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Safety Management Systems i
4SMS for AviAtionA PrActicAl GuideSaety aSSurance
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Safety Assurance
cs
What s saet assurance? 01
Saet perormance montorng and measurement 01
internal saet nvestgaton 02
Change management 04
Change management gudance, procedures and checklst 04
Contnuous mprovement o the saet sstem 09
Toolkt saet assurance 13
2012 Civil Aviation Saety AuthorityFor urther inormation visit www.casa.gov.au
This work is copyright. You may download, display, print and reproduce this material in unaltered orm only (retaining this notice) or your personal, non-commercial useor use within your organisation. Apart rom any use as permitted under the Copyright Act 1968, all other rights are reserved. Requests or urther authorisation should bedirected to: Saety Promotion, Civil Aviation Saety Authority, GPO Box 2005 Canberra ACT 2601, or email saetypromotion@casa.gov.au
This kit is or inormation purposes only. It should not be used as the sole source o inormation and should be used in the context o other authoritative sources.The case studies eaturing Bush Air and Bush Maintenance Services are entirely fctitious. Any resemblance to actual organisations and/or persons is purely coincidental.
1105.1511
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Safety Management Systems 01
Wha s say assa?Saety assurance activities are at the core o your
SMS. Saety assurance includes systematic and
ongoing monitoring and recording o your saety
perormance, as well as evaluating your saety
management processes and practices.
S ss is h w odmos h o SMS woks.
You have decided on your saety objectives;
you have implemented them; and now you
are monitoring and measuring how you are
progressing to meeting these targets.
Say pma mg
a masmYou need eedback on your saety perormance
so that you can evaluate it and make changes
where necessary. Your stakeholders may also
need assurance o the level o saety within your
organisation. For example:
Sta need to be condent that your
organisation can provide a sae working
environment
Line management needs eedback on saetyperormance to help allocate resources, given
the oten-conficting goals o production, prot
and saety
Passengers concerns about their personal
saety
Senior management seeks to protect corporate
image (and market share)
Shareholders wish to protect their investment
(in larger organisations).
What types o monitoring you do will depend on
how large and/or complex your organisation is.
You can monitor your saety perormance by:
establishing an eective hazard and occurrence
reporting system
ront-line supervisors monitor and report
day-to-day activities
regular or daily inspections (ormal or inormal)
o all saety-critical areas
using saety surveys to canvass youremployees views about saety
systematically reviewing and ollowing up
on all reports o identied saety issues,
systematically capturing daily perormance data
[using programs such as fight data analysis
(FDA), line operations saety audit (LOSA)
normal operations saety survey (NOSS) and
maintenance error decision aid (MEDA)]
regular operational audits, both internal
and external
regularly communicating saety results to
all personnel.
S pom msm
Bush Maintenance Services set SMARTsaety objectives: specic, measurable,
achievable, realistic objectives with a
specied timerame in which they are to
be achieved. By setting such objectives,
Bruce Jones can monitor and measure how
their SMS is going.
Six months into the process, he and Trevor
Brown, the saety ocer, give everyone a
report on progress with the database (which
they have set up in an Excel spreadsheet on
the hangar PC), the number o reports they
have received, and (especially ollowing the
Beechcrat engine cowl asteners incident),
the new rostering system.
S objivs
1. To encourage reporting o all incidents,
no matter how trivial they may seem
(Measure: positive increase in all reporting
or each o the next three years)
2. To build an accurate database o these
incidents, and give eedback to sta within
two weeks o the initial report
3. To set up a more ormal rostering and
reporting system, so that we can track and
minimise atigue-related mistakes. This
system will take into account limits on
consecutive shits, as well as extra time
required or task completion i a night shit
is involved.
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02 Safety Assurance
Saet perormance montorng andmeasurement checklst
SMS ELEMENT ITEMS
Saety
perormance
monitoring and
measurement
Established systems are
in place to ensure eedback
on saety perormance
is received and the data
is analysed.
Feedback data is used
to evaluate saety
perormance and indentiy
necessary changes.
An indication o the
level o saety within the
organisation is available
to all stakeholders.
A saety perormancemonitoring program
appropriate to the
organisation is established
and maintained.
ia say sgaFor every accident or serious incident in your
organisation, there are likely to be hundreds o
minor events or near-misses, many o which
have the potential to become accidents. You
should review all reported events/hazards and
decide which ones you should investigate, and
how thoroughly.
You must have a clear policy, stating that the
purpose o internal investigations is to nd
systemic causes and implement corrective
actions, NOT to blame individuals. I you use
the principles o a just culture, your internal
investigation procedures should state this.
Resources or conducting saety investigations
are normally limited, so the eort you make
should be in proportion to the perceived benet.
In other words, how will the investigation assist
in identiying systemic hazards and risks to
your organisation?
Accountability or the management o internal
saety investigations should be documented in
your SMS, which should include:
The scope o the investigation
Who will investigate, including specialist
assistance i required
Recording the investigation ndings
or ollow-up trend analysis, and who is
responsible or this
A timerame or completion.
The extent o the investigation will depend on the
actual and potential consequences o the event
or hazard. You can determine this through an
initial risk assessment. Reports that demonstrate
a high potential should be investigated in greater
depth than those with low potential.
The investigative process should be
comprehensive and should attempt to address
the actors contributing to the event, rather thansimply ocusing on the event itsel - the active
ailure. Active ailures are the occurrences that
took place immediately beore the event and
directly aect the saety o the system because
o the immediacy o their adverse eects. They
are not usually, however, the root causes o the
event, why it happened, so applying corrective
actions to these issues may not address the real
cause o the problem. A more detailed analysis
is usually required to establish the organisationalactors that contributed to the event.
The gure opposite illustrates an internal saety
investigation process.
Lessons learned about saety are more benecial
when they include a ocus on root causes
(why?) rather than on a description o the
accident or incident only (what?). Identiying
root causes requires trained investigators who
look beyond the obvious causes at other possible
contributing actors, including, but not limitedto, organisational issues.
You need to ensure that key operational sta
are properly trained to conduct saety
investigations and have appropriate support.
Their outputidentied saety issuesshould
be disseminated throughout the organisation,
along with publishing o lessons learned rom
these identied saety issues.
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Safety Management Systems 03
internal saet nvestgaton process
Hazard and occurrence
notifcation and
assessment
Data collection process
Sequence o events
Integrated investigation
Risk assessment process
Deence analysis
Risk control analysis
Saety communication
process
Estimate risk and determine
whether acceptable or each hazard
Identiy missing or inadequate
deences, and fx, replace, or
strengthen them
Identiy and evaluate risk
control options
Communicate saety message
to stakeholders
Assess notifcation and decide
whether to investigate or not
Identiy events and
underlying actors
Reconstruct logical progression
o occurrence events
Analyse acts and determinefndings regarding underlying
actors and hazards
internal saet nvestgaton checklst
SMS
ELEMENT
ITEMS
Internal
saety
investigation
The investigative process is
comprehensive, and attempts
to address the actors that
contributed to the event, ratherthan simply ocusing on the
event itsel. (The why, not just
the what.) Detailed analysis
undertaken to establish the
organisational actors that
contributed to the event.
All reported events/hazards are
reviewed and a classication
system guides the decision-
making process on which ones
should be investigated, andhow thoroughly.
The organisational saety policy
states that the purpose o
internal investigations is to nd
systemic causes and implement
corrective actions, NOT to
apportion blame to individuals.
Where a just culture policy is in
place, the policy and protocols
or internal investigations clearly
reerence it. The saety manager, or delegate,
acts as the organisations
point o contact/coordinator
or Australian Transport Saety
Bureau (ATSB) investigations as
a way o keeping inormed as
they progress.
The eort expended on
investigations is proportional to
the perceived benet in terms
o potential or identiyingsystemic hazards and risks to the
organisation.
Accountability or the
management o internal saety
investigations is documented in
the organisations SMS manual.
The extent o the investigation
is dependent on the actual and
potential consequences o the
event or hazard (as determined
by an initial risk assessment.
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04 Safety Assurance
chag maagmChanges within your organisation can create
hazards which can aect the saety o its
operations. You may make changes to meet
business demands and to be more fexible.
However, while the changes need to be made
eectively and eciently, your main ocus
should be on implementing them saely. A
change introduced to improve saety may
introduce saety risks elsewherechange
invariably creates the potential or unintended
consequences.
Change management in SMS only applies
to hazard ID and risk assessment related to
the saety o operations. Other potential risk
actors (such as the inability to sustain business
growth) should be considered, as while they
are additional to the scope o SMS change
management, they may aect operational saety.
Dierent types o change introduce varying
degrees o potential risk. The degree o scrutiny
required, and the resulting level o detail at each
step, should be proportionate to the degree o
risk potentially introduced by the change.
Large-scale changes, such as major inrastructure
projects or organisational restructures, shouldbe managed as stand-alone projects, with saety
validation documentation orming part o the
project saety plan. A project saety plan will
be an evolutionary document. For example, it
may initially set out assumptions and replace
these with more actual inormation as it
becomes available. Similarly, the project saety
plan may initially set out the risk assessment
methodology and ndings, later incorporating
the saety requirements.
chag maagm ga,ps a hsBy taking a systematic approach to implementing
change, organisations can gain a much clearer
picture o the objectives o change and how to
achieve them saely.
The need or organsatonal change
The need or organisational change can result
rom many dierent triggers. These include:
the appointment o new senior managers
or a new management team
changes in customer requirements or
expectations
changes in the work environment changes in domestic or global trading
conditions
an inadequate skills and knowledge base,
leading to new training programs
innovations in operational practice
poor perormance
new technology
new ideas about how to do things better
new contracts
recognition o operational problems,
leading to a reallocation o responsibilities
regulatory or procedural changes
relocation or expansion
sta changeover
change in contractors, or bringing on
new contractors.
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Safety Management Systems 05
Change management and rskmanagement
Whether change is to be brought about through
new projects, or through modications to
operating procedures, it will involve risks.
There is a very strong link between change
management and risk managementthe twoprocesses support each other and should be
used together.
The change management process
The steps in the change process are:
STEP 1: Develop the case
STEP 2: Conduct risk assessment and planning
STEP 3: Prepare the project plan
STEP 4: Implement the change
STEP 5: Ongoing monitoring and review
STEP 1: DEVELOP THE CASE
Provide a compelling argument or making the
change and a clear statement o the benets
that will result. I undertaken properly, this step
will enable you to respond to peoples questions,
concerns and perceptions, thereby ensuring their
willing participation, their sense o ownership andthus the projects eventual success.
K iviis
1. Establish the background and context that
rame the case or change.
2. Develop the case or change.
3. Dene the statement o need.
4. Determine the scope o change and the
boundaries o the project or new venture.
tips
Address the ollowing questions to develop
a strong and deendable case or change:
Why is a change required?
What is the purpose o the change?
Is the vision clear and are the objectiveswell dened?
What are my objectives?
What is the scope o the change?
What are the expected benets and
opportunities?
Do I have any limitations or restrictions?
Do I understand the importance o the
change and its relevance to my organisation?
Have I determined who my stakeholders are?
Whom do I need to consult?
Have all my stakeholders been consulted?
What resources do I lack?
What needs to be documented?
Have I developed a communication plan?
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06 Safety Assurance
STEP 2: CONDUCT RiSK ASSESSMENT ANDPLANNiNG
Whenever there is change, there are also likely
to be both opportunities and risks. You should
adopt a risk-based approach to planning change.
Identiy and quantiy both opportunities and risks.
Risk management planning is based onestablishing the context (as in step 1: Develop
the case), and then identiying, analysing,
evaluating and reducing risk to minimise the
negative impact o change on aviation operations,
while maximising potential benets.
Dont make this process complicated. The
most important part o the process is having
all the people who are likely to be aected by
the change, or who can add value to identiying
potential risk, in the room to openly discussthe issues.
K iviis
1. Assemble a team to conduct the
risk planning.
2. Develop your risk management plan.
3. Present this plan to the decision maker
or approval.
4. Extract the risk treatment strategies andinsert these as tasks into the project plan.
5. Re-evaluate your proposed risk treatment
strategies to identiy any new risks introduced
as a result.
tips
Ensure that the appropriate level o
consultation takes place.
Select a team encompassing the scope and
breadth o the change.
Use structured risk identication techniques
such as SWOT (strengths, weaknesses,
opportunities, threats) analysis.
Use risk analysis tools that appropriately
measure the consequences and likelihood
o hazards or your organisation.
When developing risk treatment strategies as
project tasks, ensure that the tasks address the
cause o each risk, not just the outcome.
Examine the eectiveness o the risk
treatment strategies by considering how much
the project tasks will reduce the consequences
or the likelihood o each risk.
Calculate the residual risk and prioritise
the risks.
Link the venture risk management plan to
the project plan or the change project or
new venture.
STEP 3: PREPARE THE PROJECT PLAN
Developing a project plan that considers the
decisions and planning outlined in steps 1
and 2 will ensure eective implementation.
The project plan should address the need to
manage the change and be developed specically
or the organisation, taking into account its
unique culture and circumstances. The level
o detail in the project plan will vary with the
organisation, how complex the change is and
the number o variables involved.
The critical eature o step 3 is the link back to
the risk management planning in step 2. This
is achieved by extracting the risk treatment
strategies identied and planned or in the
venture risk management plan and listing 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 sta. This will give
stakeholders condence that the risks o the
change have been taken into account, and thatthe risk treatments are being appropriately
resourced and managed.
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Safety Management Systems 07
A project plan also provides a documented record
o activities, tasks, resources and perormance
that can be used as a reerence or uture change
management. Cultural and organisational actors
need to be considered to ensure that the change
is implemented smoothly and eectively.
The key to eective implementation is
engagement and communication. Many people
in the organisation will want the benets o the
change, but will need to be given a high level o
condence or reassurance that the benets will
outweigh the costs.
K iviis
1. Appoint a project director to be accountable
or overseeing implementation and
monitoring progress.
2. Appoint a project manager to be responsible
or implementing the project plan.
3. Develop the project plan, including calculating
the resources needed to implement it.
Seek urther approval i the scope or context
has changed rom step 2.
4. Consider the people aspect o change,
the current cultural and internal barriers
to change.
tips
Document all this, including:
a brie outline o the concept.
the aim o the change.
the objectives to be achieved.
critical success actors (e.g. timerame,
resources, personnel).
a detailed description o all phases and
associated tasks, responsibilities andmilestones.
key timings and critical path.
allocation o resources.
reporting requirements.
STEP 4: iMPLEMENT THE CHANGE
Step 4 executes or implements the project plan
developed in step 3.
This is where the change takes place. The
principles o change management are used to
guide the activity, ocus and approach adopted
in this step.
The pace o change and the required momentum
also need to be considered in step 4. For
larger and more complex projects, the change
implementation program might need to be
maintained over several years.
K iviis
1. Undertake the tasks and activities in the
project plan.
2. Report progress to the project director.
3. Continually communicate with sta and
other stakeholders.
4. Review progress and perormance,
ensuring that the risk treatments listed in
the risk management plan (step 2) have
been implemented and are complete.
tips
Focus on getting it right.
It is more than just a policy.
Adopt a structured, project management
approach.
Focus on managing priority areas rst.
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08 Safety Assurance
Ongoing monitoring and review
o change
Develop the case
Fully identiy and describe the
proposed change Identiy stakeholders
Identiy and allocate responsibilities
relating to the proposed change
Undertake risk assessment
Identiy hazards and potential
controls
Undertake risk assessments and
analyse risk
Evaluate risk and identiy potential
controls
Prepare the project plan
Risks and appropriate controls
become tasks in the project plan
Assess stakeholder eedback
Document changes and or record
them in change register
Implement the plan
Undertake activities in the
project plan
Review progress and perormance
Review and revise the SMS,
incorporating the necessary
amendments, additions or deletions
brought about by the change.
Emphasis should be placed
on changes that aect the risk
register, plans or coordination
with contractors and emergency
management plans.
Continuousimprovement
Consultationwithstakeholders
Change management process
STEP 5: ONGOiNG 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. Maintain communication and
consultation with all stakeholders.The ollowing should be monitored or change:
Knowledge (new actors or inormation
are included).
Stakeholders (new stakeholders are included
over time).
Consultation (all relevant stakeholders
are consulted).
Communication (high quality and appropriate
methods used).
Risks (risk treatments are implemented,
and new risks are identied, addressed and
managed appropriately).
Common understanding (maintained by
all participants).
Quality o decisions.
Changes in legislation, regulation and
market actors.
Eectiveness o the implementation plan.
K iviis
1. Check regularly to ensure the ongoing
deliverables o the project plan are clear
and understood.
2. Establish a means o receiving eedback
communicate, communicate, communicate!
3. Monitor eedback and determine actions
to continuously improve project.4. Measure the success o any actions taken.
tips
Make sure you know what you want
to achieve.
Identiy the results that will tell you that
you have achieved your aim.
Be fexible and open to adjusting the plan.
Provide eective eedback.
Source: NTC (2007)
The ollowing diagram summarises these steps:
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Safety Management Systems 09
Change management checklst
SMS ELEMENT ITEMS
Management
o change
Change management
processes take saety
issues into account.
Changes likely to occur in
the business which wouldhave a noticeable impact on
the ollowing are identied:
- Resources - material
and human
- Management direction -
processes, procedures,
training
- Management control.
The SMS documentation
identies the changes(including human actors
issues) that require
ormal risk management
processes.
cs mpm h say sysmYou only know something is eective i you
measure it. That is why it is important that
your saety objectives are SMARTspecic,
measurable, achievable, realistic and withina timerame.
[see Book 2 Saety policy and objectives
page 08]
That way, you can measure what you have
been doing, and improve on areas where your
SMS is not as eective. For small organisations,
management reviews o the SMS should occur
at least annually to ensure that:
the SMS continues to meet its core saety
objectives
saety perormance is monitored against
objectives
identied hazards are addressed in a timely
and appropriate manner.
A practical way or small operators to maintain a
ocus on improvement is to network with other
operators and share inormation and good ideas
to try.
For larger organisations, more ormal periodic
reviews are conducted by a saety committee.
For example:
Reporting on the eectiveness o change
management activities and issues
Reporting on saety training perormance
Evaluation o acilities, equipment,
documentation and procedures through saety
audits and surveys
Continued tracking o saety culture change or
maturity level.
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10 Safety Assurance
Bush Ar hangar upgrade | case stud
Sp 1 Dvlop h s
Bush Air is preparing or their feet growth
(a 1997 King Air is due or delivery) with a
planned new hangar and oce building. Their
current oce and hangar are cramped, and the
acilities outdated. The new building will be
located near the current one, but aircrat will
have to taxi past the construction site.
John Smith identies the various stakeholders
who may be aected by his plans, and
consults with them.
th skholds h idifs :
The local shire council, and in particular the
airport manager and the tourism ocer
The local GP (who operates a Beechcrat)
The local chamber o commerce, and
potential construction companies
Outback Exploration and other resources
companies
Bush Maintenance Services and other
operators at the airport
The aero club
CASA
ATC
Sp 2 udk isk ssssm
John Smith, as CEO, and his part-time
saety ocer together draw up a risk
management plan.
They eel that the new hangar/oce building
will bring opportunities and risks. They ocus
on hazard identication and risk assessment
relating to fight saety, but also take into
account other actors, such as not being able
to sustain their planned growth, even though
this is beyond the scope o SMS change
management.
Opportunities
1. Improved, more proessional acilities toservice expanding business
2. Increased income and increased eciency
3. Additional jobs or line pilots/LAMEs etc.
4. Growth o the airport
Hazards identied
The stakeholders have identied the ollowing
potential hazards associated with the proposed
change:
1. Distraction during construction
2. Planned growth not sustainable due to lack
o available sta with the necessary skills
3. Clearance issue with aircrat taxiing past the
current building
4. Noise, dust and FOD potentially damaging
surace nishes and engines
5. Potential or miscommunication and atigueor Bush Air employees
6. Heavy machinery in the movement area.
7. Temporary removal o the boundary ence
to allow construction access, increasing the
chances that stray stock or wildlie could
wander onto the aireld
8. Builders vehicles parked near the tarmac.
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Safety Management Systems 11
S isk mgm
The review team assess the risks associated
with each identied hazard (see risk
assessment section). None o the hazards are
considered show stoppers but some require
mitigation beore and during construction.
Actions are allocated to the appropriate people,
with timerames or completion. The saety
ocer is appointed to oversee the plan to
implement the identied solutions.
Sp 3 Pp h poj/
implmio plThe saety ocer continues to consult with
the Bush Air pilots and other stakeholders as
he prepares a project plan, holding ortnightly
meetings with key personnel, as well as
one-on-one meetings with Bush Air sta as
issues arise. He also meets with a potential
construction company to ensure that any o its
concerns are covered in the implementation
plan. They raise the issue o access and
parking or construction vehicles, and the
saety ocer writes these into the plan.
To minimise noise and dust, it is recommended
that the taxiway past the hangar be closed
or the period o peak construction, and that a
NOTAM be issued regarding the change.
Sp 4 Implm h hg
All actions are completed within the required
timerames. The change management
committee meets regularly to assess progress
and take remedial actions when required.
Sp 5 Ogoig moioig d viw
A saety review validates the SMS, conrmingnot only that people were doing what they
were supposed to be doing, but also that
their collective eorts have achieved the
organisations saety objectives. Through
regular review and evaluation, management
can pursue continuous improvements in saety
standards and ensure that the SMS remains
eective and relevant to the organisations
operations.
Example o contnuous revew strateg
Continuous improvement:
Biannual benchmarking exercise with similar-
sized operators to gain urther intelligence on
practical saety initiatives
Bush Air uses the ollowing tools to track
improvement:
- Annual independent saety audit
- Annual saety culture survey.
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12 Say Assa
Contnuous mprovement o the SMS checklst
SMS ELEMENT ITEMS
Continuous
improvement
o the saety
management
system
An SMS is established that includes policies, rules, directives and standard
operating procedures (SOPs).
Management work continuously towards revising the current processes, in
response to changing needs, operational environment, or standards.
Demonstrated eorts are made towards ensuring that everybody ollows
SOPs (a combination o discipline and human resource development
measures may be employed).
Formal management reviews o the SMS occur on a regular basis.
A quarterly high-level review process is conducted via the saety committee.
Saety reviews validate the SMS, conrming not only that people were doing
what they were supposed to be doing, but also that their collective eorts
have achieved the organisations saety objectives and targets.
Through regular review and evaluation, management pursue continuousimprovements in saety management and ensure that the SMS remains
eective and relevant.
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Safety Management Systems 13
toolkitSAfETy ASSURANCE
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14 Safety Assurance
ix msThis is your saety toolkit with some best-practice
tips and practical tools that can be adapted
to meet your organisations needs. We hope
you nd them useul, whether you are urther
developing your SMS, starting an SMS rom
scratch, or simply looking or some ideas to
improve your existing SMS.
This list summarises the checklists/templates
you will nd at the back o each o the respective
booklets.
This is not an exhaustive list o resources.
There are many systems and products across
various industries, so this toolkit can only include
a very small sample o practices and/or tools
or inormation.
Inclusion o materials does not imply
endorsement or recommendation. Each
organisation must select the most appropriate
products or its individual and specic needs.
Booklet 1 Bascs
Jargon busters
Reerences
Booklet 2 - Saet polc and objectves tools SMS organisation checklist
Saety policy statement
Saety managers job description
Role o the saety committee
SMS implementation plan
Ten steps to implementing an SMS
SMS gap analysis checklist
An eective emergency responseplan (ERP)
Language and layout o procedures/
documentation
Document register
Sample saety leadership rules
Aviation saety liesavers policy
Just culture procedure
Appendix A Workfow process or applying
the just culture procedures
Appendix B Bush Air counselling/discipline
decision chart
Booklet 3 - Saet rsk management tools
Error prevention strategies or organisations
Risk register
Sample hazard ID
Guidance on job and task design
A six-step method or involving sta in saety
hazard identication
Hazard reporting orm
Booklet 4 - Saet assurance tools
Gi isss o b osidd wh
moioig d msig s
pom
adi sop pl
Bsi di hklis
Iomio lv o s
ivsigio
ev oifio d ivsigio po
aviio s iid ivsigio po
coiv/pviv io pl
chklis o ssssig isiiol
sili gis ids (caIr)
Pil s l impovm
sg
S l idx
Booklet 5 - Saet promoton tools
How to conduct a training needs analysis
Sample saety inormation bulletin on atigue
How to give a saety brieng/toolbox talk
Aviation saety toolbox talk
Saety brieng/toolbox meeting
attendance orm
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Safety Management Systems 15
G sss bs wh mga masg saypmaThe ollowing is a list o generic aspects or
areas to be considered to assure saety
through saety perormance monitoring and
measurement:
rsposibili. Who is accountable or
management o the operational activities
(planning, organising, directing, controlling)
and their ultimate accomplishment?
ahoi. Who can direct, control or
change the procedures and who cannot?
Who can make key decisions, such as
saety risk acceptance?
Pods. Specied ways to carry out
operational activities that translate the what
(objectives) into how (practical activities).
cools. Elements o the system, including
hardware, sotware, special procedures or
procedural steps, and supervisory practices
designed to keep operational activities on track.
Is. An examination o such things
as lines o authority between departments,
lines o communication between employees,
consistency o procedures, and clear
delineation o responsibility between
organisations, work areas and employees.
Poss mss. Means o providing
eedback to responsible parties that required
actions are taking place, with the expected
and required results.
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16 Safety Assurance
A sp pa
SMS ITEM Year 1 Year 2 Year 3 Year 4 Year 5
1 Saety policy and culture
2 Governance, management,
accountabilities, responsibilities and
authorities
3 Regulatory compliance
4 Saety records, document control
and inormation management
5 Review o the saety management
system
6 Internal SMS audit arrangements
7 Corrective action
8 Saety perormance targetsand perormance measures
9 Change management
10 Internal communication
11 Risk management
12 Saety-critical worker competence
13 Inormation, instruction, and training
14 Procurement and contract
management
15 Engineering and operational saety
systems
16 Process control
17 Asset management
18 Saety interace coordination
19 Occurrence and emergency
management
20 Investigations
21 Third party audits
Operators will need to develop their own audit scope planner requirements based on their own operating conditions, risks,
incident history and determined saety objectives.
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Safety Management Systems 17
Bas a hs
Audit report Page o
Auditor: Audit report no.
Activity audited: Procedure no.
Date previously audited: / / Previous audit report no.
Signed: Number o non-conormance reports issued:
Date: / / Next audit planned:
Item no. Requirement Activity
compliance
Comments Non-conormance
report no.
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18 Safety Assurance
S-assssm hsManagement can use the ollowing sel-
assessment checklist to identiy administrative,
operational and other processes, and training
requirements, that might indicate saety hazards.
They can then ocus attention on those issues
posing a possible saety risk.
Management and organsaton
Management structure
1. Does the organisation have a ormal saety
policy and written saety objectives?
2. Are the corporate saety policies and
objectives adequately disseminated
throughout the organisation? Is there
visible senior management support orthese saety policies?
3. Does the organisation have a saety
department or a designated saety
manager (SM)?
4. Is this department or SM eective?
5. Does the SM report directly to the
accountable manager?
6. Does the organisation support the periodic
publication o a saety report or newsletter?
7. Does the organisation distribute saety
reports or newsletters rom other sources?
8. Is there a ormal system or regular
communication o saety inormation
between management and employees?
9. Are there periodic saety meetings?
10. Does the organisation participate in industry
saety activities and initiatives?
11. Does the organisation ormally investigate
incidents and accidents? Are the results
o these investigations disseminated to
managers and operational personnel?
12. Does the organisation have a condential,
non-punitive, hazard and incident reporting
program?
13. Does the organisation maintain an incident
database?
14. Is the incident database routinely analysed
to determine trends?
15. Does the organisation operate a fight data
analysis (FDA) program?
16. Does the organisation operate a line
operations saety audit (LOSA) program?
17. Does the organisation conduct saety
studies?
18. Does the organisation use outside sources
to conduct saety reviews or audits?
19. Does the organisation seek input rom aircrat
manuacturers product support groups?
Management and corporate stablt
1. Have there been signicant or requent
changes in ownership or senior management
within the past three years?
2. Have there been signicant or requent
changes in the leadership o operational
divisions within the past three years?
3. Have any managers o operational divisions
resigned because o disputes about saety
matters, operating procedures or practices?
4. Are saety-related technological advances
implemented beore they are directed by
regulatory requirement, i.e. is the organisation
proactive in using technology to meet saety
objectives?
fnancal stablt o the organsaton
1. Has the organisation recently experienced
nancial instability, a merger, an acquisition or
other major reorganisation?
2. Was consideration given to saety matters
during and ollowing the period o instability,
merger, acquisition or reorganisation?
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Safety Management Systems 19
Management selecton and tranng
1. Are there well-dened management
selection criteria?
2. Is operational background and experience a
requirement in the selection o management
personnel?
3. Are rst-line operational managers selected
rom operationally qualied candidates?
4. Do new management personnel receive
ormal saety induction and training?
5. Is there a well-dened career path or
operational managers?
6. Is there a ormal process or the annual
evaluation o managers?
Workorce
1. Have there been recent layos by the
organisation?
2. Is a large number o personnel employed
on a part-time or contractual basis?
3. Does the company have ormal rules or
policies to manage contractors?
4. Is there open communication between
management, the workorce and unions
about saety issues?
5. Is there a high rate o personnel turnover in
operations or maintenance?
6. Is the overall experience level o operations
and maintenance personnel low or declining?
7. Is the distribution o age or experience levels
within the organisation considered in long-
term organisational planning?
8. Are the proessional skills o candidatesor operations and maintenance positions
ormally evaluated during the selection
process?
9. Are multicultural issues considered during
employee selection and training?
10. Is special attention given to saety issues
during periods o labour-management
disagreements or disputes?
11. Have there been recent changes in salaries,
working conditions or superannuation?
12. Does the organisation have a corporate
employee health maintenance program?
13. Does the organisation have an employee
assistance program that includes treatment
or drug and alcohol abuse?
Relatonshp wth the regulator authort
1. Are saety standards set primarily by the
organisation, or by the appropriate regulatory
authority?
2. Does the organisation set higher standardsthan those required by the regulatory
authority?
3. Does the organisation have a constructive,
cooperative, relationship with the regulatory
authority?
4. Has the organisation been subject to recent
saety-enorcement action by the regulatory
authority?
5. Does the organisation consider the dieringexperience levels and licensing standards o
other states when reviewing applications or
employment?
6. Does the regulatory authority routinely
evaluate the organisations compliance with
required saety standards?
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20 Safety Assurance
ima a asay sgaA competent, proessional saety investigation
ilds inormation needed to:
- identiy trends and problem areas
- permit comparisons
- satisy legal requirements
idifs the basic causes contributing
directly/indirectly to each incident
idifs deciencies within the system/
organisation that allowed the incident to occur
sggss specic corrective actions to
improve the SMS
phsill xmis the equipment used
during the saety event. This may includeexamining the ront-line equipment used,
its components, and the workstations and
equipment used by supporting personnel.
doms the broad spectrum o the
operation; or example:
- maintenance records and logs
- personal records/logbooks
- certicates and licences
- in-house personnel and training records andwork schedules
- operators manuals and SOPs
- training manuals and syllabuses
- manuacturers data and manuals
- regulatory authority records
- weather orecasts, records and brieng
material
- fight planning documents.
rodigs (fight recorders, ATC radar and
voice tapes etc.). These may provide useul
inormation or determining the sequence
o events.
- As well as traditional fight data recordings,
maintenance recorders in new generation
aircrat are a potential additional source
o inormation
- Smartphones and tablets (with GPS)
may also be valuable sources o relevant
inormation
Iviws conducted with individuals directly
or indirectly involved in the saety event. These
can be a principal source o inormation or any
investigation. In the absence o measurable
data, interviews may be the only source o
inormation. However, because memory is
allible, and personal recollections can bebiased, validate records o conversations
whenever possible.
Di obsvio o actions perormed by
operating or maintenance personnel in their
work environment. This can reveal inormation
about potentially unsae conditions. However,
the people being observed must be aware o
the purpose o the observations.
Simlios These permit reconstruction
o an occurrence and can acilitate a better
understanding o the sequence o events that
led up to the occurrence, and the manner in
which personnel responded to it. Computer
simulations can be used to reconstruct events
using data rom on-board recorders, ATC tapes,
radar recordings and other physical evidence.
Spilis dvi Investigators cannot be
experts in every eld relating to the operational
environment. It is important that they realise
their limitations. When necessary, they must
be willing to consult with other proessionals
during an investigation.
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22 Safety Assurance
EVENT NOTifiCATiON (cont.)
B. ENVIRONMENTAL IMPACT:
13. Environmental impact:
C. EQUIPMENT:
14. Equipment name/type:
D. PERSON(s) DETAILS:
20. Name: 21. Employer:
22. Role:
23. Duty status at time o event:
On duty at workplace
Commenced: am/pm
Travelling while on duty
Travelling to/rom work
24. Employment status:
Employee
Contractor
Other, speciy:
25. Did person cease work beore end o shit?
YES NO
26. I yes, what time? am/pm
27. Injury severity:
Fatality
Lost time
Disabling injury
Medical treatment
First aid Occupational disease/illness
28. Activity being perormed: (modiy or your operation)
Aerial agricultural operations
Aerial photography
Aerial surveying
Dropping
Feral animal control
Search and rescue
Sling load operations
Surveillance
Winching/hoisting
E. IMMEDIATE CORRECTIVE ACTIONS:
38. Immediate corrective actions:
39. Signature o person completing event report:
Name: Signature: Date: Time:
40. Event notifcation sign-o by the shit supervisor:
Name: Signature: Date: Time:
Use the guidance notes on the ollowing pages to assist in act-gathering to ensure you identiy all contributing actorsrelating to the event.
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Safety Management Systems 23
Event notifcation & investigation reportANALySiS Of CONTRiBUTORy fACTORS
Report number:
(To be completed or any actual or potential event at Level 2 and above)
InDIVIDuaL/teaM actIOnS Identiy the individual/team actions that contributed to or caused
the event. These are the errors or violations that led directly to the event. Typically, they are associatedwith those who have direct contact with equipment, such as operators or maintenance sta.
They are always committed actively (someone did or didnt do something) and have a direct relation
to the event.
chk qsio: Does the item tell you about an error or violation o a standard or procedure made in
the presence o a hazard? (Tick only i applicable)
IT1 Supervision? Absent
Inadequate
Unsuitable
IT8 Saety compliance? Absent
Inadequate
Unsuitable
IT2 Authority? Absent Inadequate
Unsuitable
IT9 Instructions given? Absent Inadequate
Unsuitable
IT3 Operating speed? Exceeded
Unsuitable
IT10 Training or task? Absent
Inadequate
Unsuitable
IT4 Equipment use? Absent
Exceeded limits
Misuse
Unsuitable selection
IT11 Experience or task? Absent
Inadequate
Unsuitable
IT5 PPE? Absent
Exceeded limitsMisuse
Unsuitable selection
IT12 Misconduct? Mitigated
Unmitigated
IT6 Work procedure
ollowed?
Partially
Not ollowed
Unsuitable
IT13 Interruptions breakdown
in team coordination?
IT7 Equip/material
handling?
Inadequate
Unsuitable
IT14 Other
CODE Based on the above event acts, IDENTIFY the individual/team actions that contributed to the event give reasons.
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24 Safety Assurance
ANALySiS Of CONTRiBUTORy fACTORS (cont.)
taSK/enVIrOnMentaL cOnDItIOnS Identiy the task/environmental conditions contributing to
the event. These are the circumstances under which the errors and violations took place and can be
embedded in task demands, the work environment, individual capabilities and human actors.
chk qsio: Does this item describe something about the task demands, work environment,
individual capabilities or human actors that promoted errors/violations, or undermined the
eectiveness o the systems deences? (Tick only i applicable)
Workplace actors impact Human actors impact
WF1 Lighting Some
Signifcant
HF1 Complacency/motivation Some
Signifcant
WF2 Weather
Time o day
Some
Signifcant
HF2 Alcohol/other drugs Some
Signifcant
WF3 Dust/contaminants Some
Signifcant
HF3 Familiarity with task Some
Signifcant
WF4 Noise Some
Signifcant
HF4 Fatigue Some
SignifcantWF5 Wildlie Some
Signifcant
HF5 Time pressure Some
Signifcant
WF6 Surace gradient/conditions Some
Signifcant
HF6 Peer pressure Some
Signifcant
WF7 Workspace access/restriction Some
Signifcant
HF7 Physical capabilities Some
Signifcant
WF8 Housekeeping Some
Signifcant
HF8 Mental capabilities Some
Signifcant
WF9 Tools/equipment condition/
availability
Some
Signifcant
HF9 Physical stress Some
Signifcant
WF10 Task planning/preparation Some
Signifcant
HF10 Mental stress Some
Signifcant
WF11 Routine/non-routine task Some
Signifcant
HF11 Confdence level Some
Signifcant
WF12 Abnormal operational situation/
condition
Some
Signifcant
HF12 Secondary goals/external
actors
Some
Signifcant
WF13 Risk perception/management Some
Signifcant
HF13 Personality Some
Signifcant
WF14 Personnel saety Some
Signifcant
HF14 Manuals and procedures Some
Signifcant
WF15 Other workplace actor/s______________________
Some Signifcant
HF15 Other human actors__________________
Some Signifcant
CODE Based on the above event acts, IDENTIFY the task/environmental conditions that contributed to the event
give reasons.
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Safety Management Systems 25
OrGanISatIOnaL actOrS Identiy the organisational actors that contributed to the event.
These are the underlying organisational actors that produce the task/environmental conditions
aecting perormance in the workplace. These may include allible management decisions,
processes and practices.
chk qsio: Does this item identiy a standard organisational actor present beore the event
and that resulted in the task/environmental conditions, or allowed those conditions to go unaddressed?
(Tick only i applicable)
HW Hardware Contributing MM Maintenance
management
Contributing
TR Training Contributing DE Design Contributing
OR Organisation Contributing RM Risk management Contributing
OR2 Provision o tools/equipment
OR3 Planning and scheduling
CO Communication Contributing MC Management o change Contributing
IG Incompatible goals Contributing CM Contractor management Contributing
PR Procedures Contributing
CODE Based on the above event acts, IDENTIFY the organisational actors that contributed to the event give reasons.
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26 Safety Assurance
Event notifcation & investigation report
CORRECTiVE ACTiONS AND SiGN-Off
Report number:
GuIDeLIneS Or raISInG cOrrectIVe actIOnS:
For each identied absent or ailed deence and organisational actor:
list the corrective actions the investigation has shown to be necessary.
identiy who will be responsible or taking the action or, where a contractor is involved, who will be
responsible or ensuring the action is completed. Continue on a new sheet o paper i necessary,
adding the report number at the top o additional sheets.
determine the date by which the corrective action must be completed.
identiy the management system reerence (Re.) to allow status tracking o the corrective actions.
identiy any statutory reporting requirements or the event.
The v ow should sign to indicate that they accept the report, including the actions and
priorities, and enter any relevant comments.
The lv mg/s d ceO should sign to indicate that they accept the report, including the
actions and priorities, and enter any relevant comments.
h ommdd oiv ios:
Codes
(rom Part 3)
Actions Person
responsible
Date Re.
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Safety Management Systems 27
Event notifcation & investigation report
iNVESTiGATiON REPORT SiGN-Off
Report number:
Ivolvd pso p d omms
Name: Signature: Date: (dd/mm/yyyy)
S of p d omms
Name: Signature: Date: (dd/mm/yyyy)
So poig qims Yes / No Completed Yes / No
coiv io viw qid? Yes / No How: (speciy)__________________
Review date: ___________________
Gl omms
Name: Signature: Date: (dd/mm/yyyy)
Gl mg p d omms
Name: Signature: Date (dd/mm/yyyy)
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28 Safety Assurance
DATA COLLECTION WORK/AREA:
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Safety Management Systems 29
AT
_______________________________________________________________________
Date
at 0000 (hos)
D R A F T
Ivsigio m:
Name/department (Leader)_____________________
Name/department ____________________________
Name/department ____________________________
Name/department ____________________________
Name/department ____________________________
Name/department ____________________________
this dom ms o b opid
Aa say sga p
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30 Safety Assurance
cs p
1. incdent/accdent descrpton
incdent/accdent
Location:
Time:Date:
Detals o njured
Name:
Company:
Injuries sustained:
Medical treatment:
Detals o damage/mpact
Damage to
equipment:
Environmental
impact:
Rsk ratng
Actual consequence
level: Level
Potential consequencelevel: Level
Events leadng up to the ncdent/accdent
Incident/accident description
Photographs
Insert photographs
Tmelne
Insert timeline chart
2. Key ndings
The key ndings outline why the incident/
accident occurred. The contributing actors
identied rom the investigation have been
categorised using the International Civil Aviation
Organization (ICAO) recommended Reason
model o accident causation. The analysis chart is
shown as an appendix in section 6 o this report.
Contrbutng actors
Based on the evidence to hand, the investigation
team believe the ollowing were the main
contributing actors to the incident:
abs o ild ds
Insert contributing actor
Insert contributing actor
Insert contributing actor
Insert contributing actor
Insert contributing actor
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Safety Management Systems 31
Idividl o m ios
Insert contributing actor
Insert contributing actor
Insert contributing actor
tsk o vioml odiio
Insert contributing actor
Insert contributing actor
Insert contributing actor
Ogisiol os
Insert contributing actor
Insert contributing actor
Insert contributing actor
3. Conclusons and observatons
The investigation concluded the ollowing
ndings were or could have been contributory
actors to the incident/accident:
Insert conclusion or observation
Insert conclusion or observation
Insert conclusion or observation
Insert conclusion or observation
Insert conclusion or observation
4. Recommendatons
The ollowing recommended corrective actions
are put orward or consideration.
The recommendations address the absent or
ailed deences and organisational actors identied
as key ndings o the investigation. These
recommendations are applicable to [insert
business group or site] and could benet otherBush Air operations.
Headng
Detail and explanation
Headng
Detail and explanation
Management revew o the nvestgaton report
The management o [business group and site]
should ormally review the investigation report
or completeness, quality o the investigation and
to endorse the recommended corrective actions.
It is recommended that the ollowing action
plan is implemented:
Disibio
To maximise the eectiveness o the
investigation report, its ndings and conclusions
should be distributed as widely as practicable
internally within Bush Air and externally to
industry bodies.
Implmio o oiv ios
Corrective actions shall be ormally presented
to the responsible manager or implementation.
An action plan and time rame shall be agreed
and endorsed by the appropriate level o
management. An action plan is attached in
section six o this report (page 33).
Implmio moioig
The completion o corrective actions must
be documented and communicated by the
responsible manager to the CEO and copied to
the aviation saety manager. Where correctiveactions have not been ully implemented,
ongoing monitoring should be maintained until
implementation is complete.
als ivss
The eectiveness o the corrective actions
should be evaluated by a review o saety
perormance and through an audit within the
next six months. A report will be prepared
or management to detail compliance and
progress achieved.
Dom hivig
Investigative data and reports shall be archived
in accordance with procedures specied in the
Bush Air SMS manual (BASMS).
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32 Safety Assurance
5. Signicant lessons
The investigation has raised a number o key
lessons which are covered in the body o the
report. The signicant lessons or Bush Air are:
Headng
Detail and explanation
Headng
Detail and explanation
Headng
Detail and explanation
Aayss ha
Organisational
actors
Task/environmental
conditions
Individual/team
actions
Absent or ailed
deencesIncident
6. Appendces
REASON MODEL ANALySiS
The eatures o the Reason model analysis chart
or the purposes o this interim report are:
It provides a graphical representation o all
the key circumstances and actors relatingto the incident
It outlines the relationship o the various
elements considered throughout this report.
The chart is also designed to:
Provide a ramework to organise the
data collected
Assist in assuring the investigation ollows
a logical path
Aid in the resolution o conficting inormationand the identication o missing data
Provide a graphic display o the investigative
process or management brieng.
Accordingly, this chart should not be considered
in isolation but in the context o all the comments
in this report and, no doubt, the additional
matters that will be addressed in the nal report.
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Safety Management Systems 33
7. Report sign-o
To maximise the eectiveness o the investigation report, its ndings and conclusions should be
distributed as widely as possible, especially to the various people involved in the incident.
The completion o corrective actions must be documented and communicated by the responsible
manager to the CEO, as well as the aviation saety manager. Where corrective actions have not been
ully implemented, ongoing monitoring should be maintained until implementation is complete.
Feedback to those involved and comments
Name: Signature: Date:
Feedback to the involved person/s manager/s and comments
Name: Signature: Date:
CEOs acceptance o fndings and comments
Name: Signature: Date:
Aviation saety managers acceptance o fndings and comments
Name: Signature: Date:
Correctve acton plan
Item
Re
Recommendation Responsible
department
Responsible
person
Completion
date
Sign o
Close-out o incident All corrective actions have been completed. Where corrective actions have not
been ully implemented, the ollowing measures have been put in place to ensure ongoing monitoring
until implementation is complete.
Name: Signature: Date:
Headng
Detail and explanation
Headng
Detail and explanation
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34 Safety Assurance
c/paa pa
Recommendatons or correctveactons
Investigations should identiy recommendationsor corrective actions to prevent incidents and
accidents recurring. Do this by addressing
all contributing actors identied during an
investigation.
Not all contributing actors can be completely
eliminated, and some may be eliminated only
at a prohibitive cost. The investigation team
should work with line management to develop
corrective actions.
The corrective actions recommended by the
investigation team should be:
SMARTER
S Specic
M Measurable
A Achievable
R Realistic
T Timely
plus
E Eective
R Reviewed
Each recommendation states the action
management should take to correct a
contributing actor. The team reviews each
contributing actor and:
ormulates recommendations which, i
implemented, will reduce the likelihood o that
actor contributing to uture similar incidents recommends improvements to the system
deences to limit the consequences o the
contributing actor, so that residual risk is
recognised by management as acceptable
makes interim recommendations or
immediate corrective actions ater an incident
or near-miss to mitigate current risks, beore
taking long-term corrective actions.
Management must ully evaluate any corrective
action to ensure change/s do not weaken otherdeences, or expose other risks.
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Safety Management Systems 35
c a pa xamp
ITEM
REF
RECOMMENDATION RESPONSIBLE
AREA
RESPONSIBLE
PERSON
COMPLETION
DATE
SIGN-OFF
1.1 commiio
Shit handovers are ormalised
between outgoing supervisorsand incoming supervisors.
As ar as possible during
these handovers there should
be no interruptions, and all
inormation on operations,
eld activities/plant status etc.
should be conveyed.
Until the handover is complete,
incoming supervisors should
not make decisions, or give
authorisation on operationalmatters.
1.2 Iompibl gols
Clear communication to all
personnel that normal protocols
or practices should not be
altered or non-operational
purposes, and that saety
must always be the key driver
above any other needs o
the organisation (including
operations/production, time
constraints etc.).
1.3 SWIs/procedures
Key roles and responsibilities
are specied to ensure
accountabilities/or
responsibilities are clearly
dened.
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36 Safety Assurance
chs assssg sa sagas as (cAir) yeS = This is defnitely the case in
this company/organisation.
? = Dont know; maybe; could be
partially true.
nO = This is defnitely not the case inthis company/organisation.
1. Midl o dg YES ? NO
Senior managers are ever-mindul o the human and organisational actors that can endanger
their operations.
2. ap o sbks YES ? NO
Senior management accepts occasional setbacks and nasty surprises as inevitable. It anticipates that
employees will make errors and trains them to detect errors and recover.
3. commim YES ? NO
Senior managers are genuinely committed to aviation saety and provide adequate resources to serve
this end.
4. rgl migs YES ? NO
Saety-related issues are considered at high-level meetings on a regular basis, not just ater a
bad event.
5. evs viwd YES ? NO
Past events are thoroughly reviewed at top-level meetings, and the lessons learned are implemented
as company-wide reorms, rather than local repairs.
6. Impovd ds YES ? NO
Ater an occurrence, the primary aim o senior management is to identiy the ailed system deences
and improve them, rather than divert responsibility to particular individuals.
7. Hlh hks YES ? NO
Senior management adopts a proactive stance towards inadequate fight saety. It does the ollowing:
Takes steps to identiy recurrent traps and remove them.
Strives to eliminate the workplace and organisational actors likely to provoke errors. Brainstorms new scenarios o ailure.
Conducts regular health checks on the organisational processes known to contribute
to occurrences.
8. Isiiol os ogisd YES ? NO
Senior management recognises that error-provoking institutional actors (e.g., under-manning,
inadequate equipment, inexperience, patchy training, human-machine interaces etc.) are
easier to manage and correct than feeting psychological states such as distraction, inattention
and orgetulness.
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Safety Management Systems 37
9. Iomio YES ? NO
It is understood that the eective management o saety, just like other management processes, is
reliant on the collection, analysis and dissemination o relevant inormation.
10. Smplig o vil sigs YES ? NO
Management recognises the necessity o combining reactive outcome data (i.e., near-miss and
incident reporting) with active process inormation. The latter entails ar more than occasional audits.It involves regular sampling o a variety o organisational processes (e.g., scheduling, budgeting,
procedures and training), identiying which vital sign is in most need o attention and then carrying out
remedial action.
11. emplos d s migs YES ? NO
Meetings relating to fight saety are attended by employees across the organisation.
12. c boos YES ? NO
Assignment to a saety-related unction (quality or risk management) is seen as a ast-track
appointment, not a dead end. Such unctions are accorded appropriate status and salary.
13. Mo vs. s YES ? NO
Acknowledgment that commercial goals and saety issues can come into confict. Measures are in
place to recognise and resolve such conficts in an eective and transparent manner.
14. rpoig ogd YES ? NO
Policies are in place to encourage everyone to raise saety-related issues. (One o the dening
characteristics o a pathological culture is that messengers are shot, and whistleblowers dismissed
or discredited.)
15. ts YES ? NO
The company recognises the critical dependence o a saety management system on the trust o the
workorce, particularly in regard to reporting systems. (A sae culture an inormed culture is the
product o a reporting culture. This can only arise rom a just culture.)
16. Qlifd idmi YES ? NO
Policies relating to near-miss and incident-reporting systems make it clear that the organisations
stance includes qualied indemnity against sanctions, condentiality and the organisational separation
o the data-collecting department rom those involved in disciplinary proceedings.
17. Blm YES ? NO
Disciplinary policies are based on an agreed (negotiated) distinction between acceptable and
unacceptable behaviour. All recognise that a small proportion o unsae acts are indeed reckless,
and warrant sanctions, but the large majority o such acts should not attract punishment. (The key
determinant o blameworthiness is not so much the act itsel error or violation as the nature
o the behaviour in which it is embedded. Did this behaviour involve deliberate and unwarranted
risk-taking, or a course o action likely to produce avoidable errors? I so, the act would be culpable
regardless o whether it was an error or a violation.)
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38 Safety Assurance
18. Skills hil & o-hil YES ? NO
Managers encourage their employees to acquire the mental/behavioural (or non-technical), as well as
the technical, skills necessary to achieve sae and eective perormance.
(Mental skills include anticipating possible errors and rehearsing the appropriate recoveries.
Such mental preparation at both the individual and organisational level is the one o the hallmarks
o high-reliability systems, and goes beyond routine simulator checks.)
19. dbk/ommiio YES ? NO
The organisation has eective, tailored, two-way eedback channels to communicate the lessons
learned rom both reactive and proactive saety inormation systems. The emphasis is always on
generalising these lessons, and communicating them widely.
20. akowldgm o o YES ? NO
The organisation has the will and the resources to acknowledge its errors, to apologise or them,
and to reassure any victims that the lessons learned rom such mishaps will help to prevent
their recurrence.
So
(Add up your score or each question to arrive at a total)
Score 1 or each question where you answered yeS = This is denitely the case in this company.
Score 0.5 or each question where you answered ? = Dont know; maybe; could be partially true.
Score 0 or each question where you answered nO = This is denitely not the case in this company.
Ipig h so
1620 So healthy as to be barely credible!
1115 In good shape, but dont orget to be uneasy.
610 Not all bad, but there is still a long way to go.
15 The organisation is very vulnerable!
0 Jurassic Park!
With acknowledgement to Proessor James Reason, published in Flight Safety Australia, January-February 2001
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Safety Management Systems 39
Each o these saety culture ingredients can be
measured using tangible and visible saety data,
most o which is already being collected, but not
always systematically tracked.
Method
Convene a representative saety taskorce tobrainstorm the type o data that could easily be
collected and represents each o the ve saety
culture ingredients.
Each indicator can then be given a rating
rom 1-5, or its implementation and
eectiveness:
Each indicator should measure a demonstrable
behaviour rather than supercial attitudes.
For example, indicators o a fexible culture
could be:
succession planning
critical role planning
or o an inormed culture:
risks identied and change managed.
Paa say mpm sagy
Managing the risks of organisational accidents. Aldershot, UK,
Reason, J. (1997), Ashgate.
LeXIBLe cuLture An organisation canadapt in the ace o high tempo operations or
certain kinds o danger - oten shiting rom the
conventional hierarchical mode to a fatter mode.
InOrMeD cuLture Those who manage and
operate the system have current knowledge
about the human, technical, organisational and
environmental actors that determine the saety
o the system as a whole.
JuSt cuLture There is an atmosphere o
trust. People are encouraged (even rewarded)
or providing essential saety-related inormation,
but they are also clear about where the line must
be drawn between acceptable and unacceptable
behaviour.
LearnInG cuLture An organisation must
possess the willingness and the competence
to draw the right conclusions rom its saety
inormation system and be willing to implement
major reorms.rePOrtInG cuLture An organisational climate
in which people are prepared to report their
errors and near-misses.
The ve key ingredients of an eectivesaet culture
Fully implemented/effective
1
2
3
4
5
Not implemented/effective
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40 Safety Assurance
Say c ixAll employees, irrespective o the area in which
they work, contribute to saety, and each is
personally responsible or ensuring a positive
saety culture. The purpose o this questionnaire
is to obtain your opinions about saety.
Please answer all the questions as honestly
as possible. Give your own answers, not those
o other employees.
Give your name so we can contact you or
clarication i necessary, but all your answers will
be kept condential and your reply will be de-
identied. Please complete the ollowing section
to best identiy your position and job description
and indicate your base.
Name:
Phone:
Grade (i known)
Job title
Work area
Base
Please send this cover sheet and the completed
questionnaire orms to: XXX
NOTE: This orm will be destroyed as soon as the data is recorded in
the database.
Circle the appropriate number (I to 5) in its box against each o the 25
questions. I you strongly disagree with the statement, circle 1. I youstrongly agree, circle 5. I your opinion is somewhere in between theseextremes, circle 2, 3 or 4 (or disagree, unsure or agree). Please respondto every question. Adding all the responses gives a saety culture score or
the company, which is checked against known benchmarks.
Notes
Svl sp sls obid om s l sv sig his om:
1. A benchmark saety culture score that
can be compared with similar companies
world-wide.
2. A means o comparing the views o
management with those o sta regarding
the companys saety culture.
3. A means o evaluating the results o any
changes made to the companys saety
management system when a ollow-up
survey is carried out.
4. Identication o areas o concern, indicated
by 1 and 2 responses, which can assist in
the allocation o saety resources.5. A means o comparing the saety
culture o dierent departments and/or
operational bases.
th high h vl, h b h s
l ig. us h ollowig s
gid ol, b vg omp
s l so o 93 is osidd
miimm. ahig lss wold sggs
h impovms dd.
Poor saety culture 25-58 Bureaucratic saety culture 59-92
Positive saety culture 93-125.
Organisations with a poo s ltreat
saety inormation in the ollowing way:
Inormation is hidden
Messengers are shot
Responsibility is avoided
Dissemination is discouraged
Failure is covered up New ideas are crushed
Organisations with a bi s
l treat saety inormation in the
ollowing way:
Inormation may be ignored
Messengers are tolerated
Responsibility is compartmentalised
Dissemination is allowed, but discouraged
Failure leads to local repairs New ideas present problems
Organisations with a positive saety culture
treat saety inormation in the ollowing way:
Inormation is actively sought
Messengers are trained
Responsibility is shared
Dissemination is rewarded
Failure leads to enquiries and reorms
New ideas are welcomedSource: Edkins, G.D. (1998). The INDICATE saety program: A method to
proactively improve airline saety perormance. Saety Science, 30: 275-295.
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Safety Management Systems 41
Number Statement Company rating
Disagree Agree
1 Employees are given enough training to carry out their
tasks saely.1 2 3 4 5
2 Managers get personally involved in saety
enhancement activities.1 2 3 4 5
3 There are procedures to ollow in the event o anemergency in my work area.
1 2 3 4 5
4 Managers oten discuss saety issues with employees. 1 2 3 4 5
5 Employees do all they can to prevent accidents. 1 2 3 4 5
6 Everyone is given sucient opportunity to make
suggestions regarding saety issues.1 2 3 4 5
7 Employees oten encourage each other to work saely. 1 2 3 4 5
8 Managers are aware o the main saety problems in
the workplace.1 2 3 4 5
9 All new employees are provided with sucient saety
training beore commencing work. 1 2 3 4 5
10 Managers oten praise employees they see working saely. 1 2 3 4 5
11 Everyone is kept inormed o any changes which may
aect saety.1 2 3 4 5
12 Employees ollow saety rules almost all o the time. 1 2 3 4 5
13 Saety within this company is better than in other airlines. 1 2 3 4 5
14 Managers do all they can to prevent accidents. 1 2 3 4 5
15 Accident investigations attempt to nd the real cause o
accidents, rather than just blame the people involved.1 2 3 4 5
16 Managers recognise when employees are working unsaely. 1 2 3 4 5
17 Any deects or hazards that are reported are rectied
promptly.1 2 3 4 5
18 There are mechanisms in place in my work area or me
to report saety deciencies.1 2 3 4 5
19 Managers stop unsae operations or activities. 1 2 3 4 5
20 Ater an accident has occurred, appropriate actions are
usually taken to reduce the chance o recurrence.1 2 3 4 5
21 Everyone is given sucient eedback regarding this
companys saety perormance.1 2 3 4 5
22 Managers regard saety to be a very important part o all
work activities. 1 2 3 4 5
23 Saety audits are carried out requently. 1 2 3 4 5
24 Saety within this company is generally well controlled. 1 2 3 4 5
25 Employees usually report any dangerous work practices
they see.1 2 3 4 5
Saety culture total:
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