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SAFETY MANAGEMENT SYSTEMS MANUAL

Edition 1; Revision 000, Date: 01July2013

Issued By : ALS Ltd Department : ALS Safety Department Address : P.O.Box 41937 Nairobi KENYA Email : [email protected] [email protected] © 2013 ALS Limited

Copy No.: ___

mailto:[email protected]

mailto:[email protected]

NOTICE

This manual is provided for the use and guidance of company staff in the safe and orderly performance of their duty. It contains information, instructions and procedures relative to the manner in which the safety operations of ALS are to be conducted. Holders of the manual must ensure that it is kept up to date, and revised in accordance with the directions provided. All relevant personnel must comply with the principles, procedures and instructions laid down in this documentation, and exercise their own best judgment where no provisions are given. Any deviation, including the reason for such deviation, must be reported to the company. No part of this manual may be reproduced, recast, reformatted or transmitted in any form by any means, electronic or mechanical, including photocopying, recording or any information storage and retrieval system, without prior written permission from:

The Chief Executive Officer ALS

P.O. Box 41937-00100 Nairobi, Kenya Wilson Airport, Nairobi, Kenya

[email protected] +254 (20) 6000019

Edition 001 ALS Section 0

Revision 000 SAFETY MANAGEMENT SYSTEMS MANUAL Page 1

Issued 01July13 DOCUMENT CONTROL

Safety Management Systems Manual Section 0 - Document Control 0.1 Forward In order to achieve its production objectives the Management of any aviation organization requires to manage many business processes. Safety is one such business process. Safety Management is a core business function just as financial management, HR Management, etc. The Safety Management System (SMS) is a systematic approach to managing Safety, including the necessary organizational structures, accountabilities, policies and procedures. An SMS is a system to assure the safe operation of aircraft through effective management of safety risk. This system is designed to continuously improve safety by identifying hazards, collecting and analysing data and continuously assessing safety risks. The SMS seeks to proactively contain or mitigate risks before they result in aviation accidents and incidents. This Safety Management Systems (SMS) Manual is issued under the authority of the Chief Executive Officer of ALS Limited. This manual outlines the Safety Management System at ALS Limited. Information on the Emergency Response Plan is contained in a separate manual, the “ALS Emergency Response Procedures Manual”. This is not a standalone manual and must be read in conjunction with ICAO Doc 9859, ICAO Annexes 6, 11 and 14, KCAA requirements as well as other regulatory guidance material published by the KCAA and ICAO. Nothing contained in this manual is meant to supersede any standard, order, instruction or recommendation issued by the KCAA. If any discrepancy is noted, the reader is advised to bring the same to the notice of the Safety Manager – ALS Ltd so that a suitable amendment can be issued.




This Page Intentionally Blank




0.3 Contents Section 0 – Document Control 0.1 Forward 1 0.2 Document Approval and Certificate of Compliance 3 0.3 Contents 5 0.4 Record of Revisions 8 0.5 Revision letter 9 0.6 List of Major Changes 10 0.7 List of Effective Pages 11 0.8 Distribution List 15 0.9 Acronyms and Abbreviations 17 0.10 Definitions 19 0.11 Administration and Control of the Safety Management Systems Manual 21 Section 1- SMS Regulatory Requirements 1.1 Introduction 3 1.2 National and International Obligations, Policies and Guidelines 3 Section 2 - Scope and Integration of the Safety Management System 2.1 Introduction 3 2.2 SMS Scope 3 2.3 SMS and QMS Integration 3 2.4 Cross Reference Documents for Expanded Guidelines 4 Section 3 - Safety Policy 3.1 ALS Safety Policy 3 3.2 ALS Non-Punitive (No-Blame) Reporting Policy 4 3.3 Disciplinary Policy/Just Culture 5 Section 4 - Safety Objectives 4.1 General 3 4.2 ALS Safety Objectives 3 4.3 ALS Safety Goals 3 Section 5 - Safety Authorities, Responsibilities and Accountabilities 5.1 General 3 5.2 Safety Accountabilities and Responsibilities of ALS Management Staff 3 5.3 All ALS Personnel 14 5.4 ALS Safety Task Force 14 5.5 ALS Safety Committee 14 5.6 Cross References 15 5.7 Safety Organization Chart 16




Section 6 - Safety Reporting 6.1 Introduction to Reporting Systems 3 6.2 Incident Reporting at ALS 3 6.3 Handling Safety Reports 7 6.4 Safety Investigations 8 6.5 Safety Recommendations 11 6.6 Cross References 13 Section 7 - Hazard Identification and Risk Assessment 7.1 General 3 7.2 Hazard Identification 3 7.3 Risk Assessment 6 7.4 Risk Mitigation 10 7.5 Implementation Procedure 11 7.6 Cross References 12 Section 8 - Safety Performance Monitoring and Measurement 8.1 Safety Performance Indicators 3 8.2 Process to Maintain and Develop the Safety Performance Indicators 3 8.3 ALS Safety Performance Indicators and Targets 4 Section 9 - Safety Training, Communication and Promotion 9.1 Introduction 3 9.2 Training Needs 3 9.3 Safety Training for Management 4 9.4 Specialist Safety Training 4 9.5 Training for Operational and Maintenance Personnel 5 9.6 Training for Safety Managers 5 9.7 Training Files 5 9.8 Safety Communications 7 9.9 Safety Promotion 8 9.10 Promotion Methods 8 9.11 Cross References 9 Section 10 - Continuous Improvement and SMS Audit 10.1 Safety Audits 3 10.2 The Safety Audit Process 4 10.3 Audit Report 9 10.4 Audit Follow-up 9 10.5 Safety Surveys 11 10.6 Line Operations Safety Audits (LOSA) 11 10.7 Flight Data Analysis 12 10.8 ALS Safety Task Force and Steering Committee 14 10.9 ALS Safety Committee 16 10.10 Safety Meetings 16 10.11 Flight Operations and Safety Meetings 17 10.11 Cross References 17




Section 11- SMS Data and records Management 11.1 Introduction 3 11.2 Document Procedures 3 Section 12 - Management of Change 12.1 Management of Change 3 12.2 Guidelines for conducting Management of Change Process 4 Section 13 - Emergency Response Plan 13.1 Introduction 3 13.2 ALS Emergency Response Plan 3 13.3 Cross References 3




0.4 Record of Revisions Edition No Revision No Revision Date Pages

000 16/04/2007 Original All Pages 001 30/04/2008 All Pages 002 24/02/2012 Intro 8,9,10,12,13; 2-9, 2-10, 5-2, 5-3, 5-4, 7-9, 7-

11, 7-12, 7-13, 7-14, 7-15, 7-16, 7-17, 9-2, 9-3 002 15/01/2013 6-4, 6-5 1 000 01/07/2013 Complete Re-Issue




0.5 Revision Letter Please amend the SMS Manual as follows: Action Date This is a complete Re-issue 01/07/2013




0.6 List of Major Changes Edition No

Revision No

Revision Date

Page No Changes

1 000 01/07/2013 All Complete Re-issue in line with KCARS




Edition Rev No Section Page Date Edition Rev No Section Page Date

Approved by: __________________________ Kenya Civil Aviation Authority




0.8 Distribution List For ease of identification all manuals will be issued using the following distribution list numbers: 1) 1-49 Nominated Positions 2) 50-99 Aircraft 3) 100-149 Operating Stations 4) 150-199 Contractors and Third Party Manual Holders 5) 200-299 Pilots 6) 300-399 Cabin Crew 7) 400-499 Engineers The Librarian will keep a Master Distribution List and will amend the list as and when necessary. The Library register will identify actual names of manual holders.

Copy Number

Edition Number

Revision Number

Holder Form of Distribution

1 1 000 KCAA Hardcopy 2 1 000 ALS Library Hardcopy 3 1 000 Accountable Manager Hardcopy 4 1 5 1 000 Director of Flight Ops Hardcopy 6 1 000 Technical Director CD 7 1 Commercial Director CD 8 9 1 000 Director of Quality Ass. CD 10 1 000 Operations Manager CD 11 1 000 QCM CD 14 1 000 Safety Manager Hardcopy 15 1 000 Chief Pilot CD 100 1 000 Nairobi Station CD 101 1 000 Khartoum Station CD 102 1 000 Juba Station CD 103 1 000 Chad Station CD 105 1 000 Niger Station CD 107 1 000 Lokichoggio Station CD 200 -299 1 000 Pilots CD 300-399 1 000 Cabin Crew CD 400-499 1 000 Engineers CD 500-599 1 000 Ops, Ground & Cargo Staff CD




0.9 Acronyms and Abbreviations AD Airworthiness Directive ADREP Accident/Incident data reporting (ICAO) AIB Accident investigation board AIR Airworthiness ALARP As low as reasonably practicable ALoSP Acceptable level of safety performance AMAN Abrupt manoeuvring AME Aircraft maintenance engineer AMP Aircraft Maintenance Program ANS Air navigation service AOC Air operator certificate AOG Aircraft on ground ASB Air service bulletin ASR Air safety report ATC Air traffic control ATM Air traffic management ATS Air traffic service(s) CAA Civil aviation authority CEO Chief executive officer (Accountable manager) CFIT Controlled flight into terrain CCC Crisis control centre CRM Crew resource management CVR Cockpit voice recorder DGR Dangerous goods regulations ECCAIRS European Coordination Centre for Accident and Incident Reporting Systems ERP Emergency response plan FDA Flight data analysis FDR Flight data recorder FRMS Fatigue risk management system FTL Flight time limitations HF Human factors HIRA Hazard identification and risk assessment HIRM Hazard identification and risk mitigation IATA International Air Transport Association ICAO International Civil Aviation Organization IFSD In-flight shutdown KCAA Kenya Civil Aviation Authority LOC-I Loss of control in flight LOFT Line-oriented flight training LOSA Line operations safety audit MCM Maintenance control manual MEDA Maintenance error decision aid




MEL Minimum Equipment List MOR Mandatory occurrence report MPM Maintenance procedures manual OEM Original equipment manufacturer OPS Operations OSHE Occupational safety, health and environment PEAT Procedural error analysis tool QA Quality assurance QC Quality control QM Quality management QMS Quality management system SA Safety assurance SAG Safety action group SARPs Standards and Recommended Practices (ICAO) SB Service bulletin SCF-NP System component failure – non-power plant SHEL Software/hardware/environment/livewire SM Safety management SOPs Standard operating procedures SRM Safety risk management UE Unsafe event WIP Work in progress




0.10 Definitions Accident. An accident is an occurrence during the operation of the aircraft which entails: 1) A fatality or serious injury; 2) Substantial damage to the aircraft involving structural failure or requiring major repair; or 3) The aircraft is missing or is completely inaccessible. Acceptable level of safety performance (ALoSP). The minimum level of safety performance of the operator, as defined in its safety management system, expressed in terms of safety performance targets and safety performance indicators Accountable manager. A single, identifiable person having the responsibility for the effective and efficient performance of the service provider’s SMS Change management. A formal process to manage changes within an organization in a systematic manner, so that changes which may impact identified hazards and risk mitigation strategies are accounted for, before the implementation of such changes. Defences. Specific mitigating actions, preventive controls or recovery measures put in place to prevent the realization of a hazard or its escalation into an undesirable consequence. Errors. An action or inaction, by an operational person that leads to deviations from organizational or the operational person’s intentions or expectations. Event. An occurrence, especially one that is particularly significant, interesting, exciting, or unusual. Hazard. Is a condition, object or activity with the potential of causing injuries to personnel, damage to equipment or structures, loss of material, or reduction in ability to perform a prescribed function. Incident. An occurrence, other an accident, associated with the operation of an aircraft which affects or could affect the safety of the operation. Mitigation. Measures to eliminate the potential hazard or to reduce the risk probability or severity. Predictive process. A process of forecasting a likely outcome or result. Pr-Active process. An approach that emphasises hazard identification and risk control and mitigation, before that safety event occurs. Probability. The likelihood that a situation of danger might occur. Re-active process. An approach that emphasises hazard identification and risk control and mitigation, after events that affect safety occur. Risk. Is the chance of a loss or injury, measured in terms of severity and probability. The chance that an event can happen and the consequences when it does. Risk index. Combined value of risk probability and severity Risk mitigation. The process of incorporating defences or preventive controls to lower the severity and/or likelihood of a hazard’s projected consequence.




Safety. Is the state in which the risk of harm to persons or property damage is reduced to, and maintained at or below, an acceptable level through continuing process of hazard identification and risk management. Safety management system. A systematic approach to managing safety, including the necessary organizational structures, accountabilities, policies and procedures. Safety performance. A service provider’s safety achievement as defined by its safety peroformance targets and safety performance indicators. Safety performance indicator. A data-based safety parameter used for monitoring and assessing safety performance. Safety risk. The predicted probability and severity of the consequences or outcomes of a hazard. Severity. The possible consequence of a situation of danger, taking as reference the worst possible situation.




0.11 Administration and Control of the Safety Management Systems Manual 0.11.1 Introduction The Safety Manager will be responsible to the Accountable Manager for the development, implementation, maintenance and the day-today administration of the SMS and of the ALS SMS Manual. This manual is used as a guideline for all company safety management procedures and the standards and procedures set forth within this manual shall be adhered to whenever practical in day-today operations. The SMS Manual shall be written in English. 0.11.2 Distribution KCAA will receive one copy of this SMS manual. Each person to whom this manual is distributed will receive either a hardcopy or a CD of the manual. Sufficient copies will be provided to ensure that all operating staff has ready access to them when required, and to enable one copy to be lodged with the KCAA. The company will maintain an up-to-date list of manuals, together with their copy numbers, form of distribution (hardcopy/CD) and their locations, or the name/appointment of the copy holder, and as appropriate. 0.11.3 Correlation with other company manuals. This SMS manual is supplemented/correlated with the following company manuals:

• The Company Corporate Manual • The Quality Assurance Manual • The Maintenance Control Manual • The Maintenance Procedures Manual • The Security Manual • The Flight Operations Manuals • The Emergency Response Procedures Manual • Kenya Civil Aviation Regulations • ICAO Document 9859 – 3rd Edition.

0.11.4 Indexing System This SMS Manual id divided into Sections Each Part is divided into Sub-sections Each Sub-section may be divided into Paragraphs Each paragraph may be divided into sub-paragraphs x. x. x. x




0.11.5 Amendments and Revisions 0.11.5.1 This SMS Manual is issued on the authority of the company, and the Accountable Manager will authorize all amendments to it as required by the company or the KCAA. The Accountable Manager has delegated this duty to the Safety Manager. Any proposed amendment should be forwarded, through the Safety Manager, on an “Amendment Proposal” form (see overleaf). All amendments will be in the form of printed, replacement pages; manuscript amendments are not permitted. Revision pages will be annoted to show the date of issue (and date of effect if different). Each amendment will be accompanied by a revised list of effective pages, with their dates of issue. An amendment list record will be maintained at the front of the manual. For those persons issued with a CD copy, a new CD copy in a read only PDF format will be issued incorporating all the amendments. The old CD copy will be handed over to the Central Library when the amended CD is issued. The amended CD will be labelled with a new revision number. The old CD will be destroyed by the Central Library. The full details of the amendment and revision procedures can be found in the ALS Corporate Manual. 0.11.5.2 Amendments will be issued to hard copy holders or nominated individuals who will be required to amend particular numbered copies. Amendments should be entered on receipt, and the amendment record completed. Certificates of incorporation should be returned to the company as soon as possible after the amendments have been completed. 0.11.5.3 Details of amendments and revisions which may be urgently required in the interests of safety whether flight, operations, or maintenance, or which are supplementary to the SMS manual, will be promulgated as Flying Staff Instructions (FSI), Operational Notices (ON) or Safety Information Letters (SIL). Those of a temporary nature may be cancelled as soon as they are no longer relevant. Those of long-term application will be incorporated into the manual when it is next amended, or within six months of their effective date, whichever is sooner. 0.11.5.4 All intended amendments and revisions must be supplied to the KCAA in advance of the effective date. When the amendment/revision concerns any part of the SMS Manual which must be approved, this approval must be obtained before the amendment or revision becomes effective. When immediate amendment or revisions are required in the interest of safety, they may be published and applied immediately, provided that application for approval has been made. 0.11.5.5 All relevant personnel must have easy access to a copy of SMS Manual. These copies will be supplied either in the form of paper copies of CD copies. All copies will be numbered and a record of the issued copies with their Revision number will be kept in the Central Library. 0.11.6 Periodic Review of the SMS Manual The SMS manual shall be reviewed every 12 months by the Safety Manager. Any proposed amendments will be forwarded to the Accountable Manager for review. Once the review has been completed the Safety Manager shall fill in the Data Review and Development form as described in the ALS Corporate Manual and follow the procedures described in it until the amendments have been distributed.




0.11.7 Amendment Proposal Form

AMENDMENT PROPOSAL FORM The following amendment/addition/deletion* is proposed to Section ________ Para ……… of the SMS Manual: *delete where applicable. PROPOSED AMENDMENT (continue on separate sheet if necessary) REASONS FOR AMENDMENT Signature of Proposer: Safety Manager Position: Signature: Authorized by: Position: See over for guidelines on the completion of this form.




GUIDELINES FOR THE COMPLETION OF THIS FORM 1. Proposed amendments to the SMS Manual will only be considered if submitted on this . . form. 2. This form should be completed, signed and handed over to the Safety Manager for comment/approval. 3. The final decision on amendments to the SMS Manual rests with the Accountable Manager 4. The Company reserves the right to amend any proposal.



Issued 01July13 REGULATORY REQUIREMENTS

Section 1 - SMS Regulatory Requirements Contents 1.1 Introduction 3 1.2 National and International Obligations, Policies and Guidelines 3




1.1 Introduction At ALS our commitment to safety will always be a major priority. The company has comprehensive safety and security procedures concerning activities on the ground and in the air in accordance with the KCAA and international norms. Our SMS Manual encompasses the review of various legislations in Kenya and guidelines from various international bodies/organizations. But over and above the legal requirements, we must all be vigilant and seek to prevent any actions which endanger safety anywhere in our system. This SMS Manual is issued in accordance with and will not be less restrictive than the applicable KCAA and other relevant international regulatory documents. 1.2 National and International Obligations, Policies and Guidelines. 1.2.1 Regulation 55 of the Kenya Civil Aviation (Air Operators Certification and Administration) Regulations requires an AOC holder to establish and maintain a safety management system to:- i) Identify actual and potential safety hazards; ii) Ensure that remedial action necessary to maintain acceptable level of safety is implemented; iii) Provide for continuous monitoring and regular assessment of safety level achieved ; and iv) The appointment of a person accountable for managing the system 1.2.2 Regulations 86, 63-66, 58 of the Kenya Civil Aviation (Air Operators Certification and Administration) Regulations and regulation 24 of the Kenya Civil Aviation (Airworthiness) Regulations describe incidents that have to be reported and responsibilities of for submitting reports to the KCAA. 1.2.3 Regulation 34 of the Kenya Civil Aviation (Approved Maintenance Organization) Regulations describes the reporting of incidents for the maintenance organization. 1.2.4 Advisory Circular CAA-AC-OPS031A describes the safety management system and occurrence reporting. 1.2.5 ICAO Doc 9859 provides guidelines on SMS 1.2.6 The IATA Integrated Management Systems Manual provides guidelines on setting up a safety management system. 1.2.7 ICAO Annexes 6, 11, and 14 have provisions relating to the SMS which are to be complied with by

all operators.



Issued 01July13 SCOPE AND INTEGRATION OF THE SMS

Section 2 - Scope and Integration of the Safety Management System Contents 2.1 Introduction 3 2.2 SMS Scope 3 2.3 SMS and QMS Integration 3 2.4 Cross-Reference Documents for Expanded Guidelines 4




2.1 Introduction ALS operates Commercial Passenger and Cargo operations as stipulated under the Air Operators Certificate. All aircraft are maintained by the company’s Approved Maintenance Organization. ALS is a supplier of aircraft under ACMI contracts to the United Nations, ICRC, Oil companies and other airlines and also runs schedule services. 2.2 SMS Scope ALS has developed an integrated Safety Management System for its entire organization. The SMS provides the highest reasonable level of safety by identifying and minimising risks, which could contribute to accidents, incidents, or injury to persons. ALS provides both safety and quality management covering the complete scope and life cycle of all systems and operational and maintenance processes including: • Flight Training Operations; • Operational Control (Dispatch / Flight Following) • Maintenance and Inspection; including:

− Parts / material − Technical data − Quality control − Records management − Contract maintenance

• Security • Aircraft ground handling and servicing • Training of all personnel • Outside Contractors 2.2.1 The SMS is implemented through the respective departmental or outstations management personnel. An ALS Safety Task Force Team has been created which comprises of people from all departments across the company and whose primary task is to identify and mitigate risks across the whole organizations. The terms of reference for this Safety Task Force can be found later in this SMS Manual. For outside contractors a safety survey or a quality audit will be conducted to ensure that these contractors do not follow any practices which may affect the safety of ALS operations. 2.3 SMS and QMS Integration 2.3.1 The QMS and SMS are complementary. QMS is focused on compliance with prescriptive (both regulatory and company) regulations and requirements to meet customer expectations and contractual obligations while the SMS is focused on safety performance. The objectives of the SMS are to identify safety-related hazards, assess the associated risk and implement effective controls. In contrast the QMS focuses on the consistent delivery of products and services that meet relevant specifications. 2.3.2 SMS and QMS utilize similar risk management and assurance processes. The objective of SMS is to identify safety-related hazards that the company must confront and to control the associated risks. SMS is designed to manage safety risks and measure safety performance during delivery of products and services. The safety risk management process eliminates hazards and provides effective controls to mitigate safety risks by maintaining an appropriate resource allocation balance between production and protection to meet safety performance requirements.




2.3.2 The QMS provides consistency in the delivery of products and services to meet performance standards as well as customer expectations. The QMS also has an independent assurance function that utilizes a feedback loop to assure delivery of products and services that are “fit for purpose” and free of defects or errors. The quality assurance function identifies ineffective processes and procedures that must be designed for efficiency and effectiveness. 2.3.3 Due to the complementary aspects of the SMS and the QMS, ALS has established an integrated relationship between both systems as follows: a) The SMS is supported by the QMS processes such as auditing, inspection, investigation, root cause analysis, process design, statistical analysis and preventive measures; b) The QMS may anticipate safety issues that exist despite the company’s compliance with standards and specifications; and c) Quality principles, policies and practices are linked to the objectives of safety management. d) The SMS auditing process will use the same Non-conformance Report Forms used in the QM System. 2.4 Cross-Reference Documents for Expanded Guidelines In addition to the policies and procedures explained in this manual further or expanded guidance may be obtained from the following documents: • ALS Flight Operations Manuals • ALS Quality Assurance Manual • ALS Maintenance Procedures Manual • ALS Maintenance Control Manual • ALS Cabin Crew Procedures Manual • ALS Security Manual • ALS Emergency Response Procedures Manual • Kenya Civil Aviation Regulations • ICAO Annexes • ICAO Document 9859



Issued 01July13 SAFETY POLICY

Section 3 - Safety Policy Contents 3.1 ALS Safety Policy 3 3.2 ALS Non-Punitive (No-Blame) Reporting Policy 4 3.3 Disciplinary Policy / Just Culture 5 Figure 1 – Decision tree for determining culpability of unsafe acts 7




3.3 Disciplinary Policy / Just Culture 3.3.1 The purpose of the company’s non-punitive reporting policy is to improve the safety and reliability of the company’s operations and thereby to avoid accidents and serious incidents. It is not the purpose of the incident reporting scheme to apportion blame, but it must be appreciated that where there is clear evidence of serious negligence or incompetence, the company has a duty to take any action that may be necessary to ensure the future safety of its operations and customers. 3.3.2 The company actively promotes a Just Safety Culture that is both attitudinal and structural, relating to both individuals and the company. 3.3.3 In order to determine whether a particular behaviour is culpable enough to require a disciplinary action, the company’s policy is to decide fairly on a case-by-case basis. 3.3.4 To help in deciding the culpability of an unsafe act the company will use a Risk-based Disciplinary Decision Making Policy. This method considers the intent of the employee with regard to an undesirable outcome. People who act recklessly, are thought to demonstrate greater intent (because they intend to take a significant and unjustifiable risk) than those who demonstrate negligent conduct. Therefore, when an employee should have known, but was unaware, of the risk he/she was taking, he/she was negligent but not culpably so, and so would therefore not be punished under the Just Culture environment. 3.3.5 Figure 1 displays a decision tree for helping to decide on the culpability of an unsafe act. The assumption is that the actions under scrutiny have contributed to an accident or to a serious incident. There are likely to be a number of different unsafe acts that contributed to the accident or incident and the decision tree should be applied separately to each of them. The concern is with individual unsafe acts committed by either a single person or by different people at various points of the events sequence. The five stages include: 1. Intended act: The first question in the decision-tree relates to intention, and if both actions and consequences were intended, then it is possibly criminal behaviour which is likely to be dealt with outside of the company (such as sabotage or malevolent damage). 2. Under the influence of alcohol or drugs known to impair performance at the time that the error was committed. A distinction is made between substance abuse with and without “reasonable purpose (or mitigation), which although is still reprehensible, is not as blameworthy as taking drugs for recreational purposes. 3. Deliberate violation of the rules and did the system promote the violation or discourage the violation; had the behaviour become automatic or part of the “local work practices.” 4. Substitution test: could a different person (well motivated, equally competent, and comparably qualified) have made the same error under similar circumstances (determined by peers). If “yes” the person who made the error is blameless, if “no” were there system-induced reasons (such as insufficient training, selection, experience)? If not, then negligent behaviour should be considered. 5. Repetitive errors: The final question asks whether the person has committed unsafe acts in the past. This does not necessarily presume culpability, but it may imply that additional training or counselling is required. Reason’s Foresight test: provides a prior test to the substitution test described above, in which the culpability is thought to be dependent upon the kind of behaviour the person was engaged in at the time.




The type of question that is asked in this test is: - Did the individual knowingly engage in behaviour that an average operator would recognise as being likely to increase the probability of making a safety-critical error? If the answer is “yes” to this question in any of the following situations, the person may be culpable. However, in any of these situations, there may be other reasons for the behaviour, and thus it would be necessary to apply the substitution test. • Performing the job under the influence of a drug or substance known to impair performances • Clowning around whilst on the job. • Becoming excessively fatigued as a consequence of working a double-shift. • Using equipment known to be sub-standard or inappropriate.




Figure 1 – Decision Tree for Determining Culpability of Unsafe Acts

Were the Actions

Intended?

NO

Unauthorized substance?

NO

Knowingly violating

safe operating practices?

NO

Pass

substitution test?

YES

History of

unsafe acts?

NO

YES YES NO

YES

YES

Deficiencies in training & selection or

inexperience?

Medical Condition?

Were procedures available, workable, intelligible

and correct?

NO

YES

Blameless error but

corrective training or counsellin

g indicated

Blame-less error

Were the consequences as intended?

NO YES

YES

NO

Possible negligent

error

System induced

error

Possible reckless violation

System-induced violation

YES

Substance abuse

without mitigation?

Substance abuse with mitigation

Sabotage,

malevolent damage,

suicide, etc.

Diminished Culpability



Issued 01July13 SAFETY OBJECTIVES AND GOALS

Section 4 - Safety Objectives Contents 4.1 General 3 4.2 ALS Safety Objectives 3 4.3 ALS Safety Goals 3




4.1 General Safety Objectives and Goals provide challenging performance targets, designed to meet specific business plans. Safety Objectives are broad directions set in place to facilitate the establishment of specific safety goals or desired targets. 4.2 ALS Safety Objectives ALS Safety Objectives are: • To identify and eliminate hazardous conditions within our aviation related processes and operations.

• To perform hazard and risk assessment for all proposed for all proposes new equipment acquisitions,

facilities, operations and procedures.

• To promulgate an on-going systematic hazard and risk assurance plan.

• To provide relevant SMS training/education to all company personnel.

• To provide a safe, healthy work environment for company personnel.

• To minimize accidents/incidents that are attributable to organizational factors

• To prevent damage and injury to property and people resulting from our operations.

• To improve the effectiveness of the safety management system through a yearly safety audit that reviews all aspects of the SMS

4.3 ALS Safety Goals ALS Safety Goals are: • Set safety goals and targets for each department and the company as a whole.

• Ensure safety policies and procedures are contained in all company manuals.

• Delivery of safety training company wide.

• Track and report hazards, incidents, injuries and accidents.

• Provision of adequate resources to achieve the safety objectives.

• Each outstation and each department to be audited for safety assurance.

• Integrate the safety management system throughout the company.

• Review the safety management system annually.



Issued 01July13 SAFETY AUTHORITIES, RESPONSIBILITIES AND ACCOUNTABILITIES

Section 5 - Safety Authorities, Responsibilities and Accountabilities Contents 5.1 General 3 5.2 Safety Accountabilities and Responsibilities of ALS Management Staff 3 5.2.1 Accountable Manager 3 5.2.2 Safety Manager 3 5.2.3 Director of Flight Operations 5 5.2.4 Chief Pilot 6 5.2.5 Operations Manager 6 5.2.6 Technical Director 7 5.2.7 Finance Director 8 5.2.8 Commercial Director 9 5.2.9 Director of Maintenance (AOC) 9 5.2.10 Director of Maintenance (AMO) 10 5.2.11 Safety Officer 11 5.2.12 Base Maintenance Engineer 12 5.2.13 Line Maintenance manager 13 5.3 All ALS Personnel 14 5.4 ALS Safety Task Force 14 5.5 ALS Safety Committee 14 5.6 Cross References 15 5.7 Safety Organization Chart 16




5.1 General Responsibility and accountability are closely related concepts. While individual staff members are responsible for their actions they are also accountable to their supervisor or manager for the safe performance of their functions and may be called on to justify their actions. Although individuals must be accountable for their own actions, managers and supervisors are accountable for the overall performance of the group that reports to them. Accountability is a two-way street. Managers are also accountable for ensuring that their subordinates have the resources, training, experience, etc. needed for the safe completion of their assigned duties. 5.2 Safety Authorities, Accountabilities and Responsibilities of ALS Ltd Management Staff 5.2.1 Accountable Manager (A.M.) Safety Accountabilities: The A.M. is accountable to the Board of Directors of ALS for the safe operations and services provided by ALS. Safety Authorities and Responsibilities: The Accountable Manager’s authorities and responsibilities include but are not limited to: a) Provision and allocation of human, technical, financial or other resources necessary for the effective and efficient performance of the SMS; b) Direct responsibility for the conduct of the company affairs; c) Final Authority over operations under the Air Operations Certificate of the company ; d) Establishment and promotion of the company’s safety policy; e) Establishment of the company’s safety objectives and safety targets; f) Acting as the company’s safety champion; g) Having final responsibility for the resolution of all safety issues; h) Establishing and maintaining the company’s competence to learn from the analysis of data collected

through the company’s safety reporting system; i) Ensuring that the company’s SMS and operational performance are evaluated for effectiveness on a

regular basis; and j) Ensuring that the company management and staff are aware and held accountable for their safety

performances. 5.2.2 Safety Manager (S.M.) Safety Accountabilities: The Safety Manager is accountable to the Accountable Manager for: • Providing advice and assurance relating to safety initiatives and requirements. • Establishing an effective corporate SMS • Maintenance of the Safety policy and the SMS • Setting safety policy and standards • Recommending resource allocations in support of safety initiatives




• Organizing emergency response planning • Establishing a safety audit and surveillance system Safety Responsibilities: The Safety Manager’s authorities and responsibilities include but are not limited to: a) Managing the SMS implementation plan on behalf of the accountable manager; b) Performing/facilitating hazard identification and safety risk analysis c) Monitoring corrective actions and evaluating their results; d) Providing periodic reports on the company’s safety performance; e) Maintaining records and safety documentation; f) Planning and facilitating staff safety training; g) Providing independent advice on safety matters; h) Monitoring safety concerns in the aviation industry and their perceived impact on the company’s

operations aimed at service delivery; i) Coordinating and communicating (on behalf of the Accountable Manager) with the KCAA and other

State agencies as necessary on issued relating to safety; j) Coordinating and communicating (on behalf of the Accountable Manager) with international

organizations on issues relating to safety; k) Coordinating safety committees; l) Promoting safety by disseminating safety lessons in-house, sustaining awareness of the company’s

safety management process across all operational and maintenance areas; and m) Managing the company’s Emergency Response Procedures Safety Authorities: The Safety Manager has the following authorities: a) Regarding safety matters, the safety manager has direct access to the accountable manager and

appropriate senior and middle management b) He is authorized under the direction of the accountable manager to conduct safety audits, surveys

and inspections in respect of the company’s operations in accordance with the procedures specified in this SMS Manual.

c) He is authorized to conduct investigations of internal safety matters in accordance with the

procedures specified in this SMS Manual. d) He is independent of any other department.




Qualification and Competence Requirements: the Safety Manager shall possess the following skills, knowledge and experience: a) A technically qualified person in the field of aircraft maintenance or flight operations (a commercial

pilot licence can be construed as qualified in the field of flight operations). b) At least five years’ experience as a pilot and/or engineer. c) Completed a Safety Management Course recognised by the Authority. d) Have a complete understanding of safety systems and risk management e) Have good leadership qualities. f) Have good communications skills g) Have good analytical skills. 5.2.3 Director of Flight Operations (DFO) Safety Accountabilities: The DFO is accountable to the accountable manager for conducting safe flight operations of the company. Safety Responsibilities: the DFO is responsible for: a) Ensuring that safety considerations are given the foremost priority; b) Ensuring the application of safety management policy and procedures in accordance with the

company safety management system; c) Ensuring that any risks or hazards that are identified within the company’s flight operations are

assessed and mitigation strategies defined in accordance with the procedures contained in this SMS manual;

d) Overseeing the safety performance of the flight operations department; e) Ensuring that the flight operations department staff including the flight crew are aware of, and held

accountable for their safety performance. f) Ensuring that all safety matters are reported in a timely manner to the safety manager; and g) Ensuring that all contractual and legal requirements including the safety requirements are met. Safety Authorities: The DFO has the following authorities: a) Regarding safety matters, the DFO has direct access to the accountable manager and appropriate

senior and middle management. b) He is authorised to carry out safety audits and inspections in the operations department c) He is authorised to conduct internal safety investigations




d) He is authorised to approve/decide on any mitigation actions to reduce risk to the safety of the flights operations.

e) He is authorised to provide the necessary resources required to maintain an acceptable level of safety

in the flight operations department. 5.2.4 Chief Pilot (CP) Safety Accountabilities: The Chief Pilot is accountable to the accountable manager and the director of flight operations for the safe conduct of ALS flights. Safety Responsibilities: The CP is responsible for: a) Ensuring that safety considerations are given the foremost priority; b) Ensuring the application of safety management policy and procedures in accordance with the

company safety management system; c) Ensuring that any risks or hazards that are identified within the company’s flight operations are

assessed and mitigation strategies defined in accordance with the procedures contained in this SMS manual;

d) Overseeing the safety and operational performance of the flight crew; e) Ensuring that flight crew are aware of and held accountable for their safety performance; f) Ensuring that all safety matters are reported to the safety manager in a timely manner; and g) Ensuring that all contractual and legal requirements including the safety requirements are met. Safety Authorities: The CP has the following authorities: a) Regarding safety matters, the CP has direct access to the accountable manager, the director of flight

operations and appropriate senior and middle management. b) He is authorised to carry out safety audits and inspections in the operations department. c) He is authorised to conduct internal safety investigations. d) He is authorised to approve/decide on any mitigation actions to reduce risk to the safety of the flights

operations. 5.2.5 Operations Manager (OM) Safety Accountabilities: The operations manager is accountable to the director of flight operations for the safe and efficient functioning of the flight operations department. Safety Responsibilities: The OM is responsible for: a) Ensuring that safety considerations are given the foremost priority; b) Ensuring the application of safety management policy and procedures in accordance with the

company safety management system;




c) Ensuring that any risks or hazards that are identified within the company’s flight operations are assessed and mitigation strategies defined in accordance with the procedures contained in this SMS manual;

d) Overseeing the safety and operational performance of the operations personnel; e) Ensuring that operations personnel are aware of and held accountable for their safety performance; f) Ensuring that all safety matters are reported to the safety manager in a timely manner; and g) Ensuring that all contractual and legal requirements including the safety requirements are met. Safety Authorities: The OM has the following authorities: a) Regarding safety matters, the OM has direct access to the director of flight operations and

appropriate senior and middle management. b) He is authorised to carry out safety audits and inspections in the operations department. c) He is authorised to conduct internal safety investigations. d) He is authorised to make recommendations on any mitigation actions to reduce risk to the safety of

the flights operations. 5.2.6 Technical Director (TD) Safety Accountabilities: The technical director is accountable to the accountable manager to support the activities for safe operations for the maintenance department. Safety Responsibilities: The TD is responsible for: a) Ensuring that safety considerations are given the foremost priority; b) Ensuring the application of safety management policy and procedures in accordance with the

company safety management system; c) Ensuring that any risks or hazards that are identified within the maintenance department are assessed

and mitigation strategies defined in accordance with the procedures contained in this SMS manual; d) Overseeing the safety and operational performance of the maintenance personnel; e) Ensuring that maintenance personnel are aware of and held accountable for their safety performance; f) Ensuring that all maintenance department staff are trained to discharge their safety related

obligations; g) Ensuring that all safety matters are reported to the safety manager in a timely manner; h) Ensuring that management of human resources is appropriate to facilitate safe practices in the

maintenance department; and i) Ensuring that all contractual and legal requirements including the safety requirements are met.




Safety Authorities: The TD has the following authorities: a) Regarding safety matters, the TD has direct access to the accountable manager and appropriate

senior and middle management. b) He is authorised to carry out safety audits and inspections in the maintenance department c) He is authorised to conduct internal safety investigations d) He is authorised to approve/decide on any mitigation actions to reduce risk to the safety of the

maintenance operations. e) He is authorised to provide the necessary resources required to maintain an acceptable level of safety

in the maintenance department. 5.2.7 Finance Director (FD) Safety Accountabilities: The finance director is accountable to the accountable manager for effective management of financial resources and timely availability of funds to meet all requirements essential for ensuring operational safety. Safety Responsibilities: The FD is responsible for: a) Ensuring that in exercising its powers and performing its functions, the finance department of the

company regards aviation safety as an important consideration; b) Assuming a leadership role to ensure commitment throughout the finance department to the safety

management policy intent and safety management requirements; c) Ensuring that all managers and staff reporting to him/her are aware of and held accountable for their

safety performance; d) Establishing the appropriate controls over finance activities to ensure the safety of the company is

not compromised by changes in the financial system; and e) Ensuring that there is effective liaison between the finance department and other company

departments and relevant external organisations to ensure that the safety aspects for any change involving the finance department are fully considered before the change is implemented.

Safety Authorities: The FD has the following authorities: a) Regarding safety matters, the FD has direct access to the accountable manager and appropriate

senior and middle management. b) He/she is authorised to conduct financial risk analysis on any changes made within the company

especially with respect to safety. c) He is authorised to conduct internal financial safety risk investigations d) He is authorised to approve/decide on any mitigation actions to reduce financial risk to the safety of

the company.




e) He is authorised to propose for any resources required to maintain an acceptable level of financial safety in the company.

5.2.8 Commercial Director (CD) Safety Accountabilities: The commercial director accountable to the accountable manager for the effective management of commercial flight activities to meet all requirements essential for ensuring operational safety. Safety Responsibilities: The C.D. is responsible for:

a) Ensuring that in performing its functions, the Commercial Department of ALS regards aviation

safety as an important consideration; b) Assuming a leadership role to ensure commitment throughout the Commercial Department to the

Safety Management Policy intent and Safety Management System requirements; c) Ensure that all managers and staff reporting to him/her are aware of and held accountable for their

safety performance; d) Establishing the appropriate controls over commercial activities to ensure the safety of ALS is not

compromised by changes in the commercial activities; and e) Ensuring effective liaison is conducted between the Commercial Department and other ALS

Departments and relevant external organisations and customers to ensure that the safety aspects for commercial activities are fully considered before the activity is begun or implemented.

Safety Authorities: The CD has the following authorities: a) Regarding safety matters, the CD has direct access to the accountable manager and appropriate

senior and middle management. b) He is authorised to carry out safety audits and inspections in the commercial department c) He is authorised to conduct internal safety investigations d) He is authorised to approve/decide on any mitigation actions to reduce risk to the safety of the

commercial operations. e) He is authorised to provide the necessary resources required to maintain an acceptable level of safety

in the commercial department. 5.2.9 Director of Maintenance (AOC) – (DOM-AOC) Safety Accountabilities: The DOM - AOC is accountable to the accountable manager for the safety and maintenance of the company aircraft. Safety Responsibilities: The DOM - AOC is responsible for: a) Ensuring the safety and maintenance of company aircraft is in a state of continuous airworthiness; b) Ensuring that the safety policies and procedures which govern maintenance operations in the MCM

are complied with;




c) Ensure that all managers and staff reporting to him/her are aware of and held accountable for their

safety performance; d) Effecting the provisions of any operational directive, airworthiness directive, and any other

continued airworthiness requirements made mandatory by the authority; e) Management of safety risks in maintenance operations; and f) Ensuring that all safety matters are reported to the safety manager in a timely manner. Safety Authorities: The DOM - AOC has the following authorities: a) Regarding safety matters, he has direct access to the accountable manager and appropriate senior and

middle management. b) He is authorised to carry out safety audits and inspections in the maintenance department c) He is authorised to conduct internal safety investigations d) He is authorised to approve/decide on any mitigation actions to reduce risk to the safety of the

company aircraft maintenance operations. e) He is authorised to provide the necessary resources required to maintain an acceptable level of safety

of the company aircraft.

5.2.10 Director of Maintenance (AMO) – (DOM -AMO) Safety Accountabilities: The DOM-AOM is accountable to the accountable manager for the safety of all activities in the Maintenance Department. Safety Responsibilities: The DOM-AMO’s responsibilities are: a) To define and deploy technical staff and available resources; b) To estimate time and cost jobs and ensure that the technical department is able to meet its targets in

a cost effective manner; c) To arrange training in order to ensure that personnel are conversant with proper safety work

practices and procedures; d) To ensure acquisition of tools and equipment for the appropriate tasks; e) To ensure that personnel observe safety precautions at the workplace to prevent injury to staff and

damage to aircraft and equipment; f) To prioritize the purchasing of spares to ensure that the aircraft fleet will always have the needed

parts on time; g) To have in place a training program with focus for present and future needs; h) To negotiate for, monitor and implement third party agreements on behalf of ALS for contracted

maintenance arrangements;




i) Ensure that personnel comply with the appropriate manuals, KCAA regulations and manufacturers recommendations, and additionally to motivate staff so as to obtain a high degree of quality and safety on work performed on aircraft and other areas;

j) To accept delivery of aircraft on behalf of ALS from third party; k) To program and progress all work and ascertain that sound engineering practices and quality control

procedures are followed, and that entries on work sheets and work orders have been duly signed off by those responsible upon completion of each job;

l) Report to Accountable Manager regularly on department performance and fleet availability status. m) Management of safety risks in maintenance operations; and n) Ensuring that all safety matters are reported to the safety manager in a timely manner Safety Authorities: The DOM - AOM has the following authorities: a) Regarding safety matters, he has direct access to the accountable manager and appropriate senior and

middle management. b) He is authorised to carry out safety audits and inspections in the maintenance department c) He is authorised to conduct internal safety investigations d) He is authorised to approve/decide on any mitigation actions to reduce risk to the safety of the


of the company aircraft. 5.2.11 Safety Officer (S.O.) Safety Accountabilities: The Safety Officer is accountable to the Safety Manager for: • Providing advice and assurance relating to safety initiatives and requirements. • Establishing an effective corporate SMS • Maintenance of the Safety policy and the SMS • Setting safety policy and standards Safety Responsibilities: The S.O.s responsibilities are: a) Assisting the Safety Manager in managing the company’s SMS b) Recommending resource allocations in support of safety initiatives c) Providing advice and Assurance relating to Safety Initiatives and requirements d) Assisting the Safety Manager in organizing the ERP. e) Managing the Safety Databases. d) Conducting Hazard Identification.




e) Providing training on Safety Management Systems f) Conducting Safety surveys and audits. g) Running the ALS Safety Task Force Safety Authorities: a) Regarding safety matters, the SO has direct access to the Safety Manager and appropriate senior and

middle management. b) He is authorised to carry out safety audits and inspections. c) He is authorised to conduct internal safety investigations. d) He is authorised to make recommendations on any mitigation actions to reduce risk to the safety of

the flights operations Qualification and Competence Requirements: the Safety Officer shall possess the following skills, knowledge and experience: a) 2 years’ experience in aviation (Pilot/Maintenance/Operations/Flight Attendant). b) Completed a Safety Management Course recognised by the Authority. c) Have a complete understanding of safety systems and risk management. d) Have good communications skills e) Have good analytical skills. 5.2.12 Base Maintenance Engineer (B.M.E.) Safety Accountabilities: The Base maintenance is accountable to the accountable manager and the technical director for the safety of all activities in the Technical Department.

Safety Responsibilities: the B.M.E.’s responsibilities are:

a) Ensuring the safety of all activities in the technical department; b) Ensuring that the safety policies and procedures which govern maintenance procedures in the MPM

are complied with; c) Ensure that all staff reporting to him/her are aware of and held accountable for their safety

performance; d) Management of safety risks in the maintenance procedures; and e) Ensuring that all safety matters are reported to the safety manager in a timely manner.




Safety Authorities: The B.M.E. has the following authorities: a) Regarding safety matters, he has direct access to the accountable manager and appropriate senior and

middle management; b) He is authorised to carry out safety audits and inspections in the technical department c) He is authorised to conduct internal safety investigations d) He is authorised to approve/decide on any mitigation actions to reduce risk to the safety of the


in the technical department. 5.2.13 Line Maintenance Manager (LMM) Safety Accountabilities: The Line Maintenance Manager is accountable Technical Director for the safety of all activities of the Line Maintenance Section. Safety Responsibilities: The LMM ‘s responsibilities are: a) To ensure acquisition of tools and equipment for the appropriate tasks. b) To ensure that personnel observe safety precautions at the workplace to prevent injury to staff and

damage to aircraft and equipment. c) Ensure that personnel comply with the appropriate manuals, KCAA regulations and manufacturer’s

recommendations d) To motivate staff so as to obtain a high degree of quality and safety on work performed on aircraft

and other areas.

e) To allocate work to staff under his supervision and ensure that the tasks are completed in accordance with the company’s requirements and the procedures in this manual.

f) To ensure the line maintenance facilities are in good, clean and orderly condition, and that they are

adequate and safe for specific tasks. .

g) To train and assist line maintenance personnel in the proper safe work practices and procedures in their respective duties.

h) To ensure that the line maintenance personnel perform safe and quality work in compliance with best

engineering practices and quality control procedures. i) To ensure industrial safety precautions are strictly maintained to prevent injury to personnel or

damage to aircraft or equipment. j) To facilitate periodic drills for personnel in the proper use and location of fire fighting equipment

and ensure the equipment is adequate and regularly serviced as required by regulation.

k) To ensure tools and equipment are maintained in clean, serviceable and safe condition and keep an accurate list of such tools/equipment.




l) To follow the ALS Ltd Safety and Security policies and programs Safety Authorities: The LMM. has the following authorities: a) Regarding safety matters, he has direct access to the accountable manager and appropriate senior and

middle management; b) He is authorised to carry out safety audits and inspections in the line maintenance department c) He is authorised to conduct internal safety investigations d) He is authorised to approve/decide on any mitigation actions to reduce risk to the safety of the

company line maintenance operations. 5.3 All Other ALS Personnel Safety Accountabilities: All ALS personnel are accountable to their respective heads of department for the safe conduct of their duties. Safety Responsibilities: All ALS personnel have the following responsibilities: a) To comply with the relevant safety requirements and procedures outlined in the com[any safety

management systems manual and other duly authorized company manuals, instructions and notices; b) To apply safety measures as required by safety management procedures and instructions; c) To advise the safety manager of any safety occurrence or system failure and to identify and report

any situation of potential risk or concern affecting safety via one of the following means:-

− Submitting Occurrence /Hazard reports; − Team meetings; and − Reporting directly to the safety manager or their heads of department. − Supporting safety audits as and when they occur; and − Supporting safety investigations as and when they occur.

Safety Authorities: All ALS personnel have the following authorities: a) Regarding safety matters they have direct access to their respective heads of department and the

safety manager; b) They are authorized to make recommendations on any mitigation actions to reduce risk to the safety

of the company. 5.4 ALS Safety Task Force Refer to Section 10, 10.8 of this manual 5.5 ALS Safety Committee Refer to Section 10, 10.9 of this manual




5.6 Cross references The safety duties of other personnel are documented in the following documents: ALS Corporate Manual ALS Flight Operations Manuals – Parts A, B, C, D, E ALS Security Manual ALS Maintenance Control Manual ALS Maintenance Procedures Manual ALS Quality Management Manual ALS Field Station SOPs KCAA Regulations ICAO Document 9859




5.7 Safety Organization Chart

Accountable Manager

Director of Quality Assurance

Safety Manager

Safety Officer

ALS Safety Task Force

Finance Director

HR Manager

Security Manager

QA/Safety Auditors/Instructors

Safety Committee

Technical Director

Commercial Director

Director of Maint. (AOC)

Director of Flight Ops

Director of Maint.(AMO)

Chief Pilot



Issued 01July13 SAFETY REPORTING AND INVESTIGATIONS

Section 6 - Safety Reporting Contents 6.1 Introduction to Reporting Systems 3 6.2 Incident Reporting at ALS 3 6.2.1 Mandatory Incident Reporting 3 6.2.2 Voluntary and Confidential Incident/Hazard Reporting System 7 6.3 Handling Safety Reports 8 6.4 Safety Investigations 9 6.5 Safety Recommendations 11 6.6 Cross References 11 Appendix “A” – Occurrence/Hazard Report 13 Appendix “B” – ALS Voluntary and Confidential Report Form 15




6.1 Introduction to Reporting Systems 6.1.1 Safety management systems involve the reactive and proactive identification of safety hazards. Accident investigations reveal a great deal about safety hazards; but fortunately, aviation accidents are rare events. They are, however, investigated more thoroughly than incidents. Research leading to the 1:600 Rule1 has shown that the number of incidents is significantly greater than the number of accidents for comparable types of occurrences. The causal and contributory factors associated with the incidents may also culminate in accidents. Often only good fortune prevents an incident from becoming an accident. Unfortunately, these incidents are not always known to those responsible for reducing or eliminating the associated risks. This may be due to the unavailability of reporting systems, or people not being sufficiently motivated to report incidents. The purpose of Incident reporting is to improve the safety and reliability of the company’s operations and thereby to avoid accidents and serious incidents. It is not the purpose of the incident reporting scheme to apportion blame, but it must be appreciated that where there is clear evidence of serious negligence or incompetence, the company has a duty to take any action that may be necessary to ensure the future safety of its operations and customers.

6.1.2 Knowledge derived from incidents can provide significant insights into safety hazards. Although incidents may not be investigated in any depth, the anecdotal information they provide can offer meaningful insight into the perceptions and reactions of pilots, cabin crew, AME, ATC and aerodrome personnel. 6.1.3 Safety reporting is not restricted to incidents but includes reporting of hazards, i.e. unsafe conditions that have not yet caused an incident. Data from such reports facilitates an understanding of the causes of the hazards, helps define mitigation strategies and helps to verify the effectiveness of these mitigation strategies. Depending on the depth to which they are investigated, incidents can provide a unique means of obtaining first-hand evidence on the factors associated with mishaps from the participants. Furthermore, many reporters are able to offer valuable suggestions for remedial action. Incident data can also be used to improve operating procedures as well as to provide a better understanding of human performance associated with the operation of the aircraft. 6.2 Incident Reporting at ALS Limited 6.2.1 Mandatory Incident Reporting At ALS, and as required by the Kenya Civil Aviation Regulations, it is mandatory to report any incident involving an unsafe, or potentially unsafe, occurrence or condition, irrespective of whether it involves injury or property damage or not. The report is to be submitted to the Safety Manager or his designated representative (normally the Safety Officer, Operations Manager and/or line station Operations Officers) as soon as possible after the occurrence/incident but in any case not later than 48 hours after the accident/incident, The accident/incident report may be submitted in the format placed at Appendix “A” to this section or in any other format the user finds more suitable. The person reporting, at his own discretion, may or may not disclose his identity.

1 Research into industrial safety in 1969 indicated that for every 600 reported incidents/occurrences with no injury or damage, there were some: 30 incidents involving property damage 10 accidents involving serious injuries; and 1 major or fatal injury




It is mandatory to report the following occurrences / incidences: 6.2.1.1 Aircraft Flight Operations Control of Aircraft a) Rejected take-off resulting from or producing a hazardous or potentially hazardous situation (e.g. at

speeds close to, or above V1); b) Go around; c) Unintentional significant deviation from an intended track or altitude (more than 300ft), caused by

procedural, systems or equipment defect or human error; d) Heavy landing, e) Unintentional contact with the ground, including touching down before the runway threshold; f) Over-running the ends or sides of the defined runway or landing strip; g) Significant inadvertent reduction in airspeed; h) Significant loss of control from any cause; i) Approach to, or landing on, lining up on or taking off from a wrong runway or airfield; j) Occurrence of a “stick push” operation other than for training or testing; k) Operations of a primary warning system associated with manoeuvring of the aircraft (e.g.

configuration warning, stall warning (stick shaker), over speed warning, etc.) unless: - i) The crew conclusively established that the indication was false, at the time it occurred, or

ii) The indication is confirmed as false immediately after landing provided that, in either case, the false warning did not result in difficulty or hazard arising from the crew response to the warning;

l) Reversion to manual control of powered primary controls, other than for training or test purposes; m) Inadvertent incorrect operation of any controls which resulted in, or could have resulted in, a

significant hazard; n) A hazard or potential hazard which arises as a consequence of any deliberate simulation of failure

conditions for training, systems checks or test purposes; o) In flight fuel quantity critically low or exhausted; p) Significant fuel imbalance; q) Incorrect setting of an SSR code; r) Incorrect setting of an altimeter sub-scale; s) Significant incorrect programming of navigation equipment; t) Flight at a level, or on a route, different from that allocated; u) Incorrect receipt or interruption of RTF messages which resulted in, or could have resulted in, a

significant hazard; v) GPWS “warning” w) ACAS / TCAS Resolution Advisory x) Repetitive arising at an excessive frequency of a specific type of occurrence which in isolation

would not be considered “Reportable”, e.g. a high frequency of :-

i) Minor loading errors at a particular field; ii) GPWS nuisance warnings at a particular field;

Emergencies: a) The use of flight or on ground of any emergency equipment or prescribed emergency procedure in

order to deal with a situation; b) The use of any non0standard procedure adopted by the flight crew to deal with an emergency;




c) The declaration of an emergency (“MAYDAY” or “PAN”) d) An emergency, forced or precautionary landing; e) Failure of any emergency equipment or procedures to perform satisfactorily including when being

used for training or test purposes. Crew Incapacitation: a) Incapacitation of any crew member of the flight deck operating crew, including that which occurs

prior to departure if it is considered that it could have resulted in incapacitation after take-off; b) Incapacitation of any member of the cabin crew which renders him / her unable to perform essential

emergency duties. Injury: Any significant injury to any person which directly results from the operation of the aircraft or its equipment but which is not considered to constitute a reportable accident. Other Incidents: a) A lightning strike which resulted in significant damage to the aircraft or the loss or malfunction of

any essential service; b) A hail strike which resulted in significant damage to the aircraft or the loss or malfunction of any

essential service; c) A bomb threat; d) A hijack; e) Wake vortex encounter – an encounter resulting in significant handling difficulties; f) A bird strike which resulted in significant damage to the aircraft or the loss or malfunction of any

essential service; g) Turbulence encounter – an encounter resulting in injury to occupants or deemed to require a

“turbulence check” of the aircraft. 6.2.1.2 Aircraft and Equipment – Failures, Malfunction’s and Defects a) Fires during flight and whether the related fire-warning system functioned properly; b) Fires during flight not protected by a related fire-warning system; c) False fire warning during flight; d) An engine exhaust system that causes damage during flight to the engine, adjacent structure,

equipment, or components; e) An aircraft component that causes accumulation or circulation of smoke, vapour, or toxic or noxious

fumes in the crew compartment or passenger cabin during flight; f) Engine shutdown during flight because of flameout; g) Engine shutdown during flight when external damage to the engine or the aircraft structure occurs; h) Engine shutdown during flight due to foreign object ingestion or icing; i) Shutdown during flight of more than one engine; j) A propeller feathering system or ability of the system to control over-speed during flight; k) A fuel or fuel-dumping system that affects fuel flow or causes hazardous leakage during flight; l) A landing gear extension or retraction, or opening or closing of landing gear doors during flight; m) Brake system components that result in loss of brake actuating force when the aircraft is in motion

on the ground; n) Aircraft structure that requires major repair;




o) Cracks, permanent deformation, or corrosion of aircraft structure, if more than the maximum acceptable to the manufacturer or the Authority;

p) Aircraft components or systems that result in taking emergency actions during flight (except action to shut down an engine);

q) Each interruption to a flight, unscheduled change of aircraft en route, or unscheduled stop or diversion from a route, caused by known or suspected mechanical difficulties or malfunctions;

r) Any abnormal vibration or buffeting caused by a structural or system malfunction, defect or failure; s) A failure or malfunction or more than one attitude, airspeed or altitude instrument during a given

operation of the aircraft; t) The number of engines removed prematurely because of malfunction, failure or defect listed by

make and model and the aircraft type in which it was installed; and u) The number of propeller featherings in flight, listed by type of propeller and engine and aircraft on

which it was installed. 6.2.1.3 Ground Services, Facilities or Equipment a) Air Traffic Services i) Provision of significantly incorrect, inadequate or misleading information from any ground sources,

e.g. ATC, ATIS. Meteorological Services, maps, etc; ii) Provision of less than prescribed terrain clearance; iii) Provision of incorrect altimeter setting; iv) Misidentification of aircraft by an ATCO or radar operator; v) Incorrect transmission, receipt or interpretation of significant messages; vi) Airprox and any occurrence in which separation between aircraft is less than that prescribed for the

situation; vii) Non-compliance with prescribed let-down departure procedures or any ATC / ATM instruction; viii) Declaration of an emergency (“MAYDAY” or “PAN”) ix) Unauthorized infringement of any form of regulated airspace; x) Unauthorized or illegal RTF transmissions; xi) ATC Overload reports; xii) Declaration of an ACS Resolution advisory by an aircraft. b) Navigation and Communications Equipment etc. – failures, malfunctions or defects i) Total failure of the navigation system or subsystem used by an aircraft; ii) Total failure of communications system; iii) Total failure of radar system or subsystem; iv) Significant malfunction or deterioration of service; c) Airfields and Airfield Facilities:’ i) Failure or significant malfunction of airfield lighting; ii) Major failure or significant deterioration of surfaces of runways or aircraft manoeuvring areas; iii) Runway incursions iv) Runways or aircraft manoeuvring areas obstructed by aircraft, vehicles or foreign objects; v) Errors or inadequacies in markings of obstructions or hazards on runway or aircraft manoeuvring

areas; vi) Collision between a moving aircraft and any other aircraft, vehicle, ground object or animals; vii) Jet or prop blast incidents resulting in significant damage or serious injury; viii) Significant spillage of fuel on airfield rams.




d) Passengers/Baggage/Cargo: i) Difficulty in controlling intoxicated, violent or armed passengers; ii) Incorrect loading of passengers, baggage or cargo, likely to have a significant effect on aircraft

weight and balance; iii) Incorrect stowage of baggage or cargo likely in any way to hazard the aircraft, its equipment or

occupants or to impede emergency evacuation (includes hand baggage): iv) Significant contamination of aircraft structure, systems or equipment arising from the carriage of

baggage or cargo; v) Presence of stowaway(s). e) Aircraft Ground Handling/Servicing i) Loading of incorrect fuel quantities likely to have a significant effect on aircraft weight and balance; ii) Loading of contaminated or incorrect type of fuel or other essential aircraft fluids (includes oxygen

and water); iii) Significant spillage of fuel; Any other occurrence of any type considered to have endangered, or which might have endangered, the aircraft or its occupants. 6.2.2 Voluntary and Confidential Incident/Hazard Reporting System The Key objective of the company’s voluntary and confidential reporting system is to enhance the safety of our company’s aviation activities through the collection of reports on actual or potential safety deficiencies that would otherwise not be reported through other channels. Such reports may involve occurrences, hazards or threats relevant to the safety of the company’s activities. This system does not eliminate the need for formal reporting of accidents and incidents according to the company’s SOPs and reporting policy, as well as the submission of mandatory occurrence reports. The ALS voluntary and confidential reporting system is a voluntary, non-punitive, confidential occurrence and hazard reporting system administered by the company Safety Department. It provides a channel for the voluntary reporting of aviation occurrences relevant to the company’s aviation activities, while protecting the reporter’s identity. The scope of the aviation sectors/areas covered by the system is as follows: a) flight operations; b) hangar aircraft maintenance; c) engineering planning; d) technical services; e) technical records; f) line maintenance; g) ground operations. Any person can make or submit a report.




The company’s voluntary and confidential reporting system pays particular attention to the need to protect the reporter’s identity when processing all reports. Every report will be read and validated by the safety manager. The safety manager may contact the reporter to make sure he understands the nature and circumstances of the occurrence/hazard and/or to obtain the necessary additional information and clarification. The manager will then de-identify the information and enter the data into the company’s safety database. Should there be need to seek input from any third party, only the de-identified data will be used. Relevant de-identified reports may be shared within the company as well as with external aviation stakeholders as deemed appropriate. This will enable all concerned personnel and departments within the company review their own operations and support the improvement of aviation safety as a whole. The reports may be submitted by filing in the ALS Voluntary and Confidential Report Form (See Appnedix “B” 6.3 Handling Safety Reports 6.3.1 The safety reports received will be handled with confidentiality as far as the names and identities are concerned. The reports which are mandatory to be sent to the KCAA will be sent and followed up with a brief investigation report, where applicable. 6.3.2 All reports will be prioritized and handled based on urgency. Those requiring immediate and urgent attention will be marked “High” and filed in a file marked “urgent reports – high priority”. These reports will be urgently analyzed and corrective action taken within 1 – 2 weeks. Reports which require quick but not urgent attention will be marked “Medium” and filed in a file marked “Medium reports”. These reports will be analyzed and corrective action taken within 2 – 4 weeks. Reports which are informative will be marked “Low” and filed in a file marked “low priority reports”. Actions on these reports, if required, will be taken within 8 weeks. After reports have been analyzed and corrective action(s) taken they will be filed in a file marked “finalized reports”. 6.3.3 In any case, each report would be investigated, analyzed and entered in a database. A trend projection and cause-effect analysis would be carried out and feedback provided to the management. Based on the above analysis, the need to review or reassess any safety measure will be evaluated, documented and acted upon accordingly. 6.3.4 In order to ensure buildup of confidence in the system, it is important to provide a feedback to the reporting employee on what action, if any, was taken on the report. It is important to remember that this feedback is even more important when no action was taken since in the absence of any visible action, the users may lose confidence in the system and stop reporting matters altogether. 6.3.5 In the event that the report received was anonymous, this feedback may be circulated in the form of a notice board entry or email containing a brief statement of the problem and action taken to resolve the same without referring to the fact that the same was a result of an anonymous report




6.4 Safety Investigations 6.4.1 Effective safety management systems depend on the investigation and analysis of safety issues. The safety value of an accident, a hazard or an incident is largely proportional to the quality of the investigative effort. 6.4.2 Major accidents, especially if fatalities occur, will be investigated by the official agencies. 6.4.3 Most occurrences do not warrant an investigation. Nevertheless, such incidents may be indicative of potentially serious hazards – perhaps systematic problems that will not be revealed unless the occurrence is properly investigated. 6.4.4 For every accident or serious incident, there will likely be hundreds of minor occurrences, many of which have the potential to become an accident. It is important that all reported hazards and incidents be reviewed and a decision taken on which ones should be investigated and how thoroughly. 6.4.5 It is important that all incident reports should include sufficient information for the incident to be fully assessed by the Safety Manager. The Chief Pilot and the Base Maintenance Engineer / DOM (AMO) are to ensure that both aircrew and engineering sections give a full account of the incident, its causes and its consequences both actual and potential. 6.4.6 The investigation of all incidents is a joint Operations/Engineering task and is to be carried out as a coordinated exercise by the Safety Manager, Chief Pilot/Director of Flight Operations and the Base Maintenance Engineer / DOM (AOM). In the case of serious incidents, the investigation is to be conducted formally and both the Operations and Engineering investigators are to be senior members of the investigating team (E.g. Training Captain, Deputy Chief Pilot). Both investigators should present be present at all interviews, component inspections, etc. and their report should be jointly produced. 6.4.7 The Investigation team, besides identifying the “what”, “who”, “when” and “how” of the incident will also focus on organizational processes, latent conditions, workplace conditions, human factors, adequacy of defenses as well as the active failures. 6.4.8 ALS will use the Integrated Safety Investigation Methodology (ISIM) in investigating Accidents and Incidents. (See below for steps and flow chart)




Accident, Incident, Hazard or Occurrence notifcation

Data collection process

Sequence of events

Integrated investigation

Risk Assessment process

Defense Analysis

Risk Control Analysis

Safety communication process

Identify events and underlying factors

Reconstruct logical progression of occurrence events

Assess notification and decide to investigate or not

Analyze facts and determine findings regarding underlying factors and hazards

Estimate risk acceptability for each

hazard

Identify defenses that are missing or inadequate

Identify and evaluate risk control options

Communicate safety message to stakeholders




6.5 Safety Recommendations 6.5.1 When an investigation identifies hazards or unmitigated risks, safety action is required. The need for action must be communicated by means of safety recommendations to those with the authority to expend the necessary resources. Failure to make appropriate recommendations may leave the risk unattended. When formulating safety recommendations the following considerations may apply:

a) Action Postholder. Who can take the necessary corrective action? Who has the necessary authority

and resources to intervene? Ideally, problems should be addressed at the lowest possible level of authority, such as the departmental head as opposed to the Accountable Manager.

b) What versus how. Safety recommendations should clearly articulate what should be done, not how

to do it. The focus is on communicating the nature of the risks requiring control measures. Detailed safety recommendations which spell out exactly how the problem should be fixed, should be avoided. The responsible manager should be in a better position to judge the specifics of the most appropriate action for the current operating condition. The effectiveness of any recommendation will be measured in terms of the extent to which the risks have been reduced, rather than strict adherence to the wording of the recommendation.

c) General versus specific wording. Since the purpose of the safety recommendation is to convince

others of an unsafe condition putting some or all of the system at risk, specific language should be used in summarizing the scope and consequences of the identified risk.

d) Recipient’s perspective. In recommending safety action, the following considerations pertain to the

recipient’s perspective:

1. The safety recommendation is addressed to the most appropriate authority (i.e. the one having the jurisdiction and authority to effect the necessary change).

2. There are no surprises (i.e. there has been prior dialogue concerning the nature of the

assessed risks).

3. It articulates what should be done, while leaving the recipient with the latitude to determine how best to meet the objective.

6.5.2 In ALS safety recommendations will be by written communications. This will ensure that the recommendations are not misunderstood and provide the necessary baseline for evaluating the effectiveness of implementation. However it is important to remember that safety recommendations are only effective if they are implemented. 6.6 Cross References a) Flight Operations Manuals b) Quality Assurance Manuals c) Maintenance Control Manual d) Maintenance Procedures Manual e) Corporate Manual f) ICAO Document 9859 – SMS Manual




Appendix A

Rev 002, Date: 1st July 2013 PTO for Risk Assessment

OBSERVED HAZARD &

OCCURRENCE REPORT.

REPORT DATE:

REPORT CLASSIFICATION HAZARD TO FLIGHT SAFETY TECHNICAL INCIDENT AIRCRAFT ACCIDENT INCLUDING MINOR DAMAGE OTHER _____________________________________

YOUR NAME : CONTACTS:

CAPACITY / OCCUPATION:

AIRCRAFT TYPE: AIRCRAFT REG: CALL SIGN: NUMBER OF CREW ONBOARD: PIC NAME: PASSENGERS ONBOARD: ORIGIN: DESTINATION: DATE OF OBSERVATION:

TIME OF OBSERVATION (UTC):

LOCATION OF HAZARD / OCCURRENCE: DESCRIPTION / OCCURRENCE DETAILS ( Use additional pages if necessary): POSSIBLE DAMAGE:

PROBABLE CAUSES / SUGGESTED REMEDY / RECOMMENDATIONS BY REPORTER: ENGINEERING / OPERATIONS COMMENTS:




Rev 002, Date: 1st July 2013

Risk Assessment Matrix Risk Probability

(Likelihood)

Risk Severity Catastrophic

(Multiple fatalities, Equipment Destroyed)

A

Hazardous ( Serious Injury

Equipment damage)

B

Major (Slight Injury,

small damage)

C

Minor (Use of abnormal

procedures)

D

Negligible ( Little

consequences)

E Frequent (Highly Likely) 5 5A 5B 5C 5D 5E Occasional (Likely Sometimes) 4 4A 4B 4C 4D 4E Remote (Unlikely) 3 3A 3B 3C 3D 3E Improbable (Very Unlikely) 2 2A 2B 2C 2D 2E Extremely Improbable (Highly Unlikely)

1 1A 1B 1C 1D 1E

Reporters Risk Assessment (Place the Index chosen in the box) Risk Assessment Index Suggested Criteria

5A, 5B, 5C, 4A, 4B, 3A Unacceptable under the existing circumstances. Risk mitigation critical. (Unacceptable)

5D, 5E, 4C, 3B, 3C, 2A, 2B Risk Mitigation required. It might require management decision. (Tolerable)

4D, 4E, 3D, 2C, 1A, 1B Acceptable after the review of Operations. (Acceptable)

3E, 2D, 2E, 1C, 1D, 1E Acceptable but monitor ( Acceptable)

REPORTER’S SIGNATURE: DATE:

Safety Department use: ACTIONS TAKEN TO MITIGATE RISK: (State “No Action Required” if none taken) RISK ASSESSMENT PRIORITY: HIGH MEDIUM LOW INITIAL RISK ASSESSMENT: FINAL RISK ASSESSMENT:

ASSESSING OFFICER NAME: DATE: REPORT REF No:




Appendix “B” – ALS Voluntary and Confidential Report Form The information supplied in this form will only be used to enhance safety. You may choose to not provide your name. If you do provide your name, upon receipt of this form your name and position will be removed and discarded. Under no circumstances will your identity be disclosed to any person in the airport or to any other organization, agency or person without your express permission. When you have completed your part of the form, it should be given to the ALS Safety Manager or his alternate.. Name: ______________________________________________ Department / Position: ___________________________________

[Name and position to be discarded by the Safety Manager]

PART A

TO BE COMPLETED BY THE PERSON IDENTIFYING THE HAZARD

Please fully describe the Hazard. . Date of occurrence: ___________________ Time: _________________ Location: _________________________ Description:_____________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

In your opinion, what is the likelihood of a similar occurrence happening again? Likely Rare 1 2 3 4 5 What do you consider could be the worst possible consequence if this occurrence did happen again? Catastrophic Minor damage 1 2 3 4 5 Rev 000 Date: 01 July 2013 Page 1 of 2




PART B TO BE COMPLETED BY THE SAFETY MANAGER

The report has been de-identified and entered into the company database Signature: ______________________ Date: ___________________

Name___________________________ Rate the likelihood of the hazard recurring Very Likely Rare 1 2 3 4 5 Rate the worst-case consequences Catastrophic Minor Damage 1 2 3 4 5 What action is required to ELIMINATE or CONTROL the hazard and PREVENT injury?

Resources Required:

________________________________________________________________

Responsibility for action:_____________________________________________

________________________________________________________________

Referred to ______________________ for further action. Signature: ______________________________ Date: _________________ Forwarded to the ALS Safety Committee for review. Signed: ________________________________ Date: ____________________ Appropriate Feedback given to staff. Signed _______________________________ Date_________________ Rev 000 Date: 01 July 2013 Page 2 of 2



Issued 01July13 HAZARD IDENTIFICATION AND RISK ASSESSMENT

Section 7 - Hazard Identification and Risk Assessment Contents 7.1 General 3 7.2 Hazard Identification 3 7.3 Risk Assessment 6 7.3.1 General 6 7.3.2 Risk Management 6 7.3.3 Risk Probability 7 7.3.4 Risk Severity 7 7.3.5 Risk Index 8 7.3.6 Risk Tolerability 9 7.4 Risk Mitigation 10 7.5 Implementation Procedure 11 7.6 Cross References 12 Appendix “A” – Hazard and Risk Assessment and Mitigation 13




7.1 General 7.1.1 Safety is a condition in which the risk of harm or damage is limited to an acceptable level. The safety hazards creating risk may become evident after an obvious breach of safety, such as an accident or incident, or they may be proactively identified through formal safety management programs before an actual safety event occurs. Having identified an actual safety hazard, the associated risks must be assessed. With a clear understanding of the nature of risks, a determination can be made as to the “acceptability” of the risks. Those found to be unacceptable must be acted upon. 7.1.2 Safety management is centered on such a systematic approach to hazard identification and risk management – in the interests of minimizing loss of human life, property damage, and financial, environmental and social issues. 7.2 Hazard Identification 7.2.1 Hazard Identification is a process where organizational hazards are identified and managed so that safety is not compromised. Organizations may employ a range of safety activities to identify hazards that may jeopardize part of its operations or may weaken its safety defenses. 7.2.2 There is a natural (and erroneous) tendency to describe hazards as an outcome. For example, “runway incursion” is an outcome, not a hazard. On the other hand, “unclear aerodrome signage” is a hazard, not an outcome. Mistaking hazards as outcomes disguise their nature and interfere with proper identification of actual outcomes or risks associated with those hazards. A correctly named hazard will enable the tracking of its source or origin on the one hand and identification of its potential outcome(s) or risk(s) on the other. Following are some examples of hazards: • Flight Operations: Unfamiliar phraseology, inclement weather, birds in take-off path, heavy traffic,

unfamiliar airports, high terrain around airport, etc.

• Aircraft Maintenance: Fuel vapor from open wing tanks, discrepant test equipment, ambiguous work instructions, improper shift handover procedures, etc.

The scope for hazards in aviation is wide, and may be related to:

• Procedures and operating practices, such as documentation and checklists • Communications, such as means and terminology • Organizational factors, such as company policies for recruitment, training, remuneration and allocation

of resources • Work environment factors, such as ambient noise and vibration, temperature, lighting and protective

equipment and clothing • Human factors, such as medical conditions, circadian rhythms and physical limitations 7.2.3 In ALS, hazards will be identified through ALS’s reactive, proactive and predictive processes. This will include the company’s voluntary and confidential reporting system, audits and surveys, accident and incident reports as well as industry incident/accident reports. 7.2.4 The hazard identification process will be open to any employee. It may be done through formal as well as informal processes. It may be performed any time as well as under specific conditions. Specific conditions would include: • When there is an unexplained increase in safety-related events or infractions. • When there is an abnormal audit or safety indicator trends




• When major operational changes are planned • Before a new project, equipment, facility is set up • During a period of significant organizational change • Before starting a new contract. • Before operating a new aircraft type • Before starting a new route • The implementation of new systems such as TCAS II/EGPWS, etc. • The implementation of new procedures, company and/or regulatory. • When there are hazards associated with weather. • Hazards associated with airstrips. • When there are operations in conflicting traffic in airspace without radar coverage. • When there is an issue with flight following capabilities in uncontrolled airspace. In essence the three steps of hazard management are: • State the generic hazard (hazard statement), e.g. airport construction • Identify specific components of the hazard, e.g. construction equipment • Project specific risk(s) associated with each hazard, e.g. aircraft colliding with construction equipment 7.2.5 All hazards identified will also be documented. See Appendix “A” to this section for example of document log. 7.2.6 See next page for Hazard Documentation and follow up-risk management flowchart which will be employed by ALS.




Risk Management flow chart

SAFETY INFORMATION MANAGEMENT SYSTEM

RISK MANAGEMENT DOCUMENTATION

Reactive method - MOR - Incident reports - Accident reports

Proactive method - Surveys - Audits - Voluntary hazard reporting

Predictive method - FDA - Direct observation systems

Assess the consequence and prioritize the hazard

Develop control and mitigate actions

- Bulletins - Safety reports - Seminars and workshops

Approve and implement actions

HAZARD

HAZARD

COLLECT ASSESS MITIGATE MANAGE DISSEMINATE




7.3 Risk Assessment 7.3.1 General Having confirmed the presence of a safety hazard, some form of analysis is required to assess its potential for harm or damage. Typically, this assessment of the hazard involves three considerations: a) The probability of the hazard precipitating an unsafe event; b) The severity of the potential adverse consequences, or the outcome of an unsafe event; and c) The rate of exposure to the hazards. The probability of adverse conditions may become greater due

to increased exposure to the unsafe conditions. Thus, exposure may be viewed as another dimension of probability.

7.3.2 Risk Management 7.3.2.1 Risk management is the identification, analysis and mitigation of risks associated with the operation of an organization. It aims at a balanced allocation of resources to address all risks and ensure that viable risk control and mitigation actions are in place. 7.3.2.2 Risk management is a key component of safety management systems. It is a data- driven approach to safety management resource allocation i.e. priority is allocated to activities based on their risk index. 7.3.2.3 In ALS the following process as depicted by the flowchart shall be used in risk management:




7.3.3 Risk Probability 7.3.3.1 Risk Probability is the likelihood that a situation of danger might occur. Certain questions may be used to guide the assessment of probability, such as: • Is there a history of the occurrences like the one being assessed, or is the occurrence an isolated event? • What other equipment, or similar types of components might have similar defects? • What number of operations or maintenance personnel must follow the procedure(s) in question? • How frequently is the equipment or procedure under assessment used? • Are there organizational, management or regulatory implications that might generate larger threats to

public safety? 7.3.3.2 The company uses the following risk probability table (Table 1) for assessing risk probabilities:

Likelihood Meaning Value

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

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

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

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

Extremely improbable Almost inconceivable that the event will occur 1

Table 1 – Safety risk probability table

7.3.4 Risk Severity 7.3.4.1 Risk severity measures the possible consequences of a situation of danger, taking as reference the worst foreseeable situation. Severity may be defines in terms of property, health, finance, liability, people, environmental, image, or public confidence. Certain questions may be used to guide the assessment of severity, such as: • How many lives are at risk (e.g. employees, passengers, bystanders, general public)? • What is the environmental impact (e.g. spillage of fuel or hazardous products, physical disruption of

natural habitats)?) • What is the severity of property, financial damage (e.g. direct asset loss; third party damage, financial

impact and economic impact for the company)? • What is the damage to the company’s reputation?




7.3.4.2 The company uses the following values in Table 2 when determining risk severity:

Severity Meaning Value

Catastrophic − Equipment destroyed − Multiple deaths

A

Hazardous − 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

B

Major − A significant reduction in safety margins, a reduction in the ability of the operators to cope with adverse conditions as a result of an increase in workload or as a result of conditions impairing their efficiency

− Serious incident − Injury to persons

C

Minor − Nuisance − Operating limitations − Use of emergency procedures − Minor incident

D

Negligible − Few consequences E

Table 2 – Safety risk severity table

7.3.5 Risk Index 7.3.5.1 Once the risk probability and risk severity values are determined, they will together constitute the “Risk Index” for that occurrence. The complete “Risk Index” matrix is shown in Table 3. The tolerability and action required for each index is reflected in the Risk Acceptability Table (Table 4).

Risk Probability

Risk Severity

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 1 improbable 1A 1B 1C 1D 1E

Table 3 – Safety risk assessment matrix




7.3.6 Risk Tolerability The index obtained from the risk assessment matrix is exported to the risk tolerability matrix. The tolerability matrix describes the tolerability criteria for the company. For example, if the safety risk is assessed as 4B, the criteria for the risk assessed falls in the “unacceptable under the existing circumstances” category and the safety risk index is unacceptable. The company must therefore: a) take measures to reduce the reduce the company’s risk exposure to the particular risk, i.e. reduce the

likelihood component of the risk index; b) take measures to reduce the severity of consequences related to the hazard, i.e. reduce the severity

component of the risk index; or c) cancel the operation if mitigation is not possible.

Assessed risk index

Criteria Recommended action

5A, 5B, 5C, 4A, 4B, 3A

High risk Unacceptable under

the existing circumstances

Cease or cut back operation promptly if necessary. Perform priority risk mitigation to ensure that additional or enhanced preventive controls are put in place to bring down the risk index to moderate or low range.

5D, 5E, 4C, 4D, 4E, 3B, 3C, 3D, 2A, 2B, 2C, 1A

Moderate risk Acceptable based on

risk mitigation. It may require management

decision

Schedule performance of a safety assessment to bring down the risk index to the low range if viable

3E, 2D, 2E, 1B,

1C, 1D, 1E

Low risk Acceptable

Acceptable as is. No further risk mitigation required.

Table 4 – Safety risk tolerability matrix




7.4 Risk Mitigation 7.4.1 Risk mitigation is the process of implementing actions or defenses to eliminate or reduce the probability or severity of risks associated with hazards. The basic defenses employed in ALS are Technology, Training and Procedures (regulations). 7.4.2 When analyzing defenses during a mitigation process, the following questions may be useful: • Do defenses to protect against such risk(s) exist? • Do defenses function as intended? • Are the defenses practical for use under actual working conditions? • Are the personnel involved aware of the risks and the defenses in place? • Are additional risk mitigation measures required? 7.4.3 The three generic safety risk mitigation approaches used by ALS are: a) Avoidance. The activity is suspended either because the associated safety risks are intolerable or

deemed unacceptable vis-à-vis the associated benefits.

b) Reduction. Some safety risk exposure is accepted, although the severity or probability associated with the risks are lessened, possibly by measures that mitigate the related consequences.

c) Segregation of exposure. Action is taken to isolate the potential consequences related to the hazard or to establish multiple layers of defences to protect against them.

7.5 Implementation Procedure 7.5.1 In ALS the risk assessment and mitigation is to be carried out as per the following seven step process:

Step 1: Development of a complete operation/procedure to be evaluated and of the environment in which the operation/procedure is to be operated;

Step 2: Identification of hazards; Step 3: Estimation of the severity of the consequences of a hazard occurring; Step 4: Estimation of the likelihood of a hazard occurring; Step 5: Evaluation of the safety risks of the hazard; Step 6: Mitigation of the risks; and Step 7: Development of the safety assessment documentation.

7.5.2 The hazards will be entered and documented in the hazards and risk assessment log as per the log shown in Appendix 1 7.5.3 A risk mitigation strategy may involve one of the approaches described above or may include multiple approaches. It is important to consider the full range of possible control measures to find the




optimal solution. The effectiveness of each alternative strategy must be evaluated before a decision can be taken. Each proposed safety risk mitigation alternative should be examined from the following perspectives: a) Effectiveness. The extent to which the alternatives reduce or eliminate the safety risks. Effectiveness

can be determined in terms of technical, training or regulatory defences that can reduce or eliminate safety risks.

b) Cost/benefit. The extent to which the perceived benefits of the mitigation outweigh the costs. c) Practicality. The extent to which mitigation can be implemented and how appropriate it is in terms

of available technology, financial and administration resources, legislation and regulations, political will, etc.

d) Acceptability. The extent to which the alternative is consistent with the stakeholder paradigms. e) Enforceability. The extent to which compliance with new rules, regulations or operating procedures

can be monitored. f) Durability. The extent to which the mitigation will be sustainable and effective. g) Residual safety risk. The degree of safety risk that remains subsequent to the implementation of the

initial mitigation and which may necessitate additional risk control measures. h) Unintended consequences. The introduction of new hazards and related safety risks associated with

the implementation of any mitigation alternatives. 7.5.4 Risk assessment and mitigation flow chart: Hazard Identification Risk analysis Probability Risk analysis Severity Risk assessment And tolerability Risk control / mitigation

Equipment, procedures, organization, etc.

Analyse the likelihood of the consequence occurring

Evaluate the seriousness of the consequence if it does

Is the assessed risk(s) acceptable and within the company’s safety performance?

Yes, accept the risk(s) No, take action to reduce the risk(s) to an acceptable level




7.5.5 Risk mitigation at a glance.

7.6 Cross References a) Flight Operations Manuals b) Quality Assurance Manuals c) Maintenance Control Manual d) Maintenance Procedures Manual e) Corporate Manual f) ICAO Document 9859 – SMS Manual

Risk mitigation at a glance

Feedback (Safety assurance)

Hazard/consequence identification

Does it address the risk(s)?

Is it effective?

Is it appropriate?

Is additional or different mitigation warranted?

Do the mitigation strategies generates additional risk(s)

H H H H

R R R R

Each

Each Risk

Intolerable

Tolerable

Acceptable region




Appendix A – Hazard and Risk Assessment and Mitigation Log (With example entries)

Type of operation or

activity Generic hazard

Specific components of the

hazard Hazard-related consequences

Existing defences to control risk(s) and risk index

Further action to reduce risk(s) and resulting risk index Responsible person

Flight operations

All weather operations at an aerodrome where one of the two parallel runways is closed due to a construction work.

(Example only.)

Aircraft taking off or landing on a closed runway.

(Example only.)

Aircraft colliding foreign object.

(Example only.)

1. NOTAM issued by the aerodrome manager to notified users on the construction work on the closed runway.

2. ATIS 3. Aerodrome layout available

in the national AIP 4. New signage and lighting 5. Company operations manual 6. Dispatch performance

manual 7. Aircraft operating manual 8. Flight crew competency

requirements in AWOP. 9. Recurrent training 10. CRM training (Example only, not related to the present case study) Risk index: 3A Risk tolerability: Unacceptable under the existing circumstances

1. Ensure that flight dispatchers and operations officers inform flight crew on the risk of taking mistakenly the closed runway.

2. Ensure that flight crew is aware of the current layout of the aerodrome.

3. Issuance of company NOTAM concerning the closed runway and new routing on the movement area.

4. Review of the Low Visibility Operations (LVO) during training sessions.

5. Review procedures in the Company Operations Manual and Route Manual.

(Example only, not related to the present case study Risk index: 1A Risk tolerability: Acceptable after review of the operation

1. Director of the operations control centre (OCC)

2. Chief pilot 3. Head of Flight

operations engineering 4. Flight training manager 5. Head of Documentation

Department 6. (Example only, not

related to the present case study)



Issued 01July13 PERFORMANCE MONITORING & MEASUREMENT

Section 8 - Safety Performance Monitoring and Measurement Contents 8.1 Safety Performance Indicators 3 8.2 Process to Maintain & Develop the Safety Performance Indicators 3 8.3 ALS Safety Performance Targets and Indicators 4




8.1 Safety Performance Indicators 8.1.1 Safety performance indicators (parameters) are generally data based expressions of the frequency of occurrence of some safety/quality related events, incidents or reports. These occurrence data may be reactive, proactive or predictive in nature. There is no single safety performance indicator that is appropriate to all organizations. The indicator(s) chosen by the company shall correspond to the company’s relevant safety objectives or goals. 8.1.2 The safety performance indicators are used to monitor known safety risks, detect emerging safety risks and to determine any necessary corrective actions. 8.2 Process to Maintain and Develop the Safety Performance Indicators 8.2.1 In ALS the safety performance indicators will be developed by each head of department for his/her department. 8.2.2 When setting the safety performance indicators each head of department should consider factors such as the company’s safety risk tolerance, the cost/benefits of implementing improvements to the system, regulatory requirements and public expectations. 8.2.3 These will then be discussed in the Safety Committee. The Safety Committee will then decide on the final safety performance indicators for each department and the company as a whole. The Safety Committee will also decide on the corresponding alerts and the targets values of each safety performance indicator. 8.2.4 When deciding on the target and settings, the safety committee will take into account the recent historical performance for a given indicator. Desired improvement targets set should be realistic and achievable for the company. 8.2.5 The safety committee will set both high-consequence as well as lower-consequence performance indicators. This will ensure that high-consequence outcomes (e.g. accidents, and serious incidents) as well as lower-consequence events (e.g. incidents, non-conformance reports, and deviations) are addressed. 8.2.6 The target and alert level for each indicator will be tracked for their respective performance status. A consolidated summary of the overall target and performance outcome of the complete safety performance shall also be compiled / aggregated every 6 months and discussed in the safety committee meetings. When an unacceptable or an abnormal trend is seen the safety committee will make recommendations on improving the safety performance. High-consequence indicators shall be addressed first while lower-consequence indicators shall be addressed later. These recommendations will be given to all Heads of Departments who will ensure that these are implemented in their respective departments.




8.3 ALS Safety Performance Targets and Indicators ALS has set the following targets for the time being:

ALS Safety performance indicators

High-consequence indicators (occurrence/outcome based)

Lower-consequence indicators (event/activity based)

Safety performance

indicator

Alert level criteria

Target level criteria

Safety performance indicator

Alert level criteria

Target level criteria

Individual fleet monthly serious incident rate per 1000 FH

5% improvement between each annual mean rate.

Occurrence/Hazard Reports received per 1000 FH

30 + 5% improvement annually

Combined fleet monthly serious incident rate per 1000 FH

5% improvement between each annual mean

Technical incidents per fleet per 100FH

5% improvement annually

Engine IFSD incident rate per 1000 FH


Internal SMS audits findings per audit

10 5% improvement annually

Quarterly rate of component mandatory/major defect reports raised due to internal quality issues


External audit findings per audit

5 5% improvement annually

Maintenance write-ups per aircraft for the first 10 days after a “major check”

3 5% improvement between each annual mean

Technical concession application rate per annum

2 1

Average fleet MEL application rate per 1000 FH

10 to 30 < 10



Issued 01July13 SAFETY TRAINING, COMMUNICATION & PROMOTION

Section 9 - Safety Training, Communication and Promotion Contents 9.1 Introduction 3 9.2 Training Needs 3 9.3 Safety Training for Management 4 9.4 Specialist Safety Training 4 9.5 Training for Operational and Maintenance Personnel 5 9.6 Training for Safety Managers 5 9.7 Training Files 5 9.8 Safety Communications 7 9.9 Safety Promotion 8 9.10 Promotion Methods 8 9.11 Cross References 9




9.1 Introduction 9.1.1. Safety promotion encourages a positive safety culture and creates an environment that is conducive to the achievement of the company’s safety objectives. A positive safety culture is characterized by values, attitudes and behavior that are committed to the company’s safety efforts. This will be achieved through a combination of technical competence that is continually enhanced through training and education, effective communications and information sharing. Senior management will provide the leadership to promote the safety culture throughout the company. 9.1.2. The company’s safety culture is linked to the success of its safety management training programme. All personnel must understand the company’s safety philosophy, policies, procedures and practices, and they should understand their roles and responsibilities within the safety management framework. Safety training shall begin with the initial familiarization (company indoctrination) of employees and continue throughout their employment. Specific safety management training shall be provided for staffs who occupy positions with particular safety responsibilities. The training programme shall ensure that the safety policy and principles of the organization are understood and adhered to by all staff, and that all staff are aware of the safety responsibilities of their positions.

9.2 Training Needs 9.2.1 The Safety Manager will, in conjunction with the personnel department and the line management, review job descriptions of all staff and identify those positions that have safety responsibilities. The details of the safety responsibilities will then be added to the job descriptions. 9.2.2 Once the job descriptions have been updated, the Safety Manager, in conjunction with the training manager, shall conduct a training needs analysis to identify the training that will be required for each position. 9.2.3 Depending on the task, the level of safety management training required will vary from general safety familiarization to expert level for safety specialists, for example:

a) Corporate safety training for all staff according to training needs evaluation; b) Training aimed at management’s safety responsibilities; c) Training for operational personnel; and d) Training for aviation safety specialists (e.g. Safety Audit Team)

9.2.4 One of the functions of safety management training is to create awareness of the objectives of the SMS of the company and the importance of developing a safety culture. All ALS staff will, therefore, receive a basic introductory course covering:

1) Basic principles of safety management;

2) Corporate safety philosophy, safety policies and safety standards (including ALS’s approach to disciplinary action versus safety issues, integrated nature of safety management, risk management decision-making, safety culture, etc.);

3) Importance of complying with the safety policy and with the procedures that form part of the SMS;

4) Organization, roles and responsibilities of staff in relation to safety;

5) Corporate safety record, including areas of systematic weakness;




6) Corporate safety management programme (e.g. incident reporting systems, voluntary reporting scheme and safety meetings);

7) Requirements for ongoing internal assessment of organizational safety performance (e.g. employee

surveys, safety audits and assessments);

8) Reporting accidents, incidents and perceived hazards;

9) Lines of communications for safety matters;

10) Feedback and communication methods for the dissemination of safety information;

11) Safety audits; and

12) Safety promotion and information dissemination. 9.3 Safety Training for Management 9.3.1 It is essential that the management team understands the principles on which the SMS is based. Training would ensure that managers and supervisors are familiar with the principles of SMS and their responsibilities and accountabilities for safety. It may also be of value to provide managers with training that addresses the legal issues involved, for example, their legal liabilities. 9.3.2 Line managers and Supervisors training will include:

(a) SMS process (b) Management commitment and responsibilities (c) Hazard and risk management (d) Continuing safety assessment

9.3.3 Senior managers training will include:

(a) Organizational and safety standards and national regulations (b) Management commitment and responsibilities (c) Management of change

9.3.4 Accountable manager’s training will include:

(a) Awareness of SMS roles and responsibilities (b) Safety policy (c) Safety assurance (d) Management of Change

9.4 Specialist Safety Training 9.4.1 A number of safety-related tasks require specially trained personnel. These tasks include:

a) Investigating safety occurrences; b) Monitoring safety performance; c) Performing safety assessments; d) Managing safety databases; and




e) Performing safety audits. 9.4.2 It is important that the staff performing these tasks receive adequate training in the special methods and techniques involved. Depending on the depth of the training required and the level of expertise in existing in ALS’s safety department, it may be necessary to obtain assistance from external specialists. 9.5 Training for Operational and Maintenance Personnel 9.5.1 In addition to the ALS’s indoctrination outlined above, personnel engaged in flight and maintenance operations (flight crews, ops personnel, cabin attendants, engineers, technicians, etc.) will receive more specific training with respect to:

a) Procedures for reporting accidents and incidents; b) Unique hazards facing operational personnel; c) Procedures for hazard reporting; d) Specific safety initiatives such as safety committee(s), Line Operational Safety Audits, Seasonal

safety hazards and procedures (Rainy season, Haboobs, etc.) and emergency procedures. 9.6 Training for Safety Managers 9.6.1 The Safety Manger needs to be familiar with most aspects of the company, its activities and personnel. These requirements may be met in-house or from external courses, however, much of the Safety Manager’s knowledge will be acquired by self-education. If the Safety Manager is to be the designated manager to manage and be responsible for the development, implementation and maintenance of the corporate ERP, he shall undergo ERP Training. 9.6.2 Areas where the Safety Manager may require formal training include:

a) Familiarization with different fleets, types of operation, routes, etc.; b) Understanding the role of human performance in accident causation and prevention; c) Operation of the SMS; d) Accident and Incident investigations; e) Crisis management and Emergency response planning; f) Safety promotion; g) Communication skills; and h) Specialized training or familiarization (such as LOSA). i) ERP Training

The records of all training shall be kept on file to verify that the requirements for qualification of the Safety Manager are fulfilled and also for traceability. 9.7 Training Files 9.7.1 Training files will be kept for each staff and the training received will be recorded in these files.




9.8 Safety Communications 9.8.1 Dissemination of Safety Information The Safety Manager is the focal point for safety-related information, hazard reports, risk assessments, safety analysis, investigation reports, audit reports, safety meeting minutes, etc. From all this information, the most relevant safety messages for dissemination will be identified. Messages will be classified as urgent, directive, for background understanding, or seasonal. Most staff do not have enough time to read all the information and the salient points will be incorporated into easily understood safety messages (Safety Information Letters) Several considerations would dictate the message classification and dissemination, for example:

a) Criticality of the information; b) The target audience; c) Best means for disseminating the information (e.g. briefings, directed letters, newsletters, email,

videos and posters); d) Timing strategies to maximize the impact of the message (e.g. rainy season briefings generate little

interest during dry season); e) Contents (e.g. how much background information should be given versus the core message); and f) Wording (e.g. most appropriate vocabulary, style and tone).

9.8.2 Safety Critical Information Urgent safety information may be disseminated using such means as:

a) Direct messages (oral or written) to responsible managers; b) Direct briefings (e.g. for crew going into a specific area of operation); c) Direct mail (post, email or fax); d) Safety Information Letters; e) Operational Notices; and f) Flying Staff Instructions.

9.8.3 “Nice-To-Know” Information The aviation industry provides a considerable amount of literature - some of it directed at particular operations. This material includes accident/incident reports, safety studies, aviation journals, etc. Increasingly, this information is available electronically. Regardless of the format of the information, it will be made available to staff and management through:

a) An internal circulation system for critical information; b) A safety library; c) Summaries notifying staff of the receipt of such information; and d) Direct distribution to selected personnel.

9.8.4 Reporting to Management Management does not have the time to sift through large amounts of material, some of which is probably irrelevant. Management is interested in such basic questions as those listed below and all reports to the management should conform to the bullet points below unless avoidable:




a) What is the problem? b) How could it affect the organization? c) How likely is it to happen? d) What is the cost if it does happen? e) How can the hazard be eliminated? f) How can the risk be reduced? g) How much will it cost to fix? h) What are the downsides of such actions?

9.9 Safety Promotion 9.9.1 An ongoing programme of safety promotion will ensure that employees benefit from the safety lessons learned and continue to understand ALS’s SMS. Safety promotion is linked closely with safety training and the dissemination of safety information. It refers to those activities which ALS caries out in order to ensure that the staff understands why safety management procedures are being taken, etc. Safety promotion provides the mechanism through which lessons learned from safety occurrence investigations and other safety-related activities are made available to all affected personnel. It also provides a means of encouraging the development of a positive safety culture and ensuring that, once established, the safety culture will remain. 9.9.2 Publication of safety policies, procedures, newsletters and bulletins alone will not necessarily bring about the development of a positive safety culture. While it is important that staff is well informed, it is also important that they see evidence of the commitment of management to safety. The attitudes and actions of management will therefore be a significant factor in the promotion of safe work practices and the development of a positive safety culture. 9.9.3 In order to propose solutions to identified hazards, staff must be aware of the hazards that have already been identified and corrective actions that have already been implemented. The safety promotion activities and training would therefore address the rationale behind the introduction of new procedures. 9.10 Promotion Methods 9.10.1 If a safety message is to be learned and retained, the recipient first has to be positively involved. Unless this is achieved, much well-intended effort will be wasted. Propaganda which merely exhorts people to avoid making errors, to take more care, etc., is ineffective as it does not provide anything substantial to which individuals can relate. 9.10.2 Safety topics would be selected for promotional campaigns based on their potential to control and reduce losses. Selection would therefore be based on the experience of past accidents or near air misses, matters identified by hazard analysis, and observations from routine safety audits. In addition, employees would be encouraged to submit suggestions for promotional campaigns. 9.10.3 The safety promotion programme will be based on several modern communication methods and will be promoted by one or all of the following methods:

a) Regular safety reports b) Safety meetings c) Safety Information Letters d) Emails e) Newsletters f) Training




9.11 Cross References ALS Flight Operations Manual Part D – Training ALS Security Manual ALS Cabin Crew Manual Maintenance Procedures Manual Maintenance Control Manual ICAO Document 9859 KCARS



Issued 01July13 CONTINUOUS IMPROVEMENT & SMS AUDIT

Section 10 - Continuous Improvement and SMS Audit Contents 10.1 Safety Audits 3 10.2 The Safety Audit Process 4 10.3 Audit Report 9 10.4 Audit Follow-up 9 10.5 Safety Surveys 11 10.6 Line Operations Safety Audits (LOSA) 11 10.7 Flight Data Analysis 12 10.8 ALS Safety Task Force and Steering Committee 14 10.9 ALS Safety Committee 16 10.10 Safety Meetings 16 10.11 Flight Operations and Safety Meetings 17 10.12 Cross References 17 Appendix “A” Safety Task Card 18 Appendix “B” SMS Log 19




10.1 Safety Audits 10.1.1 Audits are one of the principle methods for fulfilling the safety and quality performance monitoring functions. They are core activities of the Safety Management Systems (SMS) as well as the Quality Management System (QMS). Audits may be performed by an external audit authority, such as the KCAA, industry associations; other third parties (e.g. clients) or they may be carried out internally. These external audits enhance the internal audit system as well as provide independent oversight. 10.1.2 Safety (SMS) audits are used to determine that the structure of an SMS is sound. The protocol for conducting a SMS audit (from planning to final corrective action closure) is no different from any other system audit. The overall scope of an SMS audit shall include:

• Levels and accountability of staff. • Compliance with SMS hazard/risk evaluation procedure. • Adequacy of staff training for their technical/SMS roles. • Availability of performance indicators and targets. • Effective SMS component integration; etc.

10.1.2 Safety audits will be conducted regularly, following a cycle that ensures that each functional area is audited as per part of ALS’s plan for evaluating overall safety performance. Safety audits will entail a periodic detailed review of the safety performance, procedures and practices of each department with safety responsibilities. A detailed audit plan will be prepared for each individual department. This audit plan will be kept by the Director of Quality Assurance. Safety Audits will sometimes be combined with Quality Assurance Audits. 10.1.3 Safety audits go beyond just checking compliance with regulatory requirements and conformity with the company’s standards. The audit team will assess whether the procedures in use are appropriate and whether there are any work practices that could have unforeseen safety consequences. 10.1.4 The SMS audit may be undertaken by a single individual or a team, depending on the scope of the audit. Experienced and trained individuals within ALS may perform SMS audits or they may assist external auditors engaged for this purpose. As much as possible, the audit team members should be independent of the area being audited. Wherever practical, these functions shall be undertaken by persons who are not responsible for, and have not been involved in, the design or performance of the tasks and functions being audited. In this way, the evaluation is neutral and independent from the operational aspects of ALS. 10.1.5 Audits will involve the use of appropriate checklists, which shall address areas such as:

• Compliance to KCAA SMS recommendations/regulations • Compliance with customer requirements • Structure of safety accountabilities • Documentation, including SMS manual and SMS records • Hazard identification and risk management processes • Provision for assuring SMS integration with contractors where applicable • Management of change, etc.

10.1.6 The checklists to be used for audits shall be published as a separate document. The checklists contained in this document are for reference only and are not exhaustive. They may be modified appropriately by the auditor(s) to adapt to variables/special requirements of the situation or procedure being audited. 10.1.7 Following an audit, a monitoring mechanism will be implemented to verify the effectiveness of any necessary corrective actions. Follow-up audits would concentrate on aspects of the operations where the need




for corrective actions was identified. Audits to follow up previous safety audits, where corrective action was proposed or because an undesirable trend in safety performance was identified cannot always be scheduled in advance. The overall annual audit programme will make allowance for such unscheduled audits. 10.2 The Safety Audit Process

Develop Audit Plan Carry out Audit Corrective action

needed?

Determine corrective action Submit report Determine follow-

up actions

Yes No

The Safety Audit Process 10.2.1 A formal notification of intention to perform the audit is forwarded to the department to be audited in adequate time for any necessary preparations to be made. As part of the audit process the Safety Manager may contact the head of department to be audited. The department may be requested to provide preparatory material in advance of the actual audit, for example, selected records, a completed pre-audit questionnaire, and manuals. It is essential for the department being audited to have a clear understanding of the purpose, scope and resource requirements for the audit and follow-up processes, etc. before the audit begins. Pre-audit activity 10.2.2 Among the initial steps in planning an audit will be to verify the feasibility of the proposed schedule and to identify the information that will be needed before commencement of the audit. It will also be necessary to specify the criteria against which the audit will be conducted and to develop a detailed audit plan together with checklists to be used during the audit. Conduct of the audit 10.2.3 The conduct of the actual audit is essentially a process of inspection or fact-finding. Information from almost any source will be reviewed as part of the audit. 10.2.4 In conducting a safety audit, there is often a tendency to limit observations to items of regulatory non-compliance. Such inspections have a limited value for the following reasons:

a) The department may rely exclusively upon the audit authority to ensure that it is meeting the standards.

b) The standards may only be met while the auditor is undertaking the inspection.




c) An audit report will only highlight those areas of deficiency found at the time of the inspection. d) The audit will not encourage the department to be pro-active, and often, only issues raised by the

auditor will be verified. Audit procedures 10.2.5 The techniques for gathering the information on which the auditor(s) assessment will be made include:

a) Review of records; b) Interview with staff; and c) Observations by the auditor(s).

10.2.6 The auditor(s) will work systematically through the items on the relevant checklist. Observations will be noted on standardized observation sheets. 10.2.7 If a particular area of concern is identified during the audit, this will be the subject of a more thorough investigation. However, keeping in mind the need to complete the rest of the audit as planned; an excessive amount of time exploring a single issue (and so risk missing other problems) will be avoided, but another more detailed audit might become necessary. Audit interviews 10.2.8 In general auditors obtain information by asking questions. This method provides additional information to that available in writing. It also gives the staff involved an opportunity to explain the system and work practices. Face-to-face discussions also provide auditors to make an assessment of the level of understanding as well as the degree of commitment of the staff of the department to safety management. The persons to be interviewed would be drawn from a range of management, supervisor and operational positions. The purpose of the audit interview is to elicit information, not to enter into discussions. Audit observations 10.2.9 Once the audit activities are completed, the auditor(s) will review all audit observations and compare them against relevant regulations and procedures in order to confirm the correctness of the observations noted as non-conformities, difficulties or shortcomings. 10.2.10 The audit will not only focus on negative findings. An important objective of the safety audit is also to highlight good practices within the area being audited. Closing meeting 10.211 A closing meeting will be held with the head of the department at the conclusion of the audit activities to brief him/her on the audit observations and any resulting recommendations. Factual accuracy can also be confirmed and significant findings highlighted. 10.2.12 The audit findings may fall into three categories:

a) Serious discrepancies of non-compliance warranting immediate action; b) Any discrepancy or non-compliance that must be rectified within an agreed time limit; and c) Observations on issues that are likely to impact on safety or become a regulatory issue before the

next audit.




10.2.13 At the closing meeting, the auditor will present the observations made during the audit and give the representative of the department being audited the opportunity to correct any misunderstandings. Dates for issuing an interim audit report and for receiving comments on it would be mutually agreed upon. A draft copy of the final report will be left with the head of the department. Root Cause Analysis (RCA): 10.2.14. At the completion of the audit a root cause analysis shall be done to identify the root causes of the observations made by the auditor. The RCA is done by the auditee. 10.2.15. A root cause analysis is a method for assessing problems based on their root causes. It analyzes the underlying factors in any given adverse reaction to identify a problem's source and take corrective measures to fix it. This process is unique as it delves deeper to find answers based on hidden causes and their effects, rather than merely looking at the most apparent. 10.2.16 Some basic facts about root cause analysis:

• The RCA is a reactive process, meaning it is performed after the adverse event occurs • Once RCA is applied thoroughly, it soon takes the shape of a highly valuable source by becoming a

proactive mechanism as it predicts problems before they occur. • Although identifying root causes in a given situation forms the most important aspect of solving the

problem, these causes are only secondary to the solutions sought to prevent such an occurrence in the future.

There may be more than one root cause for an event, observance or a problem. The purpose of identifying all solutions to a problem is to prevent recurrence at lowest cost in the simplest way. If there are alternatives that are equally effective, than the simplest or lowest cost approach is preferred. To be effective, the analysis should establish a sequence of events or timeline to understand the relationship between contributor (casual) factors, root causes(s) and other defined problem or event to prevent in the future. 10.2.17 General RCA Corrective Action Process: Below are the steps that can be used to implement the RCA process. These are general rules that the person conducting the RCA can modify according to his own specific field. 1) Factually describe and document the whole event/observation/finding 2) Gather the evidence to support your description of the event 3) Classify your evidence along a proper timeline in which the events occurred ending with the failure 4) Identify the causes by asking “why” along each step. (The 5 Whys method – see below) 5) Separate root causes along each step that impacted the event in any way from casual causes without

direct impact on the final failure/observation/finding 6) Identify all possible preventive measures and place them in order with the simplest and cost-

effective measure at the top. 7) Classify these measures further by identifying the ones that are likely to have the highest possible

rate of preventing the problem in the future without creating other disturbances 8) Seek any other methods necessary to reach the root cause depending on the complexity of your

problem and field 9) Apply these corrective measures to ensure future prevention and safety.




10.2.18. The 5 Whys Method The 5 Whys is an investigative tool that helps you determine causes and contributing factors of an event/observation/finding. Remember, you are not interested in finding someone to blame. The aim is to “drill down” deep enough to find the underlying factors that resulted in the event. As you continue to ask why, you may find that there is more than one answer to your question. Record these multiple answers and continue to ask why for each one. In most cases there is no single root cause that will explain the reason an event occurred. When you are using this method, try to consider the interaction between the some of the causes identified. You are trying to move from the unsafe act that occurred to considering workplace factors that contributed to the event and eventually to the organizational factors that allowed the workplace factors to exist. By identifying and changing these organizational factors, you can strengthen the defenses in the company making it more resilient to human error. You may not have to ask “why” five times to identify the organizational factors. This method enables you to identify the underlying or systematic factors that create the opportunity for human errors to occur and result in an accident or incident. Unsafe Acts Local Workplace Factors Organizational Factors Example: Event: An apprentice engineer installed the landing gear pins in the main landing gear so the aircraft could be jacked up to allow a retraction test of the nose gear. When the gear switch was selected up, the main and nose gear retracted. The main jacks (which had been lowered but not removed) punched through the bottom of the wings as the aircraft came to rest on its belly on the hangar floor. (This was an actual incident which happened in Canada). 1. Why did the main gear retract with pins installed? A: The apprentice engineer installed the landing gear pins in the wrong hole.

“Unsafe Act”

2. Why did the apprentice engineer install the pins incorrectly? A: The manufacturer of the aircraft had issued a service bulletin recommending that these holes be filled. It was never complied with.

A: The apprentice had never been shown the correct location for the pins and was completing the work without supervision.

A: The lighting in the hangar was poor.

“Local Workplace Factors”

3. Why was the service bulletin (SB) not complied with?

3. Why was the apprentice completing unsupervised work without previous training?

3. Why was the lighting in the hangar not in place?




A: It was left in a pile of other SB’s some of which had been completed; others were planned.

A: The supervising engineer was on vacation that week. The apprentice had completed similar tasks to this before and felt qualified to complete this task.

A: The lights were more than 20 years old and some of the fixtures were broken.

“Local Workplace Factors”

4. Why were the completed and uncompleted SB mixed together?

4. Why were there no arrangements to ensure alternate supervision? Could the training provided the apprentice be improved?

4. Why were the fixtures not repaired or replaced?

A: There was no standard procedure for reviewing and auctioning SB’s in the company

A: Management did not foresee the schedule conflict in time to correct the omission.

A: Management had not upgraded the lighting when the hangar was purchased used, 15 years ago. There had been many complaints about poor light that were not acted on.

“Organizational Factors”

5. Why was there no standard procedure for reviewing and auctioning SBs?

5. Why did management not foresee the schedule conflict in time to compensate?

5. Why was the lighting not upgraded when complaints were received?

A: The Director of Maintenance was over tasked due to a lack of manpower. His intention was to develop a procedure but did not have the time.

A: Although staff were required to obtain approval for vacation time, no one in scheduling followed up to see if there was a conflict.

A: Senior management did not feel there was a need to upgrade the lighting. Expense was sighted as the main reason.

“Organizational Factors

Resources / Assertiveness / Norms Issues

Communications / Teamwork / Training / Fatigue Issues

Resources / Assertiveness / Norm Issues

**

** Note: At the bottom of each column are factors influencing human error. Now that you have identified the organizational factors that contributed to this event, you need to develop a corrective action plan that will address these factors and implement the changes.




Corrective Action Plan 10.2.19 At the completion of the audit, planned remedial actions will be documented for all identified areas of safety concern. The head of department has the responsibility for developing a corrective action plan setting out the action(s) to be taken to resolve identified deficiencies or safety shortcomings within the agreed time period. The Corrective Action Plan is developed after the Root Cause Analysis has been done. 10.2.20 When completed, the corrective action plan should be forwarded to the Safety Manager, The final audit report will include this corrective action plan and detail any follow-up audit action proposed. The head of the department being audited is responsible for ensuring the timely implementation of the corrective actions. 10.3 Audit Report 10.3.1 The audit report shall be an objective presentation of the results of the safety audit. As soon as possible after the completion of the audit, an interim audit report shall be forwarded to the head of department for review and comments. Any comments received would be taken into consideration in the preparation of the final report, which constitutes the official report of the audit. 10.3.2 The key principles which shall be observed in the development of the audit report are:

a) Consistency of observations and recommendations in the closing meeting, interim audit report and final audit report;

b) Conclusions substantiated with references, apply common yardsticks and give preference to measurable units;

c) Observations and recommendations stated clearly and concisely; d) Avoidance of generalities and vague observations; e) Objective presentation of the observations; f) Use of widely accepted aviation terminology, avoiding acronyms and jargon; and g) Avoidance of criticisms of individuals or positions.

10.4 Audit Follow-up 12.4.1 An audit follow-up involves Management of Change. Upon receipt of the audit report, management needs to ensure that progress is made to reduce or eliminate the attendant risks. The primary function of an audit follow-up is to verify the effective implementation of the corrective action plan. Follow-up is also required to ensure that any action taken pursuant to the audit does not in any way degrade safety. In other words, new hazards with potentially higher risks must not be allowed to enter the system as a consequence of the audit. 12.4.2 Failure to follow up on any lapses in implementing necessary (and agreed) safety actions will compromise the validity of the entire safety audit process. Follow-up action will be effected through monitoring the status of the implementation of the accepted corrective action plans or through follow-up audit visits. This report will clearly indicate the current status of implementation of the agreed corrective actions. If any non-compliance, deficiency or safety short-coming remains unresolved, the auditor will highlight this in the follow-up report.




10.5 Safety Surveys 10.5.1 Over and above SMS audits, safety surveys may be employed as a complementary procedure for examining particular elements, processes or a specific operation for any potential hazard/risk. 10.5.2 Such targeted safety surveys may be initiated in view of informal feedback or voluntary/confidential reports involving issues such as:

• Problem areas or bottlenecks in daily operations. • Perceptions and opinions about personnel’s actions with possible safety implications. • Poor teamwork and cooperation between employee groups or departments (especially involving

safety/operational/technical functions). • Areas of dissent or perceived confusion (especially involving safety/operational/technical

functions). • Unsafe working procedures or conditions.

10.6 Line Operations Safety Audits (LOSA) 10.6.1 As part of its safety survey programme ALS may also conduct LOSAs. 10.6.2 A LOSA is a formal process that requires trained observers to ride the jump seat during regular flights to collect safety-related data on environmental conditions, operational complexity, and flight crew performance. Confidential data collection and non-jeopardy assurance for pilots is fundamental to this process. 10.6.3 LOSA provides a diagnostic snapshot of strengths and weaknesses that ALS can use to bolster the “health” of its safety margins and prevent degradation. 10.6.4 LOSA is distinct from – but complementary to – other proactive safety programs such as voluntary safety reporting systems. 10.6.5 A LOSA will provide unique data about an ALS’s defenses and vulnerabilities. A LOSA does not replace other safety-data sources such as ASAP. Instead, it complements these programs and extends the reach of ALS’s safety management system. The data collected during a LOSA can impact almost every department in ALS. The data collected during a LOSA can help ALS:

a) Identify Threats in the Company’s Operating Environment. b) Identify Threats from within ALS’s Operations. c) Check the Quality and Usability of Procedures d) Assess Safety Margins

Involvement in LOSA 10.6.5 For LOSA to succeed the following must be fully involved:

a) Management. The management of ALS is fully committed to the LOSA process.

b) Observers. LOSA observers will be carefully selected to ensure the integrity of the LOSA process. LOSA observers should be fully familiar with ALS’s procedures and operations; the line pilot should also respect them.




c) Line Pilots. A LOSA cannot succeed without the full and candid cooperation of the line pilots, and there can be no cooperation without trust. Line pilots will be informed in advance about the purpose and implementation of a LOSA.

10.6.6 Full details on how a LOSA will be conducted are laid down in the ALS internal document titled “LOSA introduction and guidelines” available from the Safety manager. 10.7 Fight Data Analysis (FDA) 10.7.1 The purpose of the FDA program is to identify areas of potential hazards and risk in our operations by providing more information about, and greater insight into the total flight operations environment through analysis of the data generated through line operations. 10.7.2 At present ALS operates aircraft with a certified take-off mass below 27,000 kgs and therefore does not have any of its aircraft fitted with equipment capable of a systematic download and analysis of electronic recordable flight data. 10.7.3 Therefore, the ALS SMS will use a systematic acquisition, correlation and analysis of flight information derived from a combination of some or all of the following sources:-

a) Aircraft Flight Data Recorders (FDR) readouts; b) Confidential flight and cabin crew reports; c) Flight and cabin crew interviews; d) Quality assurance findings; e) Flight and cabin crew evaluation reports; f) Aircraft engineering and maintenance reports The other sources for useful information which may be used are:

• Regulatory Authorities; • Investigative bodies; • Safety Organizations; • Manufacturers; • Other operators.

10.7.4 The information will be analyzed collectively to identify hazards, system weaknesses, process breakdowns, regulatory violations and other trends or conditions which could potentially lead to accidents or serious incidents. The process will include analyses and prioritization of the hazards and risks to enable the development and implementation of effective corrective or preventive actions. 10.7.5 The Safety Department will prepare an FDA report every 6 months and this will be discussed at the ALS Safety Committee Meetings.




10.8 ALS Safety Task Force (STF) and Steering Committee (SC) The management recognizes the need and strength of participative management in its safety management. Towards this end a Safety Task Force and a Safety Committee have been constituted. 10.8.1 ALS Safety Task Force (STF) and Steering Committee (SC) The members of the STF will be from across all the ALS departments. The STF will report to the ALS Safety Department. The purpose of these STF is:

• To enable ALS Management, the Safety Department, and all other ALS departments to exchange information and ideas;

• To allow concerns of interested parties to be raised and taken into account by the ALS Management, with a genuine desire to resolve any safety issues that may emerge. However, the formation of the STF is NOT intended:

• To detract from or constrain the responsibility of the Safety Department to manage the Safety aspects of the company;

• To prevent interested parties from raising concerns directly with the Safety Department or the ALS Management.

The STF will provide:

• An opportunity for information exchange between various departments; • A structured forum for discussions and to make recommendations to the Management and the Safety

Department; • The opportunity to reach common understanding between the departments about the nature of Safety

in the company activities, thereby increasing the scope for safety issues to be resolved amicably; • Opportunity to promote understanding about the company operations/procedures, with specific

emphasis on safety, more widely, through dissemination of relevant information by the STF Members;

• Opportunity to promote the safety culture and practices of the company and the nature of its impact on the company operations and procedures, and the company’s clients.

However:

• The STF is not a dispute resolution forums; nevertheless, they will be interested in any safety complaints that the departments receive and may take an active interest in problems that may affect the safety of the department.

• STF members have no executive or decision making powers over the company. The primary role of the STF is to develop an action plan for safety promotion, advice the Safety Department on the potential for safety issues in the various departments and to recommend strategies for hazard identification, assessment, and mitigation actions for the risk. These strategies may be developed as a result of the team member’s knowledge of the practices and procedures of the department and/or information collected elsewhere or with the assistance of the Safety Department. The team will meet on a regular basis (weekly or monthly) and report their findings and recommendations to the Safety Department. Initially the meetings will also be attended by the Safety Manager.




The purpose of the meetings will be discussions and sharing of safety relevant information in a relaxed and open atmosphere to maximize the learning and development of ideas to improve safety. Terms of reference for the team shall include, but not be limited to:

a) Improve safety and hazard data collection, analysis, and dissemination of maintenance safety relevant data;

b) Improve safety awareness within the department by distributing safety educational and

training materials to the maintenance personnel;

c) Ensure proper procedures are being followed;

d) Develop initiatives for improving standards of communication, especially inter-departmentally;

e) Promote best working practices;

f) Generation and evaluation of safety suggestions;

g) Discussions on departmental safety procedures and guidelines;

h) Identification of undesirable conditions and mitigation processes for the same.

Based on the above practices and evaluations, a plan containing action items would be developed specifically and linked to safety concerns, issues, or problems identified in the various department. Any hazard identified by the STF will be documented in a Safety Task Card and a Master log of all the Safety Task Cards will be kept by the Safety Department. These Task Cards and the Log will show the actions and progress towards eliminating or mitigating these hazards. (See appendix at end of this section for samples). 10.8.2 Steering Committee The steering committee will be made up of senior management personnel of ALS. The purpose of the Steering Committee is to guide the STF and provide the necessary resources to enable the STF to eliminate of mitigate any identified hazards.




10.9 ALS Safety Committee 10.9.1 A Safety Committee will be established at senior management level and will include the Safety Manager as well as other senior managers. 10.9.2 The objective of the Safety Committee is to provide a forum to discuss issues related to safety performance of ALS and the health of the SMS. The safety committee will make recommendations concerning safety policy decisions, and review safety performance results. The focus of the safety committee will on “action”, as opposed to “dialogue”. 10.9.3 The role of the safety committee is to:

a) Act as a source of expertise and advice on safety matters to senior management; b) Review of the issues taken from the flight safety analysis program and progress on identified

hazards and actions taken following incidents and accidents; c) Help identify hazards and defences; d) Agreement of corrective actions taken and agreement of extensions as appropriate; e) Make safety recommendations to address safety hazards; f) Review internal safety audit reports and the Fight Data Analyses Report; g) Review and approve audit response and actions taken including those for the FDA report; h) Review of the issues arising from the flight safety analyses program; i) Review any changes in the operation that could affect safety; j) Review Company Safety performance targets and monitoring; k) Review and setting of concise safety policy and objectives; l) Set Performance measures and monitor them; m) Encourage lateral thinking about safety issues; and n) Prepare and review safety reports to be presented to the Board of Directors.

10.9.4 The Safety Committee will be chaired by the Accountable Manager or his nominee. The members of the safety committee will comprise of the following:

a) The Accountable Manager b) The Safety Manager c) The Director of Quality Assurance d) The Director of Flight Operations e) The Chief Pilot f) The Technical Director g) The Director of Maintenance (AOC) h) The Director of Maintenance (AMO) i) The Base Engineer j) The Commercial Director k) Any other person the Accountable Manager may invite.

10.9.5 The safety committee will meet every six months. However, the safety manager may decide to request for more frequent meetings if there are urgent safety issues to be discussed. 10.10 Safety Meetings 10.10.1 Minuted safety meetings will be held every two months at a pilots and engineers forum. Pertinent particulars from the minutes will be disseminated to company employees via safety bulletins. Minutes are to be kept on file.




10.10.2 At outstations minuted safety meetings will be held every 2 months. These meetings will be attended by the operations personnel, flight crew, and maintenance personnel and may also be attended by representatives of the client. The minutes shall be sent to the safety department which will go through the minutes and follow up and give a feedback on any item that concerns safety. 10.11 Flight Operations and Safety Meetings 10.11.1 A weekly meeting chaired by the Director of Flight Operations or in his absence the Operations Manager and attended by the Chief Pilot (if available), the Ground Operations Manager, and all available flight operations assistants shall be held to discuss all operational/dispatch matters, forecasts and any safety issues. A copy of the minutes shall be forwarded to the safety department. The safety department will make a note of the safety concerns and provide feedback/recommendations for implementation by the operations manager. Implementation of these recommendations shall be verified by the safety department through safety audits. 10.12 Cross References a) Flight Operations Manuals b) Quality Assurance Manuals c) Maintenance Control Manual d) Maintenance Procedures Manual e) Corporate Manual f) ICAO Document 9859 – SMS Manual




Appendix “A” - Safety Task Card

ALS Limited - SMS Implementation - Task Initiation Form

Task Description: Eye Wash Solutions not available at all stations in Hangar Area.

Level of Importance High Affected Area (s) Maintenance/Hangar

Assigned to : Maurice Supported by: DOM.

Resource Required Purchase of a pack of 24 Bottles to replenish all stations plus extra for stores.

Root cause: Lack of awareness for company property

Log reference No: 11-0001 Task Reference No. (in Gap )

Process Ref: TF1-MTN Document MPM

Date Identified 17-10-11 Target Start Date 17-10-11

Progress Check Date 18-10-11 Target Completion Date 20-10-11

Successful Completed Partial

Remarks: 1.Eye wash solution purchased on 22/10/11 and placed on all the hangar stations. 2.Staff member to be nominated to check the availability. 3.Permanent Eye Wash station to be bought/fabricated.




Appendix “B” - SMS Log

No Dept Description Start Date T Date Remarks Status

11-0001 MTN

Eye Wash Solutions not available at all stations in Hangar Area. 17-10-

2011 20-10-2011 Eye wash purchased on 22nd Oct &placed at all stations. Permanent station to be fabricated. PARTIAL

11-0002 MTN

C208 Cargo Pod Lying in the hangar was found to have rubbish inside 17-10-

2011 19-10-2011

Memo dated 16/11/2011 issued to all hangar staff to maintain cleanliness CLOSED

11-0003 MTN

Too many technicians clustered around a small work area. 19-10-

2011 01-11-2011

Memo dated 16/11/2011 issued to all hangar technical staff not to overcrowd on one task PARTIAL

11-0004 MTN C 208 Battery connected whilst work carried out on the propeller

18-10-2011 20-11-2011

Procedures in AMM followed to pull out circuit breakers CLOSED

11-0005 MTN

C 208 Main LG incorrectly stored under aircraft to be used as a step

18-10-2011 19-10-2011

Briefed engineers and Checked again and found LG now on trestles.More storage racks to be fabricated. PARTIAL

11-0006 MTN

fluids/oil spillage on workplace floor

18-10-2011 31-10-2011

Memo dated 16/11/2011 issued to all hangar staff to maintain cleanliness. QCM to carry out spot checks and report. CLOSED



Issued 01July13 SMS DATA AND RECORDS MANAGEMENT

11.1 - SMS Data and Records Management Contents 11.1 Introduction 3 11.2 Document Procedures 3




11.1 Introduction 11.1.1 This SMS Manual is the key instrument for communicating ALS’s SMS approach and methodology to the whole organization. This SMS Manual documents all the aspects of the SMS, including the safety policy, objectives, accountabilities and procedures. 11.1.2 Operating an SMS generates significant amounts of data, documents and reports. Proper management and record keeping of such data is crucial for sustaining an effective SMS. Effective analysis is totally dependent upon the availability and competent use of the safety information management system. 11.1.3 To facilitate easy retrieval and consolidation of safety data/information, it is necessary to ensure that there is a relevant integration between the various sources of such data or reports. 11.1.4 It is necessary that the company maintain a systematic record of all measures taken to fulfill the objectives and activities of the SMS. Such records would be required as evidence of on-going SMS processes including hazard identification, risk mitigation and safety performance monitoring. These records shall be appropriately centralized and maintained in sufficient detail to ensure traceability of all safety related decisions. 11.2 Document procedures 11.2.1 A flowchart of how all the documents are handled can be found in Section 7, 7.2.6 11.2.2 Incident/Accident reports are entered into a computer database and then filed as per the details given in Section 6, .3 11.2.3 Incident/Accident investigation reports are filed in a separate file marked “Accident and Incident reports”. 11.2.4 Safety/SMS audit reports are filed in a file marked “Internal audits and checks”. 11.2.5 Hazard and Risk Analysis reports are entered in an Excel sheet on the computer and filed in a file marked “Hazard reports”. 11.2.6 Minutes of safety meetings and Safety Committee meetings are filed in a file marked “Safety meeting minutes”.



Issued 01July13 MANAGEMENT OF CHANGE

Section 12 - Management of Change Contents 12.1 Management of Change 3 12.2 Guidelines for conducting Management of Change Process 4




12.1 Management of Change 12.1.1 Hazard identification and risk assessment are not static processes. They need to be performed whenever:

• A major organizational change is being planned; • The company is undergoing rapid expansion or contraction; • Introduction of new equipment or facilities is being considered; • Introduction of new procedures is being planned; • Existing procedures are being revised; • Changes to key personnel are taking place; • New contracts/routes are being considered or commencing a new contract/route; and • There are changes to the legislation that ALS operates under.

12.1.2 Whenever any of the above events is contemplated at ALS, the Management shall ask the concerned Department Head to conduct hazard identification and risk assessments and mitigation actions keeping the Safety Manager informed and involved in each stage. The entire process, including the mitigation measures proposed to be implemented, is to be documented and signed off by the concerned Department Head before being submitted for approval to the Accountable Manager. 12.1.3 Change may affect the appropriateness or effectiveness of existing safety risk mitigation strategies. In addition, new hazards, and related safety risks may be inadvertently introduced into an operation whenever change occurs. Such hazards should be identified so as to enable the assessment and control of any related safety risks. 12.1.3 The process of Management of Change should also take into account the following three considerations: Criticality of systems and activates. Criticality assessments determine the systems, equipment or activities that are essential to the safe operation of aircraft. Systems, equipment and activities that have a higher safety criticality should be reviewed following change to make sure that corrective actions can be taken to control potentially emerging risks. Stability of systems and operational environment. Changes may be the result of programmed change such as growth, operations to new destinations, changes in fleets, changes in contracted services, or other changes directly under the control of the company. Changes in the operational environment are also important, such as economic or financial labor unrest, changes in political or regulatory environments, or changes in the physical environment such as cyclical changes in weather pattern. Past performance. Past performance of critical systems and trend analysis in the safety assurance process should be employed to anticipate and monitor safety performance under situations of change. The monitoring of past performance will also assure the effectiveness of corrective actions taken to address safety deficiencies as a result of audits, evaluations, investigations or reports.




12.2 Guidelines for Conducting Management of Change Process Step 1: Develop the case: The aim of Step 1 is to provide a compelling argument for making the change and a clear statement of the benefits that will result. Key activities

1) Establish the background and context that frame the case for change. 2) Develop the case for change. 3) Define the statement for need. 4) Determine the scope of change and the boundaries of the project or new venture.

Step 2: Conduct risk and opportunity planning: Whenever there is change, there are also likely to be both opportunities and risk. Both opportunities and risks are identified and quantified. Risk management planning is based on establishing the context (Step 1: Develop the case), and then identifying, analysing, evaluating and reducing risk to minimise the impact of change in the company operations, while maximising potential benefits. At all stages of risk management planning, the right level of communication, consultation and documentation is needed. Key Activities

1) Assemble a team to conduct the risk planning. 2) Develop the Risk Management Plan (RMP) 3) Present the RMP to the Decision Maker (Accountable Manager) for approval. 4) Extract the risk treatment strategies and insert these as tasks into the project plan.

Step 3: Prepare the project plan: Developing a project plan that considers the decisions and planning in Steps 1 and 2 will ensure effective implementation. The project plan should address the need to manage the change and be developed specifically for ALS. The critical feature of Step 3 is the link back to the risk management planning in Step 2. This is achieved by extracting the risk strategies identified and planned for in the RMP and placing these items as tasks in the project plan. Each task will have a nominated timeline, responsibilities and resources. A project plan must also outline internal implementation and communication strategies, and needs to engage all staff. A project plan also provides a documented record of activities, tasks, resources and performance that can be used as a reference for future change initiatives. Key activities

1) Appoint a project director to be accountable for overseeing implementation and monitoring progress. 2) Appoint a project manager to be responsible for implementing the project plan. 3) Develop the project plan, including by calculating the resources needed to implement the plan. Seek

confirmatory approval if scope or context has changed from Step 2. 4) Consider the “people” aspect of change, the current culture and internal barriers to change.




Step 4: Implement the change Step 4 “executes” or implements the project plan developed in Step 3. This is where the change tales place. Key activities

1) Undertake the tasks and activities in the project plan. 2) Report progress to the project director. 3) Continually communicate with staff and other stakeholders. 4) Review progress and performance, ensuring that the risk treatments listed in the RMP (Step 2) have

been implemented and are complete. Step 5: On-going monitoring and review To ensure that the change is implemented as intended and changing circumstances do not alter priorities, the plan must be constantly monitored, reviewed and adjusted where necessary. Key activities

1) Ensure the deliverables of the project plan are clear and understood. 2) Establish a means of receiving feedback. 3) Monitor feedback and determine actions to continuously improve project. 4) Measure the success of any actions taken.

12.2 Cross references ICAO Document 9859 ALS Corporate Manual



Issued 01July13 EMERGENCY RESPONSE PLAN

Section 13 - Emergency Response Plan Contents 13.1 Introduction 3 13.2 ALS Emergency Response Plan 3 13.3 Cross references 3




13.1 Introduction 13.1 An emergency response plan (ERP) outlines in writing what should be done upon a major incident or accident. The purpose of an ERP is to ensure:

• Planned actions to minimize indirect or consequential damage upon the occurrence of a major incident or accident

• Recovery actions as well as procedures for orderly transition from normal to emergency operations • Designation of emergency authority • Assignment of emergency responsibilities • Authorization by key personnel for actions contained in the plan • Coordination of efforts to cope with the emergency. • Safe continuation of operations, or return to normal operations as soon as possible.

13.2 ALS Emergency Response Plan 13.2.1 ALS has a separate document which describes the emergency response procedures and plan in detail. Please refer to this document for details. 13.3 Cross references ALS Emergency Response Procedures Plan ALS Flight Operations Manual Part A ALS Security Manual ICAO Document 9859