at a minimum, company safety updates

to all operational personnel. The updates should include, but not be limited

to, the following topics:

a. Safety 1st

information

b. NATA and NATA Safety 1st newsletters

c. Safety Committee meeting highlights

d. Company memos from top management addressing safety

e. Incidents and lessons learned

f. Workers‟ Compensation data

g. Airport provided safety alerts and information

h. Industry specific information

i. OEM/equipment manufacturer recommendations


Especially in small companies

where the Safety Manager

position is out of necessity an

additional duty, it may be

advisable to enlist the aid of one

or more other employees to

assist in the generation and

dissemination of Safety

Communications.


j. Other safety-related trends as may be provided by your insurance

company or insurance broker

k. FAA recommendations, ASRS Callback, FOQA Program (if

applicable)

l. Company originating “Safety Alerts” (items reported by fellow

employees)

m. Other safety related trends as may be provided by your insurance

company or broker.

2. The frequency of communication is crucial to keeping safety fresh and on the

minds of all employees. Monthly safety communications, where the safety

manager supplies the above information to all employees, regardless of shift

or location is recommended. You can also stagger your communications to

be distributed on a monthly and a quarterly basis. It‟s important to a constant

flow of communication, and to focus on the critical issues.

Note: Safety newsletters become ineffective when they fail to focus on the

big topics. Yes, you can mention the employee barbeque, however; keep

safety as the main theme.

Directing safety communications only to specific personnel prevents you

from taking advantage of the multiple sets of eyes you have available. All

employees should get the message. They could have additional ideas to share

on how to solve problems. Take advantage of all of the resources you have

available.

3. The safety manager should also maintain a safety page on the company

website or on the company‟s safety bulletin board that lists pertinent safety-

related information.

EMPLOYEE – MANAGEMENT INTERNAL COMMUNICATION

Employees are encouraged to express their concerns or ideas to the safety

manager. Concerns or ideas can be submitted either verbally or in writing.


However, having the ideas documented creates a record that can be tracked

and filed. A verbal comment can lose its impact in translation over time.

Written correspondence should include employee names and contact

information in the event additional information is required and/or to provide

feedback.

o Feedback is important, as the employees will provide suggestions

willingly if they know that they are being taken seriously and that

their input matters to top management. Provide frequent feedback to

the employee on the progress of the idea or suggestion. Be truthful: if

the idea or suggestion won‟t work, provide an explanation. They‟ll

appreciate being in the loop.

Employee generated concerns or suggestions should be shared with appropriate

technical departments.


CHAPTER 4: ACCIDENT

PREVENTION PROGRAM & ROOT

CAUSE ANALYSIS

Contents:

1. Accident Prevention Program

2. Safety Data Management

3. Root Cause Analysis


1. ACCIDENT PREVENTION PROGRAM

GENERAL

The accident prevention program is intended to minimize the accident threat to

employees, aircraft, and equipment. This program takes an integrated view of all

functions to provide people with a safe and productive environment for the

accomplishment of required tasks. It provides for the reporting of unsafe conditions

and practices that could result in personal injury or equipment damage. It requires the

thorough investigation and resolution of reported or observed conditions that are

considered to be a threat to personnel or property.

Accident prevention involves every facet of your company‟s operations and

management. Ground personnel should be observant of every phase of line

operations and, if they believe unsafe or emergency conditions could arise for which

there are no established procedures, they are encouraged to submit a hazard report.

The following list of responsibilities provide for rapid communication and resolution

of safety matters. The safety manager will:

Act as the focal point for all reports, audits, accident prevention matters, and

accident/incident reporting/investigation.

Coordinate directly with other departments to develop recommendations for

interdepartmental safety matters.

Investigate accidents and incidents involving flight and ground operations,

and develop recommendations to eliminate any identified hazards.

Act as liaison with outside agencies concerning accident prevention and

investigation.

Maintain an active safety training program and have all employees

participate in the SMS training.

Compile accident and incident data to determine trends requiring preventive

actions and provide feedback within flight and ground operations on accident

and incident investigations.

Conduct audits to determine accident potential involving flight and ground

operations personnel, procedures, and equipment and make appropriate

recommendations to top management.


2. SAFETY DATA MANAGEMENT

SAFETY DATABASE

All safety data collected by the safety manager should be entered into a company

database for tracking, analysis and trending.

3. ROOT CAUSE ANALYSIS

BENEFITS

Root Cause Analysis is utilized to eliminate the most basic reason for an undesirable

condition or problem. The root cause analysis process is useful because it helps in

getting to the real causal factors that lead to an adverse event or undesirable outcome,

and provides insight into how an organization can proactively minimize future risks.

Root cause analysis can:

Identify barriers and the causes of problems, so that permanent solutions can

be found.

Develop a logical, systematic approach to problem solving.

Assist in solving problems with data that already exists.

Identify organizational improvement opportunities.

Establish repeatable, step-by-step processes, in which one process can

confirm the results of another.

Root cause analysis focuses on systems and processes, not on people or individual

performance, because if a process is broken or needs improvement, then the problem

will recur again and again. Ultimately, root cause analysis is about prevention;

discovering the root causes of problems so that steps can be taken to prevent a

recurrence.

Root cause analysis is a valuable tool to evaluate causal factors after an undesirable

event. The information can be used to identify problematic areas and to be proactive

in preventing a recurrence. This approach enables you to prevent problems before

they occur.

A tutorial on root cause analysis can be accessed here. This can be used to

augment your local investigation and analysis.

http://www.nata.aero/data/files/sms/web/root%20cause%20tutorial%20april%202013.ppt


CHAPTER 5: SAFETY RISK

MANAGEMENT

Contents:

The Safety Risk Management Process


THE SAFETY RISK MANAGEMENT PROCESS

General

This section discusses the principles of safety risk management (SRM) and the SRM

process.

All incidents that could have resulted in an accident should be reported to determine

relevant factors and to implement preventive action.

SRM is a decision-making tool to systematically identify operational risks and

benefits, and determine the best courses of action for any given situation, e.g.,

performing a risk analysis before every flight. The risk management process is

designed to minimize risks in order to prevent accidents, preserve assets, and

safeguard the health and welfare of people.

Risk management, as discussed throughout this guide is proactive. We manage risk

whenever we modify the way we do something to make our chances of success as

great as possible, while minimizing the likelihood of failure, injury or loss. It‟s a

commonsense approach to balancing the risks against the benefits to be gained in a

situation, then choosing the most effective course of action.

Often, the approach to risk management is highly dependent on individual methods

and experience levels and is usually highly reactive. It‟s natural to focus on those

hazards that have caused problems in the past.

Risk is defined as the probability and severity of an accident or loss from exposure to

various hazards, including injury to people and loss of resources. All aviation

operations involve risk, and require decisions that include risk assessment and risk

management.

Safety Risk Management (SRM) is a formal way of thinking about these things. SRM

is a six-step process, which identifies operational hazards and takes reasonable

measures to reduce risk to personnel, equipment and the mission.

Risk management must be a fully integrated part of planning and executing any

operation, routinely applied by management, and not a way of reacting when some

unforeseen problem occurs. Careful determination of risks, along with analysis and

control of the hazards they create results in a plan of action that anticipates


difficulties that could arise under varying conditions, and pre-determines ways of

dealing with these difficulties. Managers are responsible for the routine use of risk

management at every level of activity, starting with the planning of that activity and

continuing through its completion.

Figure 5-1 (below) lists the objectives of the SRM process: protecting people,

equipment and other resources, while making the most effective use of them.

Preventing accidents, and in turn reducing losses, is an important aspect of meeting

this objective. In turn, by minimizing the risk of injury and loss, we ultimately reduce

costs and stay on schedule. Thus, the fundamental goal of risk management is to

enhance the effectiveness of people and equipment by determining how they are most

efficiently to be used.

Figure 5-1. Objectives of the SRM process include protecting people, equipment and

other resources, while making the most effective use of them.

SRM Principles

Four principles govern all actions associated with safety risk management. These

continuously employed principles are applicable before, during and after all tasks and

operations, by individuals at all levels of responsibility.


1. Accept No Unnecessary Risk

Unnecessary risk is that which carries no commensurate return in terms of benefits or

opportunities. Everything involves risk. The most logical choices for accomplishing

an operation are those that meet all requirements with the minimum acceptable risk.

The corollary to this is “accept necessary risk,” required to successfully complete the

operation or task.

2. Make Risk Decisions at the Appropriate Level

Anyone can make a risk decision. However, the appropriate decision-maker is the

person who can allocate the resources to reduce or eliminate the risk and implement

controls. The decision-maker must be authorized to accept levels of risk typical of the

planned operation (i.e., loss of operational effectiveness, normal wear and tear on

material). Decisions should be elevated to the next level in the management chain

when the available controls will not reduce risk to an acceptable level.

3. Accept Risk When Benefits Outweigh the Costs

All identified benefits should be compared against all identified costs. Even high-risk

endeavors may be undertaken when there is clear knowledge that the sum of the

benefits exceeds the sum of the costs. Balancing costs and benefits is a subjective

process, and ultimately the balance may have to be arbitrarily determined by the

appropriate decision-maker.

4. Integrate SRM into Planning at all Levels

Risks are more easily assessed and managed in the planning stages of an operation.

The later changes are made in the process of planning and executing an operation, the

more expensive and time-consuming they will become.

When applying the SRM process, risk management is a proactive activity that

quantitatively assesses identified hazards and assists in selecting actions to maintain

an appropriate level of safety when faced with these hazards.

Six Steps for SRM

Step 1: Identify the Hazard

A hazard is defined as any real or potential condition that can cause injury, illness, or

death; damage to or loss of a system, equipment or property; or damage to the

environment. Experience, common sense, and specific analytical tools help identify

risks. (A sample risk management workshop can be accessed by clicking here.)

Step 2: Assess the Risk

http://www.nata.aero/data/files/sms/web/risk%20management%20worksheet.doc


The assessment step is the application of quantitative and qualitative measures to

determine the level of risk associated with specific hazards. This process defines the

probability and severity of an accident that could result from the hazards based upon

the exposure of humans or assets to the hazards.

Step 3: Analyze Risk Control Measures

Investigate specific strategies and tools that reduce, mitigate, or eliminate the risk.

All risks have three components: probability of occurrence, severity of the hazard,

and the exposure of people and equipment to the risk. Effective control measures

reduce or eliminate at least one of these. The analysis must take into account the

overall costs and benefits of remedial actions, providing alternative choices if

possible.

Step 4: Make Control Decisions

Identify the appropriate decision-maker. That decision-maker must choose the best

control or combination of controls, based on the analysis of step 3.

Step 5: Implement Risk Controls

Management must formulate a plan for applying the controls that have been selected,

then provide the time, materials and personnel needed to put these measures in place.

Step 6: Supervise and Review

Once controls are in place, the process must be periodically reevaluated to ensure

their effectiveness. Workers and managers at every level must fulfill their respective

roles to assure that the controls are maintained over time. The risk management

process continues throughout the life cycle of the system, mission or activity.

Implementing the SRM Process

To derive maximum benefit from this process, it must be used properly. The

following principles are essential.

Apply the steps in sequence

Each step is a building block for the next, and must be completed before proceeding

to the next. If a hazard identification step is interrupted to focus upon the control of a


particular hazard, other, more important hazards may be overlooked. Until all hazards

are identified, the remainder of the process is not effective.

Maintain a balance in the process

All six steps are important. Allocate the time and resources to perform them all.

Apply the process in a cycle

The “supervise and review” step should include a fresh look at the operation being

analyzed, to see whether new hazards can be identified.

Involve people in the process

Ensure that the risk controls are mission supportive, and that the people who do the

work see them as positive actions. The people who are actually exposed to risks

usually know best what works and what does not.

Risk versus Benefit

Risk management is the logical process of weighing the potential costs of risks

against the possible benefits of allowing those risks to stand uncontrolled.

Types of Risk Defined

Identified risk: That risk that has been determined to exist using analytical tools. The

time and costs of analysis efforts, the quality of the risk management program, and

the state of the technology involved affect the amount of risk that can be identified.

Unidentified risk: That risk that has not yet been identified. Some risk is not

identifiable or measurable, but is no less important for that. Mishap investigations

may reveal some previously unidentified risks.

Total risk: The sum of identified and unidentified risk. Ideally, identified risk will

comprise the larger proportion of the two.

Acceptable risk: The part of identified risk that is allowed to persist after controls are

applied. Risk can be determined acceptable when further efforts to reduce it would

cause degradation of the probability of success of the operation, or when a point of

diminishing returns has been reached.


Unacceptable risk: That portion of identified risk that cannot be tolerated, but must

be either eliminated or controlled.

Residual risk: The portion of total risk that remains after management efforts have

been employed. Residual risk comprises acceptable risk and unidentified risk.

Risk Identification

Once hazards have been identified, either through occurrence/hazard reporting, or a

safety assessment, the risk management process begins. Risk management is a

quantitative evaluation of the potential for injury or loss due to a hazard and the

management of that probability. This concept includes both the probability of a loss

and its severity. The basic elements of a risk management process are:

Risk Analysis

Risk Assessment

Risk Control

Monitoring

Risk Analysis is the first element in the risk management process. It includes risk

identification and risk estimation. Once a hazard has been identified the risks

associated with the hazard must be determined and the amount of risk estimated.

Risk Assessment takes the work completed during the risk analysis and goes one step

further by conducting a risk evaluation. Here, the probability and severity of the

hazard are assessed to determine the approximate level of risk. The risk assessment

matrix (Figure 5-2) provides a method to determine the level of risk.


To use the risk assessment matrix effectively, everyone must have the same

understanding of the terminology used for probability and severity.

The safety manager should define when intervention is required. The company must

decide on an acceptable level of risk.

Figure 5-2. Risk assessment matrix.

Figure 5-3 (below) lists the definitions for the likelihood scale and Figure 5-4 (next

page) lists the definitions listed in severity scale used in the risk matrix.

Figure 5-3. Likelihood scale.

SEVERITY LIKELIHOOD

Catastrophic A

Hazardous B

Major C

Minor D

Negligible E

Frequent 5

5A 5B 5C 5D 5E

Occasional 4

4A 4B 4C 4D 4E

Remote 3

3A 3B 3C 3D 3E

Improbable 2

2A 2B 2C 2D 2E

Extremely Improbable

1 1A 1B 1C 1D 1E

Likelihood Scale Definitions

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

Probable 4 Likely to occur some times (has occurred infrequently).

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

Remote 2 Very unlikely to occur (not known to have occurred).

Extremely Improbable 1 Almost inconceivable that the event will occur.

Severity Scale Definitions


Figure 5-4. Severity scale.

Risk Control addresses any risks identified during the evaluation process that require

an action to be taken to reduce the risks to an acceptable level. This is the phase

where corrective action plan is developed.

Monitoring is essential to ensure that once the corrective action plan is in place, it is

effective in managing the risk(s) as desired. Monitoring also enables your Company

to adapt itself to changing environmental or operational conditions, equipment needs

or personnel changes.

The corrective action plan (CAP) that corresponds to an identified risk should be in

written form, identified by a number corresponding to the department, sequential

CAP for that area and current calendar year (i.e. FLT-001/2004 or GND-001/2004)

and maintained in a file (either electronic or hard copy). All of the CAPs should be

recorded on a spreadsheet by year and maintained by the safety manager.

In this way, the safety manager can monitor each CAP and its disposition, i.e.,

“completed” or “in progress.” When the safety manager or quality assurance manager

performs an internal audit on that department, they can check to see that the CAP is

in effect. If conditions have changed, rendering the original CAP ineffective, this

Catastrophic: A Multiple fatalities.

Equipment destroyed.

Hazardous: B

A large reduction in safety margins, physical distress or a workload such that the operators cannot be relied upon to perform their tasks accurately or completely.

Serious injury.

Major equipment damage.

Major: C

A significant reduction in safety margins, a reduction in the ability of the operator to cope with adverse operating conditions as a result of increase in workload, or as a result of conditions impairing their efficiency.

Serious Incident.

Injury to persons.

Minor: D

Nuisance.

Operating limitations.

Use of emergency procedures.

Minor incident.

Negligible: E

Little consequences.


would be a good time to address the change by issuing a new CAP and starting the

process all over – that is recording the new CAP and providing oversight of the

implementation and future conformance to it. Module 7, “Safety Assurance,” has

additional information on how to proactively monitor CAPs.

Acceptability of Risk

Risk management requires a clear understanding of what constitutes acceptable risk,

i.e., when benefits outweigh costs. Accepting risk is a function of both risk

assessment and risk management, and is not as simple as it may first appear. Several

principles apply:

Some degree of risk is a fundamental reality

Risk management is a process of tradeoffs

Quantifying risk does not in itself ensure safety

Risk is often a matter of perspective

Realistically, some risk must be accepted. How much is accepted, or not

accepted, is the prerogative of the defined decision authority. That decision is

affected by many inputs. As tradeoffs are considered and operation-planning

progresses, it may become evident that some of the safety parameters are

forcing higher risk to successful operation completion. When a manager

decides to accept risk, the decision should be coordinated whenever practical

with the affected personnel and organizations, and then documented so that

in the future everyone will know and understand the elements of the decision

and why it was made.


CHAPTER 6: HUMAN FACTORS

Contents:

1. Human Factors – Overview

2. Safety Culture


1. HUMAN FACTORS - OVERVIEW

Introduction

General

Managing risk to an acceptable level is your company‟s main objective. A

major contributor to achieving that objective is a better understanding of

human factors and the broad application of its knowledge. Increasing

awareness of human factors in aviation will result in a safer and more

efficient working environment.

Through maximizing utilization of information and information technology,

Your company will use its best efforts to incorporate human factors practices

into all operational departments and technical programs.

The purpose of this chapter is to introduce this subject and to provide

guidelines for improving human performance through a better understanding

of the factors affecting it through the application of Crew Resource

Management (CRM) concepts in normal and emergency situations and

through understanding of the accident causation model.

The Meaning of Human Factors

Human Error

The human element is the most complex, flexible, adaptable and valuable

part of the aviation system. But it is also the most vulnerable to influence,

which can adversely affect its performance.

Lapses in human performance are continually cited as causal factors in the

majority of incidents/accidents, which are commonly attributed to “human

error.”

Human Factors have been progressively developed to enhance the safety of

complex systems, such as aviation, by promoting the understanding of

human limitations and its applications in order to properly manage the

“human error.” It is only when seeing such an error from an aviation

viewpoint that we can identify the causes that lead to it and address those

causes.


What is Human Factors?

It studies people working together in concert with machines

It aims at achieving safety and efficiency by optimizing the role of people

whose activities relate to complex hazardous systems such as aviation

A discipline devoted to optimizing human performance and reducing human

error

It incorporates the methods and principles of the behavioral and social

sciences, physiology and engineering

The Aim of Human Factors in Aviation

General

We operate within the context of broad social, political, economic and

natural constraints that are usually beyond the control of both the

organization and its staff, yet we have to interact within these aspects of the

external environment. The external environment, the human/machine

interface, together with operational pressures can significantly affect human

performance.

Manufacturers study the interface between the machine and the human when

designing a new machine and its physical components. Seats are designed to

fit the sitting characteristics of the human body, controls are designed with

proper movement, instrumentation is designed to match human

characteristics, etc.

But even if the human/machine interface is not properly matched, humans

can adapt to it in short order and will mask any mismatch, without actually

removing it, thereby constituting a potential hazard. It‟s now common

practice for manufacturers to encourage airlines and professional

organizations to participate in the design phase of aircraft in order to address

such issues.

What is also important is the human/human interface, which represents the

interaction between us as humans. Adding proficient and effective

individuals together to form a group or a set of views does not automatically

ensure that the group will function in a proficient and effective way unless

they can function as a team. For them to successfully do so we need

leadership, good communication, crew-co-operation, teamwork and


personality interactions. Crew Resource Management (CRM) and Line

Oriented Flight Training (LOFT) are two examples of accomplishing this

goal.

Corporate climate and company operating pressures can significantly affect

human performance. The advanced stage of CRM is when it becomes

Corporate or Company Resource Management, with staff/management

relationships providing the necessary leadership, interactions and teamwork.

The objective of human factors in aviation is to increase awareness of the

human element within the complex aviation system.

Safety and Efficiency

General

Safety and efficiency are so closely interrelated that in many cases their

influences overlap and factors affecting one may also affect the other.

Human factors have a direct impact on those two broad areas.

Safety is affected by the human/machine interface. Should a change affect

this interface the result could be catastrophic.

a. Safety is also affected by the quality of information. Incorrect

information set in the database and unnoticed by the crew or erroneously

entered by them can result in a tragedy.

b. Human interaction also plays a major role in safety. Failure to

communicate vital information can result in aircraft and life loss.

c. Safety is affected by the outside environment. Disgruntled individuals or

groups can give vent to their grievances, which could lead to a tragedy in

the workplace.

Efficiency is also directly influenced by human factors, and in turn has a

direct bearing on safety.

a. For instance, motivation constitutes a major boost for individuals to

perform with greater effectiveness, which will contribute to a safer

operation.

b. Properly trained and supervised crewmembers working in accordance to

SOP‟s are likely to perform more efficiently and safely.


c. Cabin crew understanding of passenger behavior and the emotions they

can expect onboard is important in establishing a good relationship that

will not only improve the efficiency of service, but will also contribute to

the efficient and safe handling of emergency situations.

d. The proper layouts of displays and controls in the cockpit enhance flight

crew efficiency while promoting safety.

Factors Affecting Workplace Performance

General

Although the human element is the most adaptable component of the aviation

system, that component is influenced by many factors that will affect human

performance, such as fatigue, circadian rhythm disturbance, sleep

deprivation, health and stress. These factors are affected by environmental

constraints like temperature, noise, humidity, light, vibration, working hours

and load.

Fatigue

Fatigue may be physiological whenever it reflects inadequate rest, as well as

a collection of symptoms associated with disturbed or displaced biological

rhythms. It may also be psychological as a result of emotional stress, even

when adequate physical rest is taken.

a. Acute fatigue is induced by long duty periods or an accumulation of

particularly demanding tasks performed in a short period of time.

b. Chronic fatigue is the result of cumulative effects of fatigue over the

longer term. Temperature, humidity, noise, workstation design and

Hypoxia are all contributing factors to fatigue.

Circadian Rhythm Disturbance

Human body systems are regulated on a 24-hour basis by what is known as

the circadian rhythm. This cycle is maintained by several factors: day and

night, meals, social activities, etc. When this cycle is disturbed, it can

negatively affect safety and efficiency.

Circadian rhythm disturbance is not only expressed as jet lag resulting from

long-haul flights where many time zones are crossed, but can also result from

irregular or night scheduled short-haul flights.

Symptoms of circadian disturbance include sleep deprivation, disruption of

eating and elimination habits, lassitude, anxiety and irritability. This leads to


slowed reaction, longer decision making times, inaccuracy of memory and

errors in computation, which will directly affect operational performance and

safety.

Sleep Deprivation

The most common symptom of circadian disturbance is sleep deprivation.

Tolerance to sleep disturbance varies between individuals and is mainly

related to body chemistry and emotional stress factors. In some cases sleep

disturbance can involve cases of overall sleep deprivation. In all cases,

reduced sleep will result in fatigue.

Some people have difficulty sleeping even when living in normal conditions

and in phase with the circadian rhythm. Their case is called Clinical

Insomnia. They should consult a medical doctor and refrain from using

drugs, tranquillizers or alcohol to induce sleep, as they all have side effects

that will negatively affect their performance and therefore the safety of

flights.

To overcome problems of sleep disturbance one should adapt a diet close to

meal times, learn relaxation techniques, optimise the sleeping environment,

recognize the adverse effects of drugs and alcohol and be familiar with the

disturbing effects of circadian disturbance, to regulate sleep accordingly.

Health

Certain pathological conditions (heart attacks, gastrointestinal disorders, etc.)

have caused sudden incapacitation and in rare cases have contributed to

accidents. But such incapacitation is usually easily detectable by other co-

workers and taken care of by applying the proper procedures.

The more dangerous type is developed when a reduction in capacity results

in a partial or subtle incapacitation. Such incapacitation may go undetected,

even by the person affected, and is usually produced by fatigue, stress, the

use of some drugs and medicines and certain mild pathological conditions

such as hypoglycemia. As a result of such health conditions, human

performance deteriorates in a manner that is difficult to detect and therefore,

has a direct impact on safety.

Even though aircrew are subject to regular medical examinations to ensure

their continuing health, that does not relieve them from the responsibility to

take all necessary precautions to maintain their physical fitness. Fitness has

favorable effects on emotions, reduces tension and anxiety and increases

resistance to fatigue. Factors known to positively influence fitness are

exercise, healthy diet and good sleep/rest management. Tobacco, alcohol,


drugs, stress, fatigue and unbalanced diet are all recognized to have

damaging effects on health. Finally, it is each individual‟s responsibility to

arrive at the workplace “fit to fly”.

Stress

Stress can be found in many jobs, and the aviation environment is

particularly rich in potential stress generating situations. Some of these

stresses have been with aviation since the early days of flying, such as

weather phenomena or in-flight emergencies. Others like noise, vibration and

G-forces have been reduced with the advent of the jet age while disturbed

circadian rhythms and irregular night flying have increased.

Stress is also associated with life events, which are independent from the

aviation system, but tightly related to the human element. Such events could

be sad ones like a family separation, or happy ones like weddings or

childbirth. In all situations, individual responses to stress may differ from one

person to another, and any resulting damage should be attributed to the

response rather than the stress itself.

Individuals are encouraged to anticipate, recognize and cope with their own

stress and perceive and accommodate stress in others, thus managing stress

to a safe end. Failure to do so will only aggravate the stressful situation and

might lead to problems.

Personality vs. Attitude

General

Personality traits and attitudes influence the way we behave and interact with

others. Personality traits are inborn or acquired at a very young age. They are

deep-rooted, stable and resistant to change. They define a person and classify

him/her (e.g. ambitious, dominant, aggressive, mean, nice, etc.).

On the contrary, attitudes are learned and form tendencies or pre-dispositions

to respond in a certain way. The response is the behavior itself. Attitudes are

more susceptible to change through training, awareness or persuasion.

Our current initial screening and selection process of aircrew and other staff

aims at detecting undesired personality characteristics in the potential

crewmember or staff member in order to avoid problems in the future.

Human factors training aims at modifying attitudes and behavior patterns

through knowledge, persuasion and illustration, revealing the impact of

attitudes and behavior on safety.


Crew Resource Management (CRM) and Maintenance Resource Management (MRM)

General

CRM and MRM are the practical application of human factors. Both teach

flight crew and maintenance technicians how to use their interpersonal and

leadership styles in ways that foster effectiveness by focusing on the

functioning of members as a team, not only as a collection of technically

competent individuals, i.e. it aims at making people work together.

Changes in aviation have been drastic throughout this century: the jet age,

airplane size, sophisticated technology, security threats, industrial strikes and

supersonic flights. In every one of those changes some people perceived a

threat, which made them anxious, even angry.

a. When first introducing CRM/MRM, some might see a threat, since it

constitutes a change. However, the majority of accidents involve

lapses in human performance as a contributing factor, so the

application of these techniques should be seen as a proactive

approach.

CRM/MRM can be introduced in many different ways. The following

essential features must be addressed: The concept must be understood,

certain skills must be taught and inter-active group exercises must be

accomplished.

To understand the concept one must be aware of the effects of individual

behavior on team work, the effect of complacency on team efforts, the

identification and use of all available resources, the statutory and regulatory

position of the pilot-in-command as team leader and Captain, the impact of

company culture and policies on the individual and the interpersonal

relationships and their effect on team work.

Skills to be Developed

Skills to be developed include:

a. Communication skills

(1) Effective communication is the basis of successful teamwork.

Barriers to communication are explained, such as cultural difference,

rank, age, crew position, and wrong attitude. Aircrews are

encouraged to overcome such barriers through self-esteem,

participation, polite assertiveness, legitimate avenue of dissent and

proper feedback.


b. Situational Awareness

(1) Total awareness of the surrounding environment is emphasized, so is

the necessity for crewmembers to differentiate between reality and

perception of reality, to control distraction, enhance monitoring and

cross-checking and to recognize and deal with one‟s own or

another‟s incapacitation, especially when it can be partial or subtle.

c. Problem Solving and Decision Making

(1) This skill aims at developing conflict management within a time

constraint. A conflict could be immediate or ongoing; it could

require a direct response or certain tact to cope with it. By

developing judgment within a certain time frame, we develop skills

required to bring conflicts to safe ends.

d. Leadership

(1) In order for a team to function efficiently it requires a leader.

Leadership skills derive from authority but depend for their success

on the understanding of many components such as:

(a) managerial and supervisory skills that can be taught and

practiced.

(b) realizing the influence of culture on individuals,

(c) maintaining an appropriate distance between team members

enough to avoid complacency without creating barriers,

(d) care for one's professional skill and credibility

(e) the ability to hold the responsibility of all team members and the

necessity of setting the good example.

e. The improvement of these skills will allow the team to function more

efficiently by developing the leadership skills required to achieve

successful and smooth teamwork.

f. Stress Management

(1) Commercial pressure, mental and physical fitness to fly, fatigue,

social constraints and environmental constraints are all part of our

daily life and they all contribute in various degrees to stress. Stress

management is about recognizing those elements, dealing with one's

stress and helping others to manage their own. It is only by accepting

things that are beyond our control, changing things that we can and

knowing the difference between both that we can safely and

efficiently manage stress.

g. Critique


(1) Discussion of cases and learning to comment and critique actions are

both ways to improve one's knowledge, skills and understanding.

Review of accidents and incidents to create problem-solving

dilemmas that we can act-out and critique through the use of feed-

back system will enhance team-members awareness of their

surrounding environment, make them recognize and deal with

similar problems and help them solve situations that might occur to

them.

h. For CRM/MRM to be successful it must be embedded within a total

training program, it must be continuously reinforced and it must become

an inseparable part of company culture.

2. SAFETY CULTURE

Your organization's culture is defined by what your employees do. Employee

decisions reveal a great deal about the values of your organization. The way your

managers and employees react to safety speaks more loudly than words about what

values motivate their actions. Safety culture is, "How you do things at your

organization.”

A safety culture requires effort on everyone‟s part. The good news is with senior

management leadership, it can be accomplished.

Safety culture is:

An informed culture o Employees understand the hazards and risks involved in your

operation

o Employees work continuously to identify and overcome threats to

safety

A just culture o Errors must be understood but willful violations cannot be tolerated

o Employees know and agree on what is acceptable and unacceptable

A reporting culture o Employees are encouraged to voice safety concerns

o Safety concerns are reported, analyzed and appropriate action is

taken

A learning culture o Employees are encouraged to develop and apply their own skills and

knowledge to enhance organizational safety

o Employees are updated on safety issues by management

o Safety reports are communicated to all employees so that everyone

learns the lessons

Organizational safety, from the worst to the best:

Pathological: The organization cares less about safety than about not being

caught.


Reactive: The organization looks for fixes to accidents and incidents only

after they happen.

Calculative: The organization has systems in place to manage hazards,

however the system is applied mechanically. Employees and management

follow the procedures but do not necessarily believe those procedures are

critically important to their jobs or the operation.

Proactive: The organization has systems in place to manage hazards.

Employees and management have begun to acquire beliefs that safety is

genuinely worthwhile.

Generative: Safety behavior is fully integrated into everything the

organization does. The value system associated with safety and safe working

is fully internalized, almost to the point of invisibility.

Arriving at the generative stage of this evolutionary process is the ultimate goal.


CHAPTER 7: SAFETY ASSURANCE

Contents:

1. Safety Oversight

1. Safety Assurance Process

2. Safety Program – Internal Review

3. External Audit Procedures

4. Environmental Compliance


1. SAFETY OVERSIGHT

Safety oversight is fundamental to your company‟s safety management processes. A

principal view of safety management policies and procedures requires your

organization to critically review its existing operations, and any proposed operational

changes for their safety significance. This is achieved through two principal means:

1. Reactive – Event/Hazard Reporting, and

2. Proactive – Safety Assessments, Audits, Quality Assurance

The reactive and proactive processes in safety oversight provide quantitative safety

information that is useful for minimizing and managing risk. The basic difference

between the two processes is the method of discovery. The reactive process responds

to events that have already occurred, while the proactive method actively seeks to

identify potential hazards through an analysis of everyday activities. The exception to

this rule occurs when a potential hazard has been reported through the company‟s

safety reporting program.

The diagram below shows the traditional SMS process flow:

Initial Risk Assessment

Further Investigation

Second Risk Assessment

Determine Root Cause

Determine and Implement

Corrective Action

Monitor Corrective Action

Confirmation of Corrective

Action – Quality Assurance

System Evaluation

No Action

No Action

No Action

System Evaluation

Data

base

(Reactive) Reports

Hazards

Incidents

Accidents

Database

Risk Analysis

(Pro-active Safety

Assessment)

Audits

Policy and

Procedures

Assessment

Hazard

Identification

Information

Assessment

Trend

Analysis

Safety

Bulletins

Accidents

Report

Distribution

Initial Risk Assessment

Further Investigation

Second Risk Assessment

Determine Root Cause

Determine and Implement

Corrective Action

Monitor Corrective Action

Confirmation of Corrective

Action – Quality Assurance

System Evaluation

No ActionNo Action

No ActionNo Action

No ActionNo Action

System Evaluation

Data

base

(Reactive) Reports

Hazards

Incidents

Accidents

Database

Risk Analysis

(Pro-active Safety

Assessment)

Audits

Policy and

Procedures

Assessment

Hazard

Identification

Information

Assessment

Trend

Analysis

Safety

Bulletins

Accidents

Report

Distribution


Reactive Process

Occurrence and Hazard Reporting

Senior management considers every event as an opportunity to learn valuable safety

lessons. As such, all occurrences shall be analyzed so that all employees, including

management, understand not only what happened, but also why it happened. The

internal reporting and recording of occurrences, hazards, and other safety related

issues will help accomplish this. The internal reporting system will always be co-

joined with the non-punitive discipline policy.

Every event will be investigated. The extent of the investigation will depend on the

actual and potential consequences of the occurrence or hazard. This will be

accomplished through a formal risk assessment. (See Chapter 5, Safety Risk

Management.)

The investigative process will be comprehensive and will attempt to address the root

causal factor(s) that contributed to the event, rather than simply focusing on the event

itself.

Proactive Safety Assessment

For an SMS to transition from a reactive to a proactive system, it must actively seek

out potential safety hazards and evaluate the associated risks. The Safety Manager

shall accomplish this process through periodic safety assessments, audits and through

its quality assurance program (if applicable). A safety assessment will allow the

Safety Manager to identify potential hazards and then apply Safety Risk Management

(SRM) techniques to effectively manage the hazard.

Your Company‟s safety assessments shall contain the following elements:

Systems for identification of potential hazards

Safety Risk Management (SRM) techniques

Continual monitoring/quality assurance

The Safety Manager shall conduct a safety assessment at a minimum:

During implementation of the SMS and then at regular intervals

When major operational changes are planned


If the company is undergoing rapid change, such as growth and expansion,

offering new services, reducing existing service, or introducing new

equipment or procedures

When key personnel change or leave their positions

2. SAFETY ASSURANCE PROCESS

A quality management system defines and establishes your company‟s quality policy

and objectives. It also allows the company to document and implement the

procedures needed to attain these goals. A properly implemented quality assurance

program ensures that procedures are carried out consistently, that problems can be

identified and resolved, and that the Safety Manager can continuously review and

improve quality assurance procedures and services. It‟s a mechanism for maintaining

and improving the quality of processes, procedures, and services in order to

consistently meet or exceed the organization‟s implied or stated needs and fulfills its

quality objectives.

In SMS, these elements are applied to an understanding of the human and

organizational issues that can impact safety. In the same way that a quality assurance

program measures quality and monitors compliance, the same methods are used to

measure safety within the organization. In the SMS context, this means quality

assurance of the overall safety program and its components, which includes the entire

operation.

The company‟s quality assurance program shall encompass the following elements:

1. Well-designed and documented procedures for service and process control.

2. Inspection and testing methods.

3. Monitoring of equipment including calibration and measurement.

4. Internal (self-audits as required by this program) and external audits (third-

party audits).

5. Monitoring of corrective and preventive action(s).

6. The use of appropriate statistical analysis, when required.

Quality assurance is based on the principal of the continuous improvement cycle. In

much the same way that SMS facilitates continuous improvements in safety, quality

assurance ensures process control and regulatory compliance through constant


verification and upgrading of the system. These objectives are achieved through the

application of similar tools i.e., internal and external audits, strict document control,

and on-going monitoring of corrective action.

Safety Assessment

To ensure that your company‟s SMS is working as effectively as possible, the Safety

Manager will conduct or over see proactive safety assessments of its operations.

The Safety Assessment includes the following principles:

A continual process incorporating the techniques of inspections, audits, and

evaluations to assess managerial controls in key programs and systems.

A review that extends beyond regulatory compliance to determine

deficiencies and detect needed improvements to company operating practices

before deficiencies occur.

An ongoing function that identifies deficiencies, develops corrective actions,

and performs follow-up evaluations.

An independent function that has straight-line reporting responsibility to

senior management.

The Safety Assessment, in conjunction with the ongoing evaluations performed by

each technical department and the involvement of all company employees, will be

comprised of these core components:

ONGOING EVALUATIONS

The continual, day-to-day reviews and audits performed by flight, ground and

maintenance operations. The responsibility for ongoing evaluations resides with each

technical department. The Safety Manager will verify through comprehensive

evaluations that ongoing evaluations are meeting their objectives and that they

receive the support and attention of senior management.

OBJECTIVE EVIDENCE

Objective evidence is a documented statement of fact that may be quantitative or

qualitative and is based on verifiable observations, tests or interviews. Objective

evidence is necessary to substantiate findings.


SPECIAL EVALUATIONS

Generally unannounced reviews performed by the Safety Department target specific

areas within flight and ground operations. The basis for conducting a special

evaluation could be any of the following conditions:

Senior management priorities

Trends identified by employees

Industry identified trends

Spot inspections

Regulatory concerns

3. SAFETY PROGRAM INTERNAL REVIEW

The Safety Manager will develop and maintain “self inspection” checklists

based on current guidance and regulations and add them to the Safety

Assessment. The purpose of the self inspection checklist is to ensure

compliance with regulations governing safety programs and to ensure the

safety program maintains the highest level of standards.

Upon receipt of information pertaining to the safety program, the Safety

Manager will make the required changes to the safety program and the

applicable self inspection checklists.

The Safety Manager will make sure the self inspection checklists are

reviewed semi-annually to ensure the safety program policies and procedures

are being followed.

At a minimum of six-month intervals, the Safety Manager will review the

safety program with senior management. Senior management will be

provided a copy of the safety program and results of the completed self

inspection checklists.

OBJECTIVES AND POLICIES STRATEGIES

The Safety Assessment Program is tasked to fulfill the following strategic objectives:

Verify that technical departments are tailored to current operations and future


plans.

Determine whether technical departments have adequate resources for

current operations.

Evaluate the effectiveness of ongoing audit structures within flight,

maintenance and ground operations.

Ensure that technical issues receive the attention and support of executive

management.

4. EXTERNAL AUDIT PROCEDURES

PREPARATION

Good preparation is essential to effective auditing. The Safety Manager is responsible

for ensuring that previous findings, relevant regulations, and policies and procedures

are thoroughly reviewed before each audit. In addition, the Safety Manager must

have access to, and review any manuals, policies, regulations or records before and

during an audit to ensure departments are performing as required by the written

guidance.

CHECKLISTS

Standardized audit checklists are to be maintained by the Safety Manager and shall

be available to assist in providing standardization and ensuring complete coverage of

the audit scope. However, these checklists are not exhaustive for all situations and

should be supplemented with questions and issues specific to the audit areas.

CONDUCTING THE AUDIT

When possible, each scheduled audit should begin with an opening meeting.

The purpose and goal of the meeting is to ensure the person responsible for

the area being audited understands the reason for the audit, how the audit will

be conducted, and what will be accomplished at the completion of the audit.

When auditing, the Safety Manager must base their assessment objective

evidence of conformance or non-conformance to documented regulatory or

company requirements.

NOTE: Objective evidence is found through the review of records, interviews of

personnel, and observations of work in progress.

When possible, a closing meeting should be held with the department head to

ensure the responsible person completely understands any and all non-


conformance issues discovered during the audit process. Areas that exceed

your company requirements should also be discussed.

Any findings that represent a critical failure of the facilities, system or

function should be corrected on the spot. The Safety Manager, noting

whether or not they were corrected immediately, shall document on-the-spot

corrections.

Internal Evaluations with disputes arising and not resolved during the closing

meeting will be arbitrated and decided by top management.

AUDIT FOLLOW-UP

Audit follow-up is usually assigned 15 days from the time the audit is entered into the

database with the issues to be addressed. This can be accomplished either by a

corrective action, or by a corrective action plan with a timeline identifying when the

issue will be corrected. Depending on the nature of the problem, more time can be

allotted. If a corrective action plan is provided, and the issues are not time critical, the

safety manager should change the follow-up date to reflect the completion date on the

corrective action plan.

The Safety Manager will review the audit database monthly to ensure all

audits have been accomplished and close-out actions are acceptable.

The Safety Manager is usually responsible for accomplishing the audit

follow-up and reviewing the audit program database to ensure no responses

become overdue. However, this responsibility can be delegated based on

operational needs. Once acceptable corrective actions for all audit findings

have been received, the Safety Manager will close out the audit.

When conducting follow-up activities, the Safety Manager must verify that

an effective corrective action has been implemented. It may not be practical

to accomplish onsite follow-up. The Safety Manager will determine which

audits require an onsite follow-up, based on the severity of the findings and

recommendation of the auditor.

The Safety Manager will act upon requests for extensions for corrective

action. If the Safety Manager believes an extension should be granted, an

annotation can be made and the audit database updated. If corrective actions

are not progressing satisfactorily, the Safety Manager will involve top

management as appropriate.


AUDITOR TRAINING

RECORDS

A training file should be maintained to document that the Safety Manager has

received training in quality auditing, evaluation and management practices. Records

should include the date of training, type of course and a certificate of completion.

TRAINING AREAS

Training could come from any of the following areas:

College courses

Home study course materials

Industry sponsored seminars and workshops

Locally developed training programs

More information can be accessed at:

The American Society for Quality (ASQ): http://www.asq.org

AUDIT RECORDS

The Safety Manager shall maintain copies of all audit records used in the evaluation

within its company database in accordance with the company document retention

policy.

AUDIT REPORTING PROCEDURES

PURPOSE

The Safety Assessment is designed to encourage an open sharing of information at all

levels within the company. The Safety Assessment has been created to ensure that

management is directly informed about technical trends, concerns and issues.

Additionally, the Safety Manager has implemented reporting procedures to facilitate

the timely sharing and resolution of concerns before serious problems develop.

Through the reporting procedures outlined below, all managers, supervisors, and

employees should be aware of the latest company developments, changes and plans.

http://www.asq.org/


BRIEFINGS WITH MANAGEMENT

The Safety Manager will brief senior management on an as needed basis (a six-month

interval is recommended as a minimum) on pertinent Safety Assessment issues, such

as:

The results of comprehensive evaluations.

Trends identified through ongoing evaluations or the employee-management

internal communication program.

The status of follow-up actions taken in response to evaluation findings.

The status of the scheduled/completed accomplishment of the schedule.

Management may schedule briefings with the Safety Manager to review evaluation

results or to mandate a special evaluation of a particular area.

5. ENVIRONMENTAL COMPLIANCE

GENERAL

It should be the policy of your company to conduct all business activities in

accordance with applicable federal, state, and local environmental regulations,

standards, and policies. The following guidelines serve to express your company‟s

commitment to environmental compliance.

Prevent the release of pollutants to the environment.

Promptly and completely clean up pollutants that have been released into the

environment.

Advise appropriate corporate officials and appropriate regulatory authorities

of actual intended or unintended release of pollutants, violation of discharge

limits, or other prohibitions.

Reduce the quantities, prevent the release, and minimize the hazardous

characteristics of waste material that is generated.

Ensure that products are designed, formulated, packaged, or used so that they

do not present unreasonable risks to human health or the environment.

Protect resources, species, and ecological amenities.

Minimize the risks inherent in the transportation of hazardous material and

wastes, oil, or other potentially harmful substances.


CHAPTER 8: EMERGENCY

PREPAREDNESS

Contents:




Policies

Other Organizations & Individuals



1. EMERGENCY PREPAREDNESS

General

Your company‟s emergency response plan should be an integral part of the SMS.

This section discusses the planning process to develop an Emergency Response Plan

(ERP) Manual, and is intended to assist in reviewing, updating or creating an

emergency plan that focuses on the possibility of an accident, incident, or other

serious event. The following issues should be addressed in the ERP planning

process.


The company must have an ERP, not only for response to the accident, but

for the continued viability and operation of the business despite the accident.

o Checklists must be developed and used. They provide a touchstone

in the chaos and ensure nothing gets overlooked or lost.

The ERP must be exercised on a regular basis to:

o Ensure your people understand their roles and responsibilities.

o Discover resources needed to implement the ERP.

o Discover and correct deficiencies in the ERP.

o Train new people.

How do you prepare the entire company?

o Employee morale (grief, job security fears, etc.)

o Family assistance for employees, customers and others involved in

the actual accident/incident.

What physical resources must be replaced and how quickly?

o Insurance company assistance

o Farming out business impacted by loss of resources (i.e., aircraft)

Who will mind the store?

o The company must identify backup staff to fulfill the duties of those

staff members who will participate in the investigation.



Senior Management must recognize that an accident can happen.

Senior Management must commit to the ERP and support its staffing,

training and drills. A successful ERP requires drills (exercises), money,

management enthusiasm and support.

Senior Management must decide what it wants the ERP to accomplish:

o Only the immediate notifications and first 24-48 hours following the

accident?

o The entire accident response and investigation cycle?

o Only the on-site team preparations?

Which of the following “categories of events” does top management want the

plan to address?

A. Major or Catastrophic Accident:

o Substantial damage to aircraft, or

o Serious or fatal injury to one or more persons, or

o Substantial damage to property caused by aircraft

B. Missing Aircraft

C. Emergency Airborne or Potentially Hazardous Situation

D. Hijacking

E. Bomb Threat/Terrorist Act

F. Reportable Incidents to NTSB

G. Facility Accident/Incident:

o Substantial damage to company property, loss of life or serious

injury caused by any event not covered by Category A, F, or H.

H. Aircraft Damaged

o Minor damage on ground, no loss or life, minor injury to person(s).

I. Environmental Event

Senior Management must understand that, in the case of an actual accident,


other organizations such as FAA and NTSB will be in charge of the

investigation.


Notification of NTSB and FAA

o Determine disposition of any survivors (i.e., hospital location, etc.)

o Preservation of wreckage and aircraft contents.

o Preservation of all records and documents pertinent to the flight.

Immediate care of the crewmembers involved in the accident.

o Medical care and housing (hotel or hospital as appropriate)

o Shelter from media.

o Provide legal counsel.

o Make crew available to NTSB and FAA investigators.

Notification of the company employee who has been designated and trained

to be the company‟s accident investigation representative to the NTSB. This

person must be an employee, known as the “Party Coordinator,” and cannot

be a “consultant.”

Transportation to the accident site and housing at the site.

o Company team and equipment.

o Immediate family members.

Company spokesperson that knows and stays with the corporate message.

The company must have a media plan and “template” messages that are

developed prior to the emergency.

Policies

Corporate policies must be developed prior to an event on topics such as:

Post accident drug and alcohol testing: how soon will it be accomplished and

by whom.

Who and how to handle the Media: Frontline employees who would be first


contact (i.e., receptionist, Customer Service Representative, Dispatcher) must

be trained in what to say and how to diplomatically hand-off the media

person to your designated media spokesperson.

Who may surviving crewmembers talk to and what may they say? What

legal representation will the company provide?

Notification of Next-of-Kin. Emergency contact information and updates.

Policy on the security of this contact information.

Security of records relating to the accident flight: aircraft maintenance

records, aircrew and mechanic training records, duty time records, flight

documents, manifests and airbills, fueling records, etc.

Who will make the required notifications and reports required by NTSB Part

830? If the designated person is unavailable, who is their backup and are

they trained?

Do you want to participate fully in an accident investigation on-site? This

will require a designated employee receiving training on blood-borne

illnesses, how to use a biohazard suit, and basic investigative techniques. Or

will you be satisfied with allowing the NTSB/FAA to gather the evidence

and helping them interpret the data?

Other Organizations and Individuals

Examine who else will be affected by the actions of your company

representatives. Every member of your team that either travels to the

accident site or represents the company at home base will be talking to

investigators, victims, victim‟s family members, or the media. Everyone

needs to understand their roles and coordinate with the company

management to support the company‟s image, reputation and continued

viability.

Family and friends of any casualties. How to offer condolences without

accepting blame.

Government agencies: their need for information and their agendas. The

company is not in charge of the investigation.

Insurance Company: How soon can assistance be provided?

Customers directly and indirectly affected by the event.


The two key elements of a successful Emergency Response Plan are “What” and

“Who.”

WHAT a company must accomplish immediately after an accident:

Respond to the critical nature of the first hours of the accident

Have trained, prepared leaders and backup for each task (backup at home and

the accident site. The business must continue to operate.)

Have clear, rehearsed plans and checklists

Keep ahead of the situation – do not get overwhelmed

Understand how all requirements overlap and interact

Communicate – Internal and External

WHO manages the Plan? Company employees who:

Fully understand the challenges presented by an accident

Represent the Company and understand the Company‟s rights and

responsibilities

Have appropriate training and practice

Understand the requirements and how the Company must all work together

Have the unequivocal support of the Company (People under stress will

make mistakes. Your employees must know that they can and must go on

despite any faux pas.)

Have authority to act (this is absolutely critical to success)

Have a sense of urgency

Have a strong public presence

Have confidence in the Company and the Plan


1. A plan and checklist for immediate notification of:

Rescue first responders (if required, i.e., a hangar accident)

Management personnel (ensure there is a backup person if primary person

cannot be reached)


Appropriate government agencies (i.e., FAA to start a search for an overdue

aircraft, NTSB for an aircraft accident, etc.)

Plan for a “go team” to travel to the accident site. You have 6-12 hours to

arrive at the accident scene if you intend to participate in the investigation.

It is recommended that a credit card(s) or line of credit be set aside just for

emergencies and kept in a safe place until needed. Transportation to the

accident site, hotels, rental cars, equipment and hospital bills will all need to

be paid for immediately, long before the insurance company will be able to

lend a hand.

2. Plan to provide technical support to the NTSB/FAA accident investigation. The

only way to see/hear all the evidence is to participate in the investigation. Such

participation allows you to:

Ensure the facts are interpreted properly.

Ensure that the investigators review the proper areas.

Fix problems with your operation immediately before the final report is

issued.

Enhance / rehabilitate the reputation of your Company and perhaps influence

the investigators to give your Company the benefit of the doubt on some

issues.

Identify who your “party participants” will be. You may need to insist on

your rights. The NTSB investigator(s) might not be familiar with your

equipment and does not know your company. Your Party Participant must

be courteous, but assertive to ensure all the facts are considered, especially

evidence that supports your theory of the accident.

Visit your aircraft manufacturer‟s accident investigators annually. What kind

of accidents have they seen? How do they prepare their “go team?” How can

they be contacted if you have an accident / incident?

3. Media Plan

During the planning phase of your Emergency Response Plan, obtain and

review a copy of the NATA Community Relations Toolkit. This will help

you develop a relationship with the media (prior to, and invaluable in, a

crisis) and show you how to develop an appropriate press release.

Corporate public relations staff are generally not equipped to handle crisis


communication with the media, unless they have been trained in advance. It

is up to management to present the company‟s best image. You must

designate someone to talk to the media who will be cool under fire and

credible.

Reaffirm the safety and technical efficiency reputation of the company.

Humanize the company. Talk of your employees affected by this tragedy.

Offer words of concern and comfort.

Provide positive, proactive information to the media.

If labor organizations (unions) are on the property, come to an agreement

with their leadership prior to an event so that an accident will not be used to

air disagreements in public.

4. Family Assistance Plan & Employee Assistance Plan

FAR 121 air carriers are required by law to provide on-site assistance to the

families involved.

The ability to quickly and competently address the needs of the families and

survivors will help protect your company‟s reputation and relationship with

your other customers and the NTSB.

Employees will need instruction, comfort and reassurance that the Company

is responding appropriately to the situation.

Plan to care for crewmembers of the flight and other company employees

who were associated with the flight. Use your company‟s Employee

Assistance Plan.

Employees involved in caring for families, survivors and the “Go Team”

could be at risk for post-traumatic stress.

Plan for internal company communications to get out the correct facts to all

employees. Stop rumors before they start.

5. Business Continuity Plan.

Individuals should be designated prior to any accident/emergency who will

act on behalf of key personnel to maintain normal business operations. Your

key personnel may be unavailable due to being involved in the accident,

having traveled to the accident site or absent from the business (vacation,

etc.). Any individuals designated to assist in the accident investigation will

be unavailable to your business for days, weeks, perhaps months depending


on the size of your operation and the location and nature of the accident.

Create a company process manual for all personnel with user names,

passwords, key codes, etc. Keep this in a secure place, but provide a means

for the individual designated to keep the business running to access it.

Obtain the assistance of your insurance carrier to replace the assets involved

in the accident (i.e., an aircraft) as quickly as possible to restore your revenue

stream.

Maintain a list of other air charter operators who are willing to service your

customers until you resume business. It might be advantageous to negotiate

“disaster rates” in advance. Obtain the operator‟s agreement to not “poach”

your customer from you.

Ensure someone in management is designated to contact your customers and

explain that this is a temporary arrangement for the customer‟s benefit.

Assure them that this accident does not mean that your company is unsafe.

(If you were safe on Monday, had an accident on Tuesday, you are still safe

on Wednesday.)

Have an agreement in advance with any labor groups that an accident will

not be used as an opportunity to press for collective bargaining issues.

6. Plan to respond to the regulator.

Keep your FAA Principal Operations Inspector (POI) and Principal

Maintenance Inspector (PMI) informed so that they can respond to their

manager who may be following up rumors, media inquiries, etc.

Gather all the paperwork and records related to the accident flight and secure

them in a manner that ensures there can be no accusation of tampering.

Never hide evidence or information.

Provide requested data, employees for interview, etc., in a timely manner.

The sooner the investigation(s) are completed the sooner you can return to

running your business and correcting any identified causes of the accident.

Assume every member of your team will be talking to investigators or

victims/family members. Ensure each person is properly trained and briefed

to protect the company.

It is very important to provide logistical support to company investigators.

7. Plan for an internal investigation


Review (or institute) your SMS to identify deficiencies and causes of the

accident and institute corrective action.

8. Exercise the Emergency Response Plan

Each department should have a portion of the plan and checklists tailored to

that department.

The master departmental plans should be exercised at least twice a year. One

of these tests should be random and unscheduled.

Scenarios should be conducted on a simulated basis and the results

documented.

A post scenario meeting should be conducted to identify weak areas, which

then can be trained to.

A full-scale drill coordinated with such outside agencies, as the airport

operations and fire department should be conducted at least every two years.

Continuously update, revise and train the Plan.

Note: A template for developing a facility emergency response plan can be

accessed by clicking here.

http://www.nata.aero/data/files/sms/web/emergency%20response%20quick%20ref%20template.doc


REFERENCES

Air Charter Safety Foundation (ACSF) has an SMS resource page on its

website: www.acsf.aero/sms

Dekker, Sidney: (2007), Just Culture: Balancing Safety and Accountability,

Ashgate Publishing; (2005), Ten Questions About Human Error, Lawrence

Erlbaum Associates, Inc. Publishers.

Federal Aviation Administration: Advisory Circular (AC) 120-92A, Safety

Management Systems for Aviation Service Providers; AC 120-82, Flight

Operational Quality Assurance; AC 120-79, Developing and Implementing a

Continuing Analysis and Surveillance System; AC 120-66B, Aviation Safety

Action Programs (ASAP); AC 120-59A, Air Carrier Internal Evaluation

Programs; AC 00-58B, Voluntary Disclosure Reporting Program (VDRP).

Global Aviation Information Network (2001): Operator’s Flight Safety

Handbook (Issue 2), available at http://flightsafety.org/archives-and-

resources/global-aviation-safety-network-gain

Griffiths, R.F. (1982), Dealing With Risk, Halsted Press. ISBN 0470273410.

Grose, V.L. (1987), Managing Risk: Systemic Loss Prevention for

Executives, Prentice-Hall, Inc. Englewood Cliffs, NJ. ISBN 0-13-551110-0.

International Civil Aviation Organization (ICAO): Safety Management

Manual, ICAO Document 9859.

Lowrance, W.W. (1976), Of Acceptable Risk: Science and the Determination

of Safety, William Kaufmann. ISBN 0913232300.

Mcintyre, G.R. (2000), Patterns in Safety Thinking, Ashgate Publishing

Company, Burlington, VT. ISBN 0-7546-1322-4.

National Safety Council (2000), Aviation Ground Operation Safety

Handbook (5th Edition). ISBN 0-87912-214-5

Reason, J. (1997), Managing the Risks of Organizational Accidents, Ashgate

Publishing Company, Brookfield, VT. ISBN 1840141050.

TapRooT® (root cause analysis programs), System Improvements, Inc.,

Knoxville, Tennessee 37923, http://www.taproot.com/

Weick, K.E and Sutcliffe, K.M. (2001), Managing the Unexpected: Assuring

High Performance in the Age of Complexity, Jossey-Bass. ISBN 0-7879-

http://www.acsf.aero/sms

http://flightsafety.org/archives-and-resources/global-aviation-safety-network-gain

http://flightsafety.org/archives-and-resources/global-aviation-safety-network-gain

http://www.taproot.com/


5627-9.

Wells, A.T. and Rodrigues, C.C., (2004), Commercial Aviation Safety (4th

Edition), McGraw-Hill, New York, NY. ISBN 0071417427.

Wood, R.H. (2003), Aviation Safety Programs: A Management Handbook

(3rd

Edition), Jeppesen Sanderson, Inc. ISBN 0-88487-329-3.

ADDITIONAL REFERENCES

Industry & Government Organizations

Air Charter Safety Foundation: www.acsf.aero

Flight Safety Foundation: www.flightsafety.org

International Society of Air Safety Investigators: www.isasi.org

National Air Transportation: http://www.nata.aero/Safety-1st.aspx

National Business Aviation Association:

http://web.nbaa.org/public/ops/safety/

National Transportation Safety Board (NTSB): www.ntsb.gov

Transportation Safety Board of Canada: http://www.tsb.gc.ca/

United Kingdom Air Accidents Investigation Branch http://www.aaib.dft.gov.uk/home/index.cfm

United Kingdom Civil Aviation Authority: www.caa.co.uk

Training Organizations

The following institutions provide formal courses in safety management, aircraft

accident investigation and associated subjects.

1. Southern California Safety Institute: www.scsi-inc.com

2. Embry-Riddle Aeronautical University: www.erau.edu\

http://www.acsf.aero/

http://www.flightsafety.org/

http://www.isasi.org/

http://www.nata.aero/Safety-1st.aspx

http://web.nbaa.org/public/ops/safety/

http://www.ntsb.gov/

http://www.tsb.gc.ca/

http://www.aaib.dft.gov.uk/home/index.cfm

http://www.caa.co.uk/

http://www.scsi-inc.com/

http://www.erau.edu/


3. University of Southern California: http://viterbi.usc.edu/aviation/

4. The FAA Civil Aeromedical Institute (CAMI)

http://www.faa.gov/pilots/training/airman_education/aerospace_physiology/cami

_enrollment/index.cfm

Hands-on instruction is provided in the use of cabin and cockpit safety equipment

(oxygen systems and equipment, fire-fighting equipment, personal survival

equipment, etc). There are also practical aircraft slide evacuation and ditching

exercises and live decompression training - probably the only decompression training

facility accessible to the civil aviation community. The three-day (non-residential)

course is free. Participants must be in possession of a current FAA Class 3 medical

certificate (or equivalent) to be accepted for decompression training.

http://viterbi.usc.edu/aviation/

http://www.faa.gov/pilots/training/airman_education/aerospace_physiology/cami_enrollment/index.cfm

http://www.faa.gov/pilots/training/airman_education/aerospace_physiology/cami_enrollment/index.cfm