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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 [email protected]

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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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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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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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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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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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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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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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.


18/44

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.


19/44


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.


20/44

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?


21/44


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?


22/44

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.


23/44


24/44

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.


25/44


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.


26/44

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.


27/44


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.


28/44

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.


29/44


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


So poig qims Yes / No Completed Yes / No

coiv io viw qid? Yes / No How: (speciy)__________________

Review date: ___________________

Gl omms


Gl mg p d omms

Name: Signature: Date (dd/mm/yyyy)


30/44

28 Safety Assurance

DATA COLLECTION WORK/AREA:


31/44


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


32/44

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






33/44


Idividl o m ios




tsk o vioml odiio




Ogisiol os




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





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


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).


34/44

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


Headng


Headng


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.


35/44


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


CEOs acceptance o fndings and comments


Aviation saety managers acceptance o fndings and comments


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.


Headng


Headng



36/44

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.


37/44


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.


38/44

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.


39/44


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.)


40/44

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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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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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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