sms

Department of Civil Aviation Mauritius

Air Traffic Services

SAFETY

MANAGEMENT MANUAL

WARNING

CONTROLLED COPY NUMBER

This document and the information contained herein is the property of DCA Mauritius.

No part of this work may be reproduced or copied in any form or by any means (graphic, electronic or

mechanical, including photocopying recording, taping or information retrieval system) or otherwise disclosed

to any party without the prior consent of the Divisional Head of Air Traffic Services.

© DCA Mauritius 2003.

All rights reserved.

First Amendment : 11 June 2007 Second Amendment : 05 October 2009

Safety

Management Manual

Sections Section 1: Safety Management Policy

Section 2: Safety Management Document Management

Section 3: Safety Management Strategy

Section 4: Safety Management Program

This document and the information contained herein is the property of DCA Mauritius. No part of this work may be reproduced or copied in

any form or by any means or otherwise disclosed to any party without the prior consent DCA Mauritius.

DCA Mauritius 2003. All rights reserved. First Amendment : 11 June 2007 Second Amendment : 05 October 2009

The Safety Management Manual supports the Safety Management System. The Safety Management Manual and

supporting documentation will continue to evolve and undergo further development throughout the life of the

National Airways System. This Manual and all supporting documentation will always

be subject to review, further development and addition.

SAFETY MANAGEMENT - POLICY

DCA Mauritius Safety Management Manual Effective 01 August 2003 Safe 1:1

Safety

Management Manual

Section 1

Safety Management

Policy

SAFETY MANAGEMENT - STRATEGY

DCA Mauritius Safety Management Manua l Effective 05 October 2009 Safe 1:1:1

Table of Contents Page

Safety- An Uncompromising Approach.................................................

1.2

ICAO ATM Safety Management Requirements.......................................... 1.3

ATS Safety Management...................................................................... 1.3

ATS Safety Management Activities....................................................... 1.3

ATM Safety Management System........................................................ 1.4

Policy......................................................................................... 1.4

Strategy..................................................................................... 1.4

Program..................................................................................... 1.4

Responsibility and Accountability.......................................................... 1.4

CNS –ATM Approach and Commitment- Safety Policy........................ 1.5

Reactive Component................................................................. 1.6

Proactive Component................................................................ 1.6

Predictive Component............................................................... 1.6

External Services................................................................................. 1.6


DCA Mauritius Safety Management Manual Effective 05 October 2009 Safe 1:2

Safety - An uncompromising approach Safe Navigation Of Aircraft

ATM will provide the highest reasonable standard of safety within the air traffic systems which it plans, provides and operates by identifying and minimising those risks arising from ATM activity which could affect aircraft safety. The ATM SMS is established to ensure that safety in the provision of air navigation services is maintained in compliance with :

(1) The Civil Aviation Regulations of Mauritius(2007)

(2) Civil Air Navigation Requirements of Mauritius (2009)

(3) ICAO SARPS on safety Management contained in Annexes 1,

6,8,11,13,14 and ICAO Guidance Materials in ICAO Doc 9859 (2nd

Edition 2009)

Priority Of Safety

ATM will regard the safety of the air traffic system as the most important consideration throughout all its activities.

Management Responsibility

Safety is an integral part of the provision of an efficient, effective air traffic system. All Supervisory staff are accountable for the performance of their areas of Responsibility.

Adoption Of Explicit Safety Standards

ATM will continue to adopt safety standards that comply with statutory obligations and with the safety requirements of ICAO and industry best practice.

Safety Culture

ATM will develop a culture among all managers and staff which fosters an increasing understanding of the importance of safety in all our activities and will provide the environment, support and training necessary to achieve this goal.

Systems

ATM will ensure that the systems and technology it uses, whether developed internally or bought externally, meet appropriate system safety standards.



ICAO ATM Safety Management Requirements.

• ICAO Doc 4444 ATS SAFETY MANAGEMENT 2.2 OBJECTIVES The objectives of ATS safety management are to ensure that: a) the established level of safety applicable to the provision of ATS within an airspace or at an aerodrome is met; and b) safety-related enhancements are implemented whenever necessary. 2.3 ATS SAFETY MANAGEMENT ACTIVITIES 2.3.1 An ATS safety management programme should include, inter alia, the following with

respect to the provision of air traffic services: a) monitoring of overall safety levels and detection of any adverse trend; b) safety reviews of ATS units; c) safety assessments in respect of the planned implementation of airspace re-organizations, the introduction of new equipment systems or facilities, and new or changed ATS procedures; and d) a mechanism for identifying the need for safety enhancing measures. 2.3.2 All activities undertaken in an ATS safety management programme shall be fully

documented. All documentation shall be retained for such period of time as is specified by the appropriate authority.



3. ATM Safety Management System Safety Management is that part of the overall management function that defines, implements and maintains ATM’s stated safety policy. ATM meets ICAO SMS requirements by maintaining its Safety Management System (SMS) as follows: The implementation and maintenance of the ATM SMS is endorsed at the most senior level of management within ATM and follows a logical philosophy:

1. POLICY

ATM safety “Policy” defined and documented. (SMS Section 1)

a. This is ATM’s fundamental approach to safety and the management of safety and ;

b. Commits all levels of staff to implement and maintain the stated ATM “Policy”.

2. STRATEGY

From the “Policy” statement, ATM defines safety management “Strategy”. (SMS Section 3)

a. This provides a framework of actions required to meet the objectives in “Policy”.

b. This defines the required actions to identify, remedy and provide ongoing assurance that

safety levels are not only being met but also improved.

3. PROGRAM

The ATM “Program” records how these actions are implemented and documented. (SMS Section 4)

a. The “Program” lists where processes and procedures are documented that achieve the action requirements defined in “Strategy”.

4. RESPONSIBILITY & ACCOUNTABILITY The responsibilities and accountabilities of all ATM staff in respect of safety are clearly defined within the documents referred to in the ATM safety “Program”.


DCA Mauritius Safety Management Manual Effective 05 October 2009 Safe 1: 5

5. CNS –ATM Approach and Commitment- Safety Policy The policy of Department of Civil Aviation (CNS-ATM) is to comply with both the letter and the spirit of its legal obligations with regard to Safety whilst regarding them as minimum requirements. The ATM SMS shall ensure that safety in the provision of air navigation services is maintained in compliance with :

(1) The Civil Aviation Regulations of Mauritius (2007). (2) Civil Air Navigation Requirements of Mauritius (2009). (3) ICAO SARPS on safety Management contained in Annexes 1, 6,8,11,13,14 and ICAO

Guidance Materials in ICAO Doc 9859 (2nd Edition 2009). In conducting our safety policy we shall work in close partnership with the other ANSPs and International Organisations in particular with regards to Safety Data exchange. Furthermore airspace users will be consulted wherever appropriate from a safety perspective. The Department of Civil aviation (CNS-ATM) is committed to the safety of the users of the airspace of Mauritius as well as to the efficient handling of their flights. We will therefore afford the safety the highest priority over commercial pressures or constraints. To this end Safety Objectives will be set, periodically assessed using predefined success criteria and revised accordingly. The Department of Civil Aviation (CNS-ATM) will adopt a formal approach to the management of safety by implementing its Safety Management System. The Department of Civil aviation (CNS-ATM) SMS will be concerned with the ATM system (ground component) as a whole i.e. Equipment-Procedures and Humans. Human Factors will therefore be integrated in all functions of the SMS as relevant. Our top management and in first place the Director of Civil aviation will be responsible for the achievement of the Safety Objectives. To this end the director and the top management will set-up the Safety Organisational structure and make available the required resources and budget. The Safety Manager will ensure that all safety management activities required are carried out in a satisfactory manner. The Safety Manager will report directly to the Director of Civil Aviation. The Safety Manager will provide guidance, advice and support to all staff members and in particular will keep the Director and top management informed of the Safety and Safety Management performance of the Department of Civil Aviation (CNS-ATM) Safety Specialists will conduct the specialised tasks so as to provide the required results to (e.g.) the Divisional Heads. However, Safety would not be achieved without the dedication of all Staff members who all have safety responsibilities in relation with their own tasks as detailed in their Job Descriptions. The Safety Committee and Unions shall be consulted about issues affecting the staffs that have a safety implication. The Director of Civil aviation and top management need feedback and active participation of all the staff to improve safety. The required communication link will be ensured via the Safety Committee which will comprise an of both staff and management representatives. The Safety Committee will convene periodically and as circumstances may require.


DCA Mauritius Safety Management Manual Effective 05 October 2009 Safe 1: 6

The Department of Civil Aviation (CNS/ATM) Safety Management system will be established on three major components: 1. REACTIVE COMPONENT

We have a legal but more importantly a moral obligation to take remedial actions when identifying deficiencies that affect the services it provides. This requires a Reporting System and agreed Investigation processes and procedures. Success of such a reporting system can only be achieved by implementing a fair culture within the Department of Civil Aviation (CNS/ATM) section. The Director of civil Aviation commits to ensuring through arbitration when necessary to make the fair culture become reality. 2. PROACTIVE COMPONENT

• Safety surveys will enable to identify shortcomings prior to producing effect. • Competency. Staff ability to carry out their work will be verified periodically • Lessons learnt shall be widely disseminated with emphasis on those staff primarily

concerned. • All staff shall be encouraged to voice concerns and/or make suggestions likely to improve

our safety performance via a Voluntary Reporting System. 3. PREDICTIVE COMPONENT

New system elements or changes to system elements shall be subject of a Safety assessment prior to actual implementation. Safety Cases shall therefore provide basis for decision making i.e. to implement when and how or not to implement. The Department of Civil Aviation (CNS/ATM) Safety Management will require a sound Documentation system. We shall implement such a documentation system which will ensure Traceability and Transparency. Traceability is required by Safety Management to ensure consistency of successive decisions. Transparency is required to show to the external world, including but not necessarily restricted to the Regulator, what the Department of Civil Aviation CNS/ATM Safety achievements are. EXTERNAL SERVICES

Department of Civil Aviation (CNS/ATM) is dependent upon a number of external suppliers the deliverables of which shall NOT degrade the safety levels otherwise achieved by the Department of Civil Aviation (CNS/ATM). To this end External services shall be assessed. The Department of Civil Aviation (CNS/ATM) Safety Policy is effective as of 05 October 2009 however actual implementation of the full Safety Management System is planned to take place over period of (2) years. The Safety Policy shall be revised annually to take account of the progress accomplished by Department of Civil Aviation (CNS/ATM) as well as of the new safety developments.

SAFETY MANAGEMENT - DOCUMENT MANAGEMENT

DCA Mauritius Effective 1st August 2003 Safety Management Manual Safe 2:1

Safety

Management Manual

Section 2

Safety Management

Document Management



Table of Contents Table of Contents ...................................................................................... 2 Introduction ............................................................................................... 3 Writing documentation for inclusion in the Manual ............................. 3 Documentation Approval ......................................................................... 4 Controlling the Manual ............................................................................ 4 Amending the Manual .............................................................................. 5 Document Control Sheet .......................................................................... 6 Description............................................................................................... 7 CHECKLIST OF CURRENT PAGES ................................................... 7



Introduction Purpose

The purpose of this document is to establish and maintain procedures for writing, approving, controlling, and amending documentation in the Safety Management Manual (SMM).

Scope

This procedure applies to all DCA ATM staff.

Responsibilities

Holders of hard-copies of the Manual are responsible for ensuring their Manual is kept up to date. This includes inserting new documents or document amendments in a timely manner, and complying with any instructions on amendment advice. The Chief Officer Operations is responsible for: • ensuring currency of information contained in the Manual; • periodic review of information contained in the Manual; and • amendment advice.

Writing documentation for inclusion in the Manual

Consultation

Staff tasked with writing documentation for inclusion in the Manual must consult with affected parties and provide an opportunity for comment on drafts of amendments or new documents prior to formal issue.

Format

Documentation and all amendments residing in the Manual must contain headers and footers that are consistent with those in this document.



Documentation Approval Approving Authority

The Approving Authorities for Safety Management Manual (SMM) documentation are:

Document Approving Authority

Safety Management Policy Safety Management Strategy Safety Management Program Other Safety Management documentation and procedures that support the above

Divisional Head ATM Divisional Head ATM Divisional Head ATM Chief Officers & ATC Supervisors

Controlling the Manual

Controlled document

The Chief Officer Operations will control the Manual

Version control

All Manual documentation must have version control, achieved through: Page numbers; Issue Dates; Issue dates will be included in the footer of each page

Distribution of the manual

The manual will be distributed to all affected parties in accordance with the published distribution list.

Master Copy

The Master Copy of the Manual will be held and maintained by the Chief Officer Operations



Amending the Manual

Periodic review

Documents contained within the Manual must be reviewed on a periodic basis, at intervals not exceeding three years. The process for amending the Manual follows:

Who does it

What happens

User/Originator

Sends a description of the proposed amendment to: The Chief Officer Operations

Chief Officer Operations

• Ensures review of the proposed change and, discussion with the originator and other relevant staff. • Decides whether or not to support the change for approval. • Seeks the appropriate approval for the recommended changes to Policy, or approves the changes for Procedures. If approved, then ensures: • The relevant pages are revised • Amendment advice is provided to all holders • Master Copy is updated • Obsolete/superseded documents from Master Copy are marked as such, and placed on archive • The original document proposing the change is archived. If not approved, the original document proposing the change is filed, and a copy is sent to the originator with an appropriate explanation.



Document Control Sheet

Explanation A controlled document is an individually numbered document assigned to

a specific registered copy holder.

The Supervisor responsible for document control must keep a list of authorised copy holders, and ensure that each copy holder receives all controlled documents and subsequent amendments. The list of authorised copy holders appears below.

Uncontrolled copies

Photocopying of controlled documents is permitted, however these are uncontrolled copies.

Persons in possession of uncontrolled copies will NOT be sent updates and amendments, and should be wary that they may not have the latest version of the document.

Control Information The control information for this manual is detailed in the tables below:

Title ATM Safety Management Manual. Owner The Chief Officer Operations Location of master copy Office of the Chief Officer Operations Date last updated 1st August 2003 Controlled distribution

Copy No

Position

1

2

3

4

5

6

7-10

11

12

13

Director of Civil Aviation

Deputy Director of Civil Aviation

Divisional Head

Chief Officer (Operations)

Chief Officer (Planning)

Supervisor

Reserved

Plaisance Tower

Reserved

Library

continued on next page.



Document Control Sheet, continued

Authority Amendments to these Instructions must be authorised by the Chief Officer

Operations

Amendments Amendments to these instructions must be by insertion, deletion or

complete re-issue of a section. Single page amendment is not permitted. Staff carrying out an amendment to these instructions MUST complete the Amendment Record sheet below, and check that all pages are current according to the checklist.

Change summary

Changes made to this document are summarised in the following table.

Date

Description

1st August 2003 New Issue

CHECKLIST OF CURRENT PAGES

Section Effective Date Page Numbers

Section 1 Safety Management Policy

1st August 2003 1.1 – 1.4

Section 2 Safety Management Document

Management

1st August 2003 2.1 – 2.7

Section 3 Safety Management Strategy

1st August 2003 3.1 – 3.25

Section 4 Safety Management Program

1st August 2003 4.1 – 4.34


DCA Mauritius Safety Management Manual Effective 1st August 2003 Safe 2:1

Safety

Management Manual

Section 2

Safety Management

Document Management



Table of Contents Page

Introduction.............................................................................................. 2:3

Writing documentation for inclusion in the Manual..................................

2:3

Documentation Approval.........................................................................

2:4

Controlling the Manual............................................................................

2:4

Amending the Manual.............................................................................

2:5

Document Control Sheet........................................................................

2:6

Checklist of Current Pages .................................................................... 2:8




The purpose of this document is to establish and maintain procedures for writing, approving, controlling, and amending documentation in the Safety Management Manual (SMM).

Scope

This procedure applies to all DCA ATM staff.

Responsibilities

Holders of hard-copies of the Manual are responsible for ensuring their Manual is kept up to date. This includes inserting new documents or document amendments in a timely manner, and complying with any instructions on amendment advice. The Chief Officer Operations is responsible for: • ensuring currency of information contained in the Manual; • periodic review of information contained in the Manual; and • amendment advice.

Writing documentation for inclusion in the Manual

Consultation

Staff tasked with writing documentation for inclusion in the Manual must consult with affected parties and provide an opportunity for comment on drafts of amendments or new documents prior to formal issue.

Format

Documentation and all amendments residing in the Manual must contain headers and footers that are consistent with those in this document.



Documentation Approval Approving Authority

The Approving Authorities for Safety Management Manual (SMM) documentation are:

Document Approving Authority

Safety Management Policy Safety Management Strategy Safety Management Program Other Safety Management documentation and procedures that support the above

Divisional Head ATM Divisional Head ATM Divisional Head ATM Chief Officers & ATC Supervisors

Controlling the Manual

Controlled document

The Chief Officer Operations will control the Manual

Version control

All Manual documentation must have version control, achieved through: Page numbers; Issue Dates; Issue dates will be included in the footer of each page

Distribution of the manual

The manual will be distributed to all affected parties in accordance with the published distribution list.

Master Copy

The Master Copy of the Manual will be held and maintained by the Chief Officer Operations



Amending the Manual

Periodic review

Documents contained within the Manual must be reviewed on a periodic basis, at intervals not exceeding three years. The process for amending the Manual follows:

Who does it

What happens

User/Originator

Sends a description of the proposed amendment to: The Chief Officer Planning

Chief Officer Operations

• Ensures review of the proposed change and, discussion with the originator and other relevant staff. • Decides whether or not to support the change for approval. • Seeks the appropriate approval for the recommended changes to Policy, or approves the changes for Procedures. If approved, then ensures: • The relevant pages are revised • Amendment advice is provided to all holders • Master Copy is updated • Obsolete/superseded documents from Master Copy are marked as such, and placed on archive • The original document proposing the change is archived. If not approved, the original document proposing the change is filed, and a copy is sent to the originator with an appropriate explanation.



Document Control Sheet

Explanation A controlled document is an individually numbered document assigned to

a specific registered copy holder.

The Supervisor responsible for document control must keep a list of authorised copy holders, and ensure that each copy holder receives all controlled documents and subsequent amendments. The list of authorised copy holders appears below.

Uncontrolled copies

Photocopying of controlled documents is permitted, however these are uncontrolled copies.

Persons in possession of uncontrolled copies will NOT be sent updates and amendments, and should be wary that they may not have the latest version of the document.

Control Information The control information for this manual is detailed in the tables below:

Title ATM Safety Management Manual. Owner The Chief Officer (Planning) Location of master copy Office of the Chief Officer (Planning) Date last updated 05 October 2009 Controlled distribution

Copy No

Position

1

2

3

4

5

Director of Civil Aviation

Library

Control Tower

ACC

Master Copy

continued on next page.



Document Control Sheet, continued

Authority Amendments to these Instructions must be authorised by the Chief Officer

Operations

Amendments Amendments to these instructions must be by insertion, deletion or

complete re-issue of a section. Single page amendment is not permitted. Staff carrying out an amendment to these instructions MUST complete the Amendment Record sheet below, and check that all pages are current according to the checklist.

Change summary

Changes made to this document are summarised in the following table.

Date

Description

1st August 2003 New Issue 11 June 2007 AMN 05 October 2009 AMN



CHECKLIST OF PAGES

Safety Management : 1. Policy 1:1 01 AUG 03

1:1:1 05 OCT 09 1:2 05 OCT 09 1:3 01 AUG 03 1:4 01 AUG 03 1:5 05 OCT 09 1:6 05 OCT 09

Safety Management : 2. Document Management 2:1 01 AUG 03 2:2 05 OCT 09 2:3 01 AUG 03 2:4 01 AUG 03 2:5 05 OCT 09 2:6 05 OCT 09 2:7 05 OCT 09 2:8 05 OCT 09 Safety Management : 3. Strategy 3:1 01 AUG 03 3:2:1 05 OCT 09

3:2:2 05 OCT 09 3:2:3 05 OCT 09 3:2:4 05 OCT 09 3:3 01 AUG 03 3:4 01 AUG 03 3:5 01 AUG 03 3:6 01 AUG 03 3:7 01 AUG 03 3:8 01 AUG 03 3:9 01 AUG 03 3:9:1 05 OCT 09 3:9:2 05 OCT 09 3:9:3 05 OCT 09 3 :10 01 AUG 03 3 :11 01 AUG 03 3 :11:1 05 OCT 09 3 :11:2 05 OCT 09 3 :11:3 05 OCT 09 3 :11:4 05 OCT 09 3 :11:5 05 OCT 09 3 :11:6 05 OCT 09

3 :11:7 05 OCT 09 3 :11:8 05 OCT 09 3 :11:9 05 OCT 09 3 :11:10 05 OCT 09 3:12 01 AUG 03 3:13 01 AUG 03 3:14 01 AUG 03 3:15 01 AUG 03 3:15:1 05 OCT 09 3:15:2 05 OCT 09 3:16 01 AUG 03 3:17 01 AUG 03 3:18 01 AUG 03 3:19 01 AUG 03 3:20 01 AUG 03 3:21 01 AUG 03 3:22 01 AUG 03 3:23 01 AUG 03 3:24 01 AUG 03 3:25 01 AUG 03 3:26 05 OCT 09 3:27 05 OCT 09 3:28 05 OCT 09 3:29 05 OCT 09 3:30 05 OCT 09 3:31 05 OCT 09 3:32 05 OCT 09 3:33 05 OCT 09 3:34 05 OCT 09 3:35 05 OCT 09 3:36 05 OCT 09 3:37 05 OCT 09 3:38 05 OCT 09 3:39 05 OCT 09 3:40 05 OCT 09 3:41 05 OCT 09 3:42 05 OCT 09 3:43 05 OCT 09 3:44 05 OCT 09 3:45 05 OCT 09 3:46 05 OCT 09 3:47 05 OCT 09 3:48 05 OCT 09 3:49 05 OCT 09 3:50 05 OCT 09 3:51 05 OCT 09 3:52 05 OCT 09 3:53 05 OCT 09 3:54 05 OCT 09 3:55 05 OCT 09 3:56 05 OCT 09 3:57 05 OCT 09 3:58 05 OCT 09 3:59 05 OCT 09 3:60 05 OCT 09

3:61 05 OCT 09 3:62 05 OCT 09 3:63 05 OCT 09 Safety Management : 4. Program 4:1 01 AUG 03 4:2 05 OCT 09 4:3 05 OCT 09 4:4 01 AUG 03 4:5 01 AUG 03 4:6 01 AUG 03 4:7 01 AUG 03 4:8 01 AUG 03 4:9 01 AUG 03 4:10 01 AUG 03 4:11 01 AUG 03 4:12 01 AUG 03 4:13 01 AUG 03 4:14 01 AUG 03 4:15 01 AUG 03 4:16 01 AUG 03 4:17 01 AUG 03 4:18 01 AUG 03 4:19 01 AUG 03 4:20 01 AUG 03 4:21 01 AUG 03 4:22 01 AUG 03 4:23 01 AUG 03 4:24 01 AUG 03 4:25 01 AUG 03 4:26 01 AUG 03 4:27 01 AUG 03 4:28 01 AUG 03 4: 29 01 AUG 03 4:30 01 AUG 03 4:31 01 AUG 03 4:32 01 AUG 03 4:33 01 AUG 03 4:34 01 AUG 03 4:35 05 OCT 09 4:36 05 OCT 09


DCA Mauritius Safety Management Manua l Effective 01 August 2003 Safe 3:1

Safety

Management Manual

Section 3

Safety Management

Strategy


DCA Mauritius Safety Management Manual l Effective 05 October 2009 Safe 3:2:1

Table of Contents Page Definitions .................................................................................................. 3:3

Chapter 1

Introduction.............................................................................................

3:5

Chapter 2

Establishment of ATM’ Safety Management System...............................

3:6

Chapter 3

Safety Management System Strategy.....................................................

3:7

Safety Accountabilities................................................................. 3:7

Safety Management................................................................................ .

3:8

Safety Organisation, Responsibilities and Accountabilities..................... 3:9:1

Safety Management Steering Group ( SMSG)............................. Safety Management Committee................................................... Safety Specialists......................................................................... General – the Safety Management Shield................................... Director of Civil Aviation............................................................... The Divisional Head.................................................................... The Safety Manager.................................................................... Chief Officer Planning................................................................. Air Traffic Control Supervisors.................................................... All Operational Staff....................................................................

3:9:1 3:9:1 3:9:1 3:9:1 3:9:2 3:9:2 3:9:2 3:9:2 3:9:3

Change Management............................................................................. Objective..................................................................................... The Safety Assessmant Process Flowchart................................ The Safety Assessmant Process Steps...................................... Severity Classification Scheme................................................... Estimation of Likelyhood of the Hazard Occuring ...................... Evaluation of the Risk................................................................. Risk Mitigation............................................................................ Development of Safety Assessment Documentation..................

3:10 3:10 3:11:2 3:11:3 3:11:5 3:11:6 3:11:7 3:11:8 3:11:8

Documentation...................................................................................... Objective....................................................................................

3:12 3:12

Training................................................................................................. Objective....................................................................................

3:13 3:13



Table of Contents ( Cont) Page

Competency Assurance Rationale for Staff......................................................................

Responsibilities in Ensuring Competency of ATM Staff The ANSP.................................................................................. The Safety Manager.................................................................. ATCO’s.....................................................................................

3:15:1 3:15:1 3:15:1 3:15:2

Interfaces Objective..................................................................................

3:16

Air Traffic Services, Aeronautical Radio Navigation & Aeronautical Telecommunications Services Objective..................................................................................

3:17

Abnormal Operations Objective.................................................................................. Emergency Operations............................................................ Interruptions to Level of Operational Service........................... Incident and Occurences Procedures.....................................

3:19 3:19 3:20 3:21

Aeronautical Information Service (AIS) Objective..................................................................................

3:22

ATS Personnel Licensing Objective..................................................................................

3:23

Air Traffic Services Message Recording Objective..................................................................................

3:24

Airspace Design Objective..................................................................................

3:25

Mandatory Reporting system The DCA Mandatory Air Traffic Management Reporting System Obligation of Reporting............................................................ Reportable Occurences........................................................... Role of DCA ATM Staff in the Reporting and Investigation

Procedure................................................................................ Appendix A ATM-related safety occurrences to be reported and analysed

3:26 3:26 3:26 3:27 3:28



Table of Contents (Cont) Page

DCA –ATM Voluntary reporting scheme Relationship Between Mandatory and Voluntary Reporting

systems.................................................................................. Legal Framework...................................................................

Systems Description Scope.................................................................................... Confidentiality........................................................................ Reporting Mechanism............................................................ Roles and Responsibilities.....................................................

Handling of reports.......................................................................... Feedback......................................................................................... Recommendations............................................................................ Expectations from the system.......................................................... Appendix A – DCA/ATM Voluntary Reporting form Safety Occurrences Investigation Purpose of the Investigation............................................... Rationale for investigations by DCA ATM......................... Scope of Investigations made by the DCA ATM Division.. Decision to carry out an investigation................................ Action by Safety Manager on Receipt of ATS Occurence Report Written Reports.................................................................. Interviewing Procedure...................................................... Safety Occurence Analysis................................................ Safety Occurence risk Assessment...................................

3:32 3:32 3:32

3:33 3:33 3:33 3:33 3:33 3:34 3:34 3:35 3:36 3;36 3:36 3:37 3:37 3:37 3:38 3:39 3:40

Safety Indicators and Targets for Reporting Safety targets for reporting operational safety occurrences........

3:41

Safety Monitoring

Legal Framework......................................................................... Purpose of Safety Monitoring activities........................................ Responsibilities........................................................................... Activities to be carried out...........................................................

3:42 3:42 3:43 3:43

Safety Reviews Legal Requirements................................................................... Scope of Safety Reviews........................................................... Types of Safety Reviews and their objectives........................... Planning of Safety Reviews....................................................... Selection and Training Requirements of eview Team Members Safety Review Techniques....................................................... Role of the Surveyed units and unit Staff................................. Protection of Staff participating to safety Surveys....................

3:45 3:45 3:47 3:47 3:48 3:48 3:48 3:49



Table of Contents (Cont)

Safety Survey Results.............................................................. Management of recommendations and Suggestions.................. DCA/ATM Policy and Roadmap to a Just Culture Policy Definitions and Principles of a just Culture

Page 3:49 3:49 3:51 3.52



Definitions Accountability

A relationship that exists between two people or groups of people, the person held accountable and the person to whom they are accountable. Accountability exists where : • an outcome is defined; • responsibility is clear; and • appropriate authority is granted.

Accountability versus responsibility

By example, an employee is responsible for their actions in performing an activity whereas they are accountable to someone for the outcome of the activity being performed.

Air Traffic Services (ATS)

A generic term meaning variously air traffic control service, area control service, approach control service, aerodrome control service, flight information service, alerting service, air traffic advisory service, aeronautical information service and flight services.

Airways service

An air traffic service, aeronautical radio navigation service, aeronautical telecommunications service, or rescue and fire fighting service.

Authority

The permission granted to perform a particular task resulting from the issue of an operational, financial, human resource etc. delegation or authorisation.

Availability

The probability that a system will be able to perform its intended function when required for use.

Critical airways system

An airways system is deemed to be critical where the failure of the system will result in a significant reduction in the safety of operation of air traffic services.

Failure

Inability of the system to perform its intended service or function.

Fault

Degradation in the performance of a system.

Hazard

A source of potential harm or a situation with a potential to cause loss.

Hazard identification

The process of determining what can happen, why and how.

Maintainability

The ability of a system to be retained in, or restored to service.



National Airways System

Facilities, equipment, personnel and procedures, which, in combination, ATM Mauritius uses to provide an airways service to the aviation industry.

Reliability

The probability that, during a certain time period, a system performs its prescribed functions.

Risk

The probable rate of occurrence of a hazard causing harm and the degree of severity of the harm. The concept of risk always has two elements; the frequency with which a hazard occurs and the consequences of the hazardous event.

Responsibility

The state of ownership resulting from the performance of an activity or action.

Risk analysis

A systematic use of available information to determine how often specified events may occur and the magnitude of their likely consequences.

Risk assessment

The process used to determine risk management priorities by evaluating and comparing the level of risk against pre-determined standards, target risk levels or other criteria.

Risk control

That part of risk management which involves the provision of policies, standards and procedures to eliminate, avoid or minimise adverse risks facing an enterprise.

Risk management

The systematic application of management policies, procedures and practices to the tasks of identifying hazards, analysing, assessing, treating and monitoring risks.

Risk mitigation

A selective application of appropriate techniques and management principles to reduce either likelihood of an occurrence or its consequences, or both.

Safety

Being in a situation where the risks of an aircraft accident or air safety incident are reduced to a level as low as is reasonably practicable.

Safety Management System (SMS)

The policies, Strategy, Program, procedures and activities by which means safety management is undertaken by an organisation.

Safety Case

A document which provides substantial evidence and argument of whether the airways system to which it pertains meets its safety objectives.



Chapter 1


The purpose of this document is to: • detail ATM’s SMS Strategy; • address legislative, regulatory and corporate requirements; and • promote awareness in all staff of the many aspects of Safety Management.

Scope

This document is applicable to ATM staff, and contractors working for or on behalf of ATM, who undertake activities which may directly or indirectly affect the safe operation of the National Airways System.



Chapter 2

Establishment of ATM’ Safety Management System Executive Management Responsibility

ATM’ executive management must ensure that:

• A policy indicating ATM’ safety objectives and its commitment to safety is defined, documented and promulgated;

• This policy is understood, implemented and maintained at all levels of the organisation;

• A Safety Management System (SMS) is established, documented and maintained as a means of ensuring that the services delivered meet ATM’ own performance standards, and as a minimum, conform with regulatory requirements and standards;

• Procedures for SMS preparation, maintenance, approval, ownership and update are in place;

• The SMS is reviewed at defined intervals sufficient to ensure its continuing suitability and effectiveness; and

• Τhe SMS is embedded in all levels of the organisation.

The benefits of an SMS

Apart from ATM’ legislative requirements and regulatory requirements and standards, ATM’ derives benefits from establishing, documenting and maintaining an SMS. These benefits include:

• Improvement of safety awareness; • Provision of evidence of effective management of risks to safe

operation; • Identification of areas of higher risk to allow for the improved

utilisation of resources based on significance; • Provision of assurance to ATM’ Management that formal safety

management practices are in place; • Elevation of the standard of safety management, which should result

in lower insurance premiums if implemented effectively; and • Provision of a competitive advantage in future ATM’ business and

commercial activities.



Chapter 3

Safety Management System Strategy Safety Accountabilities ATM defines the following Strategy: Accountability

The responsibility, authority and the interrelation of staff, who manage, perform and verify work affecting safety must be defined and documented. Supervisory staff must detail key safety accountabilities for staff, for actions relating to system design, system acceptance, system operation, or restoration of a service or facility.

Safety Accountabilities structure

The safety accountabilities structure must be compatible with ATM’ general management structure. Safety accountabilities should be included in job descriptions and safety performance included in personnel appraisals.

Staff training

Staff identified with key safety accountabilities must have appropriate qualifications and competencies to enable them to fulfil their organisational roles



Safety Management Objective: To ensure that there is a system in place to assess the safety implications and safety hazards in ATM' operations, to determine the action necessary to minimise those hazards and to monitor the implementation of that action on a periodic basis. To achieve the above objective, ATM defines the following Strategy: Vigilance

All Supervisory staff must ensure that the necessary level of vigilance is in place to enable early detection of deviation from practices and procedures which may degrade the level of safety.

Existing systems

Processes must be established which identify, assess and control operational safety implications and hazards. These processes must enable the monitoring of the effectiveness of such controls on a periodic basis to ensure the ongoing integrity of operations.

Safety indicators

Processes must be established for monitoring and reviewing the effectiveness of the safety management procedures against key safety indicators.

Safety levels

Wherever practicable, quantitative safety levels must be derived and maintained for operational systems. Overall system safety levels must be based on assessment of the levels of risk which is acceptable to the organisation and the community, and subject to regulatory and statutory obligations.

Safety reporting

A system of safety reporting must be in place to ensure the timely reporting of all safety related issues, incidents and accidents. The reporting system must enable appropriate review, investigation, trend analysis and change to be effected, as necessary.

Lessons learnt from safety occurrences must be given wide distribution.

Investigation reports must be de-identified prior to dissemination for lessons learnt.

Remedial action

Remedial action must be taken to address identified hazards to safe operation.

Due consideration of risks to safe operation must be taken to ensure that an appropriate course of action is adopted with a clear statement of reasons for decisions recorded.

Following implementation, remedial action must be reviewed to assess effectiveness.



Safety issue tracking

Processes must be in place which ensure capture and tracking of safety issues through to resolution.

Audits

Formally documented processes, procedures and where necessary audits, must demonstrate the overall safety of the Airways System. Audits may be of the following types:

• compliance; • effectiveness; and • efficiency.

Environmental and other influences

Processes must be established to assess the effects of environmental and other influences on safety.

External Authority

Recommendations from statutory authorities and ICAO must be reviewed, and if agreed, implemented as quickly as possible.



Safety Organisation, Responsibilities and Accountabilities

Safety Organisation: While the Safety Manager has responsibility of developing the Safety Management system, he needs the support of the organization in general and of top level management in particular. To this end the following are set up as part of the SMS Safety Organisation: 1. Safety Management Steering Group (SMSG):

The role of this group is to make or endorse policy decisions, set time scale objectives and approve any directives or procedures that will be implemented. The members of the SMSG are the Director of Civil Aviation, the Deputy Director of Civil aviation responsible for CNS/ATM, the Safety Manager (the Divisional Head - ATM) and the Divisional Head (CNS).

2. Safety Management Committee

The role of this committee is to provide an expert forum for the formulation of safety policy and the development of new procedures. This committee is chaired by the Safety Manager and other members shall consist of the Chief Officer (ATM), Chief Officer (CNS), Safety Specialists, and other co-opted members from the operational staff ( depending on the agenda on hand for each meeting and which include safety specialists)

3. Safety Specialists

Safety specialists consist of Operational Staff (ATM or CNS) who have been provided specific training in some area of safety Management. As at 1st July 2008 these are:

Name SMS Related Training R.Guruvadoo SMS Workshop - Nairobi B.Heeramun ATS Safety Management and Investigation - SAA R.Sewraj ATS Safety Management and Investigation - SAA

General – The Safety Management Shield Having a well developed Safety Management system that reflects best-practice is not a shield from an accident. No matter how good it is, it will serve no purpose whatsoever if it is not implemented effectively and with commitment as part of the business. This is the responsibility of everyone from the Director of Civil Aviation downwards. Director of Civil aviation

As the accountable chief executive having control over the financial and human resources of the organisation, the Director of Civil Aviation shall be responsible for the provision of the Safety Organisational structure and making available the required resources and budget for the proper implementation of the Safety Management system.



The Divisional Head

The Divisional Head, ATM shall be responsible for ensuring that: A Safety Management System is established, documented and maintained as a means of ensuring that the services delivered meet DCA.s performance standards, and as a minimum meet the regulatory requirements and standards. The SMS is reviewed at defined intervals sufficient to ensure its continuity and effectiveness. Safety Manager

The Safety Manager shall be the Divisional Head - ATM and shall report directly to the Director of Civil Aviation on safety Matters. The Safety Manager shall be the responsible officer for ensuring that the SMS is properly implemented and performing to requirements in all areas of the organisation. The functions of the Safety Manager shall also comprise the following: 1. Advise the Director of Civil aviation on the safety performance of the organisation as a

whole. 2. Chair the Safety Committee. 3. Analyse Key result areas and trends. 4. Ensure that the day to day Safety Management is performed within the ATM Division. 5. Develop and revise the Safety Management System of the Organisation. 6. Provide specialist advice and assistance where required. 7. Provide/arrange for specialist safety management training at all levels. 8. Act as a proactive focal point for all safety issues. (While it is preferable for the Safety Manager to have no additional roles, this may not be possible in smaller organizations. In that case, the Safety Manager’s other responsibilities should not present a conflict of interest with safety management. The Safety Manager should be high enough in the organization to be able to communicate directly with top management).

Chief Officer Planning The Chief Officer Planning shall assist the Divisional Head, ATM in the tasks described above.

Air Traffic Control Supervisors

On occurrence of an a reportable incident, implement immediate actions, as necessary to restore safe operations Ensure that an occurrence report form is duly filled and forwarded to the Director of Civil Aviation. Continuously reviews work processes to assure that results meet the Departments mission and the customer's needs, adds value to facility services, and are efficiently achieved. Serves as a member of the management team to improve organizational performance and to meet strategic goals. When assigned as Watch Supervisor, assumes overall management and supervision of the control room.



All Operational Staff

1. Comply with regulations, rules and laid down procedures. 2. Where necessary determines appropriate action beyond guidelines; 3. Reports potentially unsafe conditions whether these are covered by the compulsory

reporting requirements or not. 4. Uses equipment and materials properly



Change Management Objective: To control and manage safety hazards in any change to existing systems, equipment or procedures, to ensure any unacceptable hazards are eliminated by the time the change is completed. To achieve the above objective, ATM defines the following Strategy: Management responsibility

Management must ensure that processes are in place to formally document the identification of hazards to safe operation, the risk analysis and assessment of these risks, and the control of the resulting risk, for any significant change to existing systems, processes or procedures. Any unacceptable risks must be eliminated or reduced to an acceptable level before a change is implemented.

When a Safety Case is required

A Safety Case must be used to document the safety aspects of:

• all new National Airways System components having operational safety implications; and

• major modifications or upgrades to the existing National Airways System

Change Management Process

The change management process must:

• describe the existing system in sufficient detail to allow an understanding of the safety issues;

• identify the impact of change on the existing system; • detail the hazard identification methodology used; • describe the risk analysis and assessment methodology used; • describe the risk control process for eliminating or reducing risk

factors which have been identified; • describe the safety management arrangements for implementation of

the change through to commissioning and ongoing safety monitoring;

• ensure that all changes are documented in such a way that all system users are informed of the change; and

• detail approval authority for the identified safety and accountability.

Risk control/ mitigation

Risk controls may employ any, or a combination of:

• process and/or procedures redesign; • equipment redesign; • staff training; • administrative controls; • testing; • communication of risks.



Risk analysis method

A hazard identification and risk analysis method may take any of the following forms: • assessment of overseas experience where relevant; • quantitative modelling based on sufficient data, a validated model and analysed assumptions; • judgement based on relevant experience within a process designed to ensure that:

(a) relevant competence and experience is applied; (b) relevant issues and components of the decision have been

addressed; (c) no component of judgement is anonymous; (d) the infrastructure lends itself to continuity of services supplied,

either stated or implied. • trial implementation under surveillance and with sufficient backup or reversion strategy, until sufficient data and experience has been acquired.


DCA Mauritius Safety Management Manua l Effective 05 October 2009 Safe 3:11: 6



Probability of Occurence

Extremely Improbable

Extremely Remote

Remote Reasonably Probable

Frequent

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Catastrophic Review Unnaceptable Unnaceptable Unnaceptable Unnaceptable

Hazardous Review Review Unnaceptable Unnaceptable Unnaceptable

Major Acceptable Review Review Review Review

Minor Acceptable Acceptable Acceptable Acceptable Acceptable

AFETY MANAGEMENT - STRATEGY

DCA Mauritius Safety Management Manua l Effective 05 October 2009 Safe3:11:10

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AFETY MANAGEMENT - STRATEGY

DCA Mauritius Safety Management Manua l Effective 05 October 2009 Safe3:11:11



Documentation

Objective: To record procedures, actions and results to facilitate operations, analysis and review on a periodic basis. To achieve the above objective, ATM’ defines the following Strategy: Management responsibility

Management must ensure that ATM has a document management system defined, documented and in place to record policies, procedures, actions and results of its operations, and which facilitates analysis and review.

Document control

Document control processes must: • ensure that the authority for issue and/or amendment is appropriate to management and safety accountability;

• ensure that the latest version of all documentation is readily available to all users;

• ensure that a master copy of documentation is secure; • ensure that a copy of obsolete documentation is archived and all other versions are destroyed promptly;

• check that operational and technical instructions conform with agreed policy and internal documentation standards;

• ensure document review on a periodic basis.



Training Objective: To ensure that processes exist which deliver staff who are qualified and competent to perform their required tasks and to periodically monitor their continuing competence. To achieve the above objective, ATM defines the following Strategy: Management responsibility

Management must ensure that processes are defined, documented, in place and maintained which ensure staff are trained, qualified and competent to perform their tasks. The processes must allow for monitoring the continuing competence of these personnel on a periodic basis. Staff must understand the ATM SMS and its obligations and apply them in day to day activities.

Needs

Training courses must be provided on the basis of a training needs analysis or other equivalent method. Legislative and/or ICAO training requirements are accepted.

Training records

A process for maintaining and updating records of staff qualifications, certifications, licenses and competencies must be in place.

Training categories

Training courses can be divided into the following categories: • initial training to achieve a new qualification or competency; • training to maintain a qualification or competency; • training to transfer or upgrade from a current qualification or competency to a new qualification or competency; or

• specific requirements for "direct entry" personnel.

Selection of staff for courses

The process for selection of staff for courses must be documented and consider the following requirements: • medical criteria which are normally set by ICAO Standards and Recommended Practices (SARPS)

• competency criteria which are set by ATM having regard to prerequisites deemed necessary to the successful achievement of the training course.



Training, Continued Training programs

The training programs for each course must facilitate achievement of the training goals through: • a curriculum, or synopsis for courses with a short life; • method of delivery; • method of assessment; • remedial process; and • recency criteria.

Curriculum

The training curriculum must detail learning outcomes required through the various stages of the course and on completion. The curriculum must ensure compliance with national and international requirements and any relevant competency based training standards.

Delivery

The method of delivery must utilise facilities and instructors with current expertise and identified competencies appropriate to achieving the goals of the course.

Assessment

The method of assessment must utilise qualified assessors and appropriate facilities; The assessment process must include a record keeping process which records all progress and completed assessments.

Remedial process

The training program must employ a remedial process which ensures that deficiencies in technique, application or knowledge are identified and rectified. The process must ensure that staff in need of remedial training are afforded the appropriate level of assistance.

Recency

Appropriate time limits must be placed on the validity of elements of the training program.



Course evaluation

Processes must be in place to evaluate courses to ensure that learning outcomes continue to satisfy training needs.

Emergency training

Emergency training specifically to prepare the candidate for abnormal operations must be provided, either as stand alone training or as part of relevant operational training courses.

Transition

Transition training to ensure efficient integration into new systems or environments must be provided.

Consolidation

The training course must also allow for consolidation of acquired skills and competencies prior to candidates achieving full operational service.



Competency Assurance

Rationale for “staff competency” The Human component is essential to ATM system. Humans have unrivalled abilities e.g. the ability to learn how to perform challenging tasks under time pressure, however they also have weaknesses e.g. humans are prone to slips and lapses especially under stress or high workload. There is therefore a need to verify at regular intervals that operators do keep the knowledge, understanding and skills that their own job responsibilities and accountabilities require. Though as State employees, Mauritian Air Traffic Controllers and Air Traffic Control Supervisors operate as unlicensed air traffic controllers they are still required to meet all the requirements of ICAO Annex 1 with respect to Licensed Air Traffic Controllers. Refer to the ATS Operational Administration Manual, Chaper 3 – Licensing for the detailed requirements regarding Licensing and certification of Air Traffic Management staff. Responsibilities in ensuring Competency of ATM Staff: The ANSP 1. DCA – ATM shall provide the training, conduct the required practical assessments and

inform the director of Civil Aviation of results of such training, practical assessment 2. Records of ATCOs assessments, qualifications, ratings, endorsements will be kept in the

ATCO database 3. DCA – ATM shall maintain the database of medical records and make the required

arrangements for ATCOs to hold at all times a valid medical certificate. 4. Random tests for alcohol and other narcoleptics will be carried out by MOH medical team

as per arrangements made by DCA. 5. Refresher training: once a year 1 week training including emergency situations (for both

aircraft emergencies and ATM system degraded modes)-once a year 1 week English language course

6. MOH medical team as per arrangements made by DCA will conduct regular awareness programmes on psychoactive substances (alcohol, marcoleptics and medecines)

The Safety Manager The Safety Manager must ensure that all processes and procedures do take place in a satisfactory manner. It is to be noted that this often leads to a dispersion of the records which the Safety Manager/safety manager is responsible for. Supervisors are responsible and accountable for making sure that controllers hold valid ratings for the working positions they occupy at all times. Supervisors are responsible and accountable for ensuring that ATCOs occupy working positions that are consistent with their qualifications, ratings and endorsements at any time. Tested staff will be first asked whether they are under such substances. Staff confessing having taken any psychoactive substance (be it later detected or not) will be offered a programme for drug/alcohol addiction treatment. Staff not confessing having taken such substances but testing positively would be subject to disciplinary action.



ATCOs are personally responsible for ensuring that they are aware of all applicable changes to the ATM system by checking the procedures in place prior to taking over duties ATCOs Qualifications/ratings/endorsements The Management and Supervisors in particular shall keep a close eye on validity of qualifications/ratings and endorsements by checking on the ATCO records on a regular basis. This does not relieve all staff concerned with the provisions of this procedure of their own responsibility to not use the privileges of a licence/qualification/rating/endorsement which would NOT be valid anymore.

Medical

The Management and MOH in particular shall make sure that: • staff whose medical is about to end are advised and informed of their medical

appointment; • an appointment is being made for staff concerned with • the supervisors are informed so as to take these appointments for rostering of staff.

This does not relieve all staff concerned with the provisions of this procedure of their own responsibility to not use the privileges of a licence/qualification/rating/endorsement which would be valid due to medical requirements.

Extended absence The provisions of DCA-ATM Operational Administration Manual shall apply.



Interfaces

Objective: To identify the boundaries of responsibility between organisations to enable control of the interchange of services and data as and when it occurs. To achieve the above objective, ATM’ defines the following Strategy: Management responsibility

Management must ensure that interface arrangements between ATM’ organisational elements are defined and consistent with safety accountabilities. Management must ensure that interface arrangements are in place with external agencies, which address requirements to accept and provide data and services. Processes must be put in place to ensure the effective management of these interfaces.

MoUs, SLAs, Agreements, Contracts.

Interface arrangements must be identified in documents such as Memoranda of Understanding (MoUs), Letters of Agreement, Contracts and Service Level Agreements (SLAs).

Service, data or Process integrity

The interface arrangements must seek to ensure:

• the integrity and reliability of the data or service being accepted; • internal and external service providers have management processes

in place which will support the services provided at a defined level of performance and ;

• internal and external service providers have processes in place which will detect any change in their operation affecting the data and/or services provided and will facilitate prompt rectification.

ATM’ and Neighbouring FIR’s

ATM must ensure that interface arrangements exist with neighbouring FIR’s, which ensure efficient, effective and unambiguous communications between organisations. A process must be in place to ensure resolution of any area of dispute or conflict arising from both organisations carrying out their respective statutory functions.

Industry

ATM’ must ensure that arrangements exist which ensure the clear communication of operational information and procedures to the aviation industry (e.g. NOTAM, AIC etc.).



Air Traffic Services, Aeronautical Radio Navigation & Aeronautical Telecommunications Services Objective: To ensure processes are in place to facilitate the safe and effective management of the operations of ATM facilities and services on a continuing basis. To achieve the above objective, ATM defines the following Strategy: Management responsibility

Management must ensure that processes are defined, documented, in place and maintained which ensure continuous safe operation of the Airways System.

Safety reporting

Reporting processes must capture:

• critical system failures; • system defects; • equipment faults; • deficiencies in processes, procedures, or standards; • aircraft accidents or incidents; and • potential safety hazards.

Corrective and preventative action

Processes for corrective and preventative maintenance must be defined documented, in place and maintained to assure that ongoing operations are in accordance with performance standards.

System configuration

The current configuration of the Airways System and Services, including the standards, procedures, facilities, equipment and staffing levels must be defined, documented, in place and maintained.

System monitoring and control

Processes for monitoring and control that assure the ongoing operation of the system is in accordance with its performance standards must be defined, documented, in place and maintained.



Data analysis

Processes for reliability and maintenance of data analysis, to confirm performance standards and/or safety level assessment must be defined, documented, in place and maintained.

Potential hazards

Potential hazards identified either through data analysis, performance monitoring or other sources must have mitigating strategies developed and implemented, which are commensurate with the level of risk associated with the hazards.

Defect reporting

Defect reporting processes must ensure the equipment and procedures meet an ongoing performance standard equal to its performance expectation at design, and as refined during acquisition, acceptance, and after modification.

Air safety incident and fault reporting

Air safety incident and equipment fault reporting processes must ensure there is a method for monitoring the level and safety of service provision against that required by the users

Air Traffic Services, Aeronautical Radio Navigation & Aeronautical Telecommunications Services, Continued



ABNORMAL OPERATIONS Objective: To ensure processes are in place to minimise the impact of any abnormal operation on those utilising the service and report and record the abnormal operation, thereby providing a mechanism for review, as and when required, after the event. To achieve the above objective, ATM’ defines the following Strategy: Management responsibility

Management must ensure that business continuity plans, encompassing contingency plans, business resumption plans and emergency procedures, are defined, documented and in place which minimise the impact of any abnormal event on those utilising the Airways System.

Testing and revision

Contingency plans, business resumption plans and emergency procedures must be subject to regular testing and review.

Testing and review must also be undertaken following significant change to existing systems, processes or procedures.

Results of testing and revision must be documented.

Plans and procedures

Processes must ensure the satisfactory operation of procedures and equipment in all situations, in particular:

• emergency operations; • interruptions to level of operational service; and • incidents and occurrences.

Emergency Operations Recognition and response

Recognition and response procedures must be available to ensure that staff are prepared, ready and able to respond appropriately to an emergency situation.

Reporting

Reporting processes must ensure that all occurrences of emergency operations are reported promptly and relevant information reaches the appropriate authority.



Checklists

Checklists of procedures which assist in the provision of an appropriate response to any given situation must be available to operational staff.

Training

Exposure to and training in procedures, must be utilised, (which may include simulation) to ensure that staff are experienced in responding to emergency situations.

Review

Post-occurrence review processes must ensure that emergency situations are reviewed and assessed for the appropriateness of the reaction and response, and documentation, procedures and training are appropriately revised.

Interruptions to Level of Operational Service Contingency procedures

Contingency procedures must describe in detail, requirements for operational staff in the event of any interruption to the level of service provision.

Notification

Processes must be in place which ensure all affected and interested parties are promptly notified of the interruption to the operational service and its consequences. The notification processes will address both internal and external needs.

Business resumption

Procedures for the re-establishment of normal service must ensure the safe and orderly transition back into full operational service.

Abnormal Operations, Continued Emergency Operations, Continued



Abnormal Operations, Continued Incident and Occurrence Procedures Reporting and investigation

Incident and occurrence reporting procedures must include appropriate timeframes for reporting. Reports must be investigated to determine root causes. Appropriate strategies must be put in place to minimise the potential for re-occurrence.

Interface arrangements

Interface arrangements must be documented between ATM and other agencies for the exchange of information relating to incident and occurrence reports.

Facility status

Procedures must detail the requirement to immediately record the state of facilities which may be implicated in incidents.

Dissemination of investigation results

Procedures must detail the dissemination of the results of any investigations to interested parties. These processes must protect the legal rights of all involved or affected by investigations.



Aeronautical Information Service (AIS) Objective: To ensure processes are in place to deliver accurate presentation of aeronautical information to users of that information as and when they require it. To achieve the above objective, ATM’ defines the following Strategy: Management responsibility

Management must ensure that processes are defined, documented, in place and maintained which ensure the integrity and quality of the aeronautical information and guidance material produced and distributed.

AIS Program

AIS processes must include the following aspects:

• catalogue of services • proofing and data verification • error analysis and notification • consistency • promulgation and publication

Catalogue of service

A catalogue of services must be available. Services provided must be of a minimum level arising from a needs analysis.

Proofing and data verification

Proofing methods must ensure the integrity of the data to be published. AIS must ensure that the data custodian for any input to their operation has authorised that data.

Error notification and analysis

Error notification and analysis processes must be utilised, to facilitate timely rectification of identified errors.

Consistency

AIS processes must ensure the consistency and compatibility of maps and charts and displayed operational information

Promulgation

Promulgation processes must ensure the synchronisation and timely distribution of publications, in preference to short term amendments (NOTAMs).



ATS Personnel Licensing Objective: To ensure the control of entry of personnel into functions that require a licence and to periodically monitor and endorse the continuing competency of those personnel. To achieve the above objective, ATM defines the following Strategy: Management responsibility

Management must ensure that processes are in place which:

• ensure the control of entry of personnel into functions that require a licence; and • periodically monitor and endorse the competency of licensed personnel.

Performance guidelines and competencies

Effective processes must be utilised for setting performance guidelines and required competencies for licensed staff, consistent with ICAO SARPS

Assessment

Effective processes must be utilised for the initial and ongoing assessment and endorsement of competencies and proven proficiency.

Training Records

Record keeping processes must ensure the accuracy, integrity and availability of licences and endorsements.

Timely processing of information

Administrative processes must ensure the timeliness of receipt and processing of medical and competency information and the issue of associated licences or endorsements.

Temporary suspension and reinstatement

A process must be utilised which identifies the authority for, and enables the temporary suspension of, an ATS licence, pending investigation of an incident or occurrence. This process must include the nomination of the appropriate authority for reinstatement of the licence.



Air Traffic Services Message Recording Objective: To comply with ICAO standards for message recording and access to recordings on a continuing basis. To achieve the above objective, ATM’ defines the following Strategy: Management responsibility

Management must ensure that processes are defined, documented, in place and maintained which comply with ICAO requirements for ATS message recording, access and storage.

Security

Processes must ensure the appropriate level of security for operational records and data is applied.

Interface arrangements

Arrangements for cooperation with authorised investigative bodies must ensure compliance with relevant regulations regarding the access to, and the release of, records and data



Airspace Design Objective: To ensure processes are in place which assure the facilities for safe navigation are provided on an on-going basis. To achieve the above objective, ATM defines the following Strategy: Management responsibility

Management must ensure that processes, are defined, documented, in place and maintained.

Design integrity

Processes must ensure the integrity, validity and appropriateness of existing and proposed airspace configuration.

Levels of service

Processes must establish and administer the level of service to be provided in designated airspace.

ATM and Neighbouring FIR’s

ATM must ensure that interface arrangements exist with neighbouring FIR’s, which ensure communications between organisations when necessary, for airspace and procedures design.

Compliance with ICAO standards

Processes must be utilised which ensure that procedures, existing and proposed for use in designated airspace are in accordance with ICAO standards and recommended practices.

Procedure Enhancement

The development and promulgation of recommendations on enhancing operational procedures must be facilitated through appropriate procedures

Review

The Airways System must be periodically reviewed to confirm its relevance to current aviation industry needs.


DCA Mauritius Safety Management Manua l Effective 05 October 2009 Safe 3:26

MANDATORY REPORTING SYSTEM The DCA Mandatory Air Traffic Management Reporting System The DCA ATM Division implements a Mandatory reporting System with the objective of:

1. Complying with the legal obligations that of rests on the department by virtue of its role as ANSP for the Republic of Mauritius

2. Improving the safety levels achieved by the company by detecting system deficiencies and implementing appropriate remedial actions; and

3.Enable safety data exchange at international, regional and bilateral levels. Obligation of Reporting

All Air Traffic Management Staff members have an obligation to report safety occurrences under the provisions of this scheme. However some staff categories should be aware more than others of their key role in the reporting process. These are broadly the Operational and Technical staff that have real time duties. Note: Failure to report an occurrence that falls within the scheme does not necessarily mean that the staff concerned will be considered at fault. Due consideration will be given as to the circumstance that lead to the failure to report (e.g. whether it qualifies as an “honest omission”) before any disciplinary action is taken under the provisions of 8.3 below. Reportable Occurrences

An ATS Safety occurrence can be defined as any event that affected the safety if an aircraft where the air traffic service pr ground based navigation aid was a possible contributory factor to the occurrence or had the potential to be so in different circumstances. The reportable occurrences are listed in Appendix A to this Chapter. ATS Safety Occurrences that qualify for reporting under this Scheme shall be reported without delay i.e. before leaving work premises at the end of the shift. In addition TCAS alerts shall be reported and investigated) regardless of their impact of ATC operations.



Role of DCA ATM Staff in the Reporting and Investigation Procedure: Filled- in Reporting Form

INPUT STAFF OUTPUT

Any Occurrence All Staff Filled In Reporting form

Filled- in Reporting Form

Supervisor Take all actions to safeguard the system Inform CO-OPS if further urgent action required Provide feed back to reporter if appropriate Filled in Reporting form

Filled- in Reporting Form

Divisional Head In consultation with CO (ATM) & Safety Manager/

Set up investigation committee to determine any immediate action required to prevent recurrence Report to the Director of Civil Aviation



APPENDIX A

ATM-related safety occurrences to be reported and analysed The following list of ATM-related occurrences shall, as a minimum, be reported and assessed. A1 ATM-related safety occurrences to be reported and analysed

The following categories of ATM-related occurrences shall be reported and assessed.

Note:- (i) This shall not preclude the reporting of any occurrence, situation or condition

which, if repeated in different but likely circumstances or allowed to continue uncorrected, could create a hazard to aircraft safety.

(ii) Other safety occurrences identified as part of the monitoring requirements of specific programmes shall be added (E.g., Monitoring requirements as identified in the RVSM Programme).

A1.1 Accidents: In particular the following types of accidents, of specific interest to the ATM-

community:

• Mid Air collision • Controlled Flight Into Terrain (CFIT) • Collision on the ground between aircraft • Collision between an airborne aircraft and vehicle/another aircraft on the ground • Collision on the ground between aircraft and vehicle/person/obstruction(s) • Other accidents of special interest would include “losses of control in flight”, due to

VORTEX or meteorological conditions. A1.2 Incidents:

In particular the following types of incidents, of specific interest to the ATM community

A1.2.1 Near collision Encompassing specific situations where one aircraft and another aircraft/the ground/a

vehicle/person or objects are perceived to be too close to each other:

• Separation minima infringement • Inadequate separation • Near Controlled Flight Into Terrain (Near CFIT) • Runway incursion where avoiding action was necessary

A1.2.2 Potential for collision or near collision

Encompassing specific situations having the potential to be an accident or a near collision, if another aircraft is in the vicinity: • Runway incursion where no avoiding action is necessary



• Runway excursion by aircraft • Aircraft deviation from ATC clearance • Aircraft deviation from applicable ATM regulation • Aircraft deviation from applicable published ATM procedures • Unauthorised penetration of airspace • Deviation from aircraft ATM-related equipment carriage and operations, as

mandated in applicable regulation(s) A 1.3 ATM-specific occurrences

Encompassing those situations where the ability to provide safe ATM services is affected, including situations where, by chance, the safe operations of aircraft has not been jeopardised. This shall include the following occurrences: • Inability to provide Air Traffic Management Services • Inability to provide Air Traffic Services • Inability to provide Airspace Management Services • Inability to provide Air Traffic Flow Management Services • Failure of Communication function • Failure of Surveillance function • Failure of Data Processing and Distribution function • Failure of Navigation function • ATM system security

A-2 Note to Appendix A The minimum contextual/factual data to be collected when initiating and undertaking the assessment/investigation of an occurrence shall consist of the following (This list is by no means exhaustive):

• Number of aircraft involved • Vehicle(s) involved (Y/N) • Person(s) involved (Y/N) • Animal(s) involved (Y/N) • ATS Unit(s) • Date of occurrence • Number of fatal injuries:

a) Crew member fatal injuries b) Passengers fatal injuries c) Third party fatal injuries

• Number of serious injuries •

Data related to each aircraft:

• Damage to aircraft • Aircraft Type • Type of Flight (To identify more specifically Commercial Air Transport or General • Aviation Operation) • Type of operations (General Air Traffic and Operational Air Traffic)



• Phase of ATM operations (From Taxi to Arrival) • Flight Rules (IFR, VFR) • Type of Air Traffic Management service provided (Refer to list in Glossary at • appendix C) Class of Air Traffic Services airspaces • Other Airspace areas (Restricted, prohibited, danger areas) • Type of report (I.e., AIRPROX report, ACAS report, Others) • Type of monitoring system alerts (I.e., STCA, MSAW, GPWS, APW, ACAS, • S-MGCS, Others)

As results of the assessment/investigation of the occurrence the following details should as a minimum be produced and stored:

• level of severity of the occurrence • level of contribution from the ground element of the ATM system and establish if such

contribution is: a) Direct b) Indirect c) With no ATM involvement ( to cover situations where the ground element of the

ATM system had nothing to do with the occurrence) A-3 Results of the assessment/investigation to be stored

A-3.1

The assessment/investigation of the occurrence shall enable the determination of the

Classification of the accident or incident Refer to SRC Guidance Material “Severity Classification Scheme for Safety Occurrences in ATM”, Released Issue 1.0.

A-3.2

The assessment/investigation of the occurrence shall enable the determination of the chain of events that led to the occurrence and enable the identification of the various reasons why each event took place, thus enabling the development of remedial measures, corrective actions and safety interventions or recommendations.

A-3.2.1 Causes that combined to result in the occurrence shall be classified according to the following high level categories:

Note:- However, the assessment/investigation of the occurrence may require a significant breakdown of those categories in order to better identify the reasons why the occurrence took place and to take adequate prevention measures.

• ATM services personnel • Physical/Physiological/Psychosocial • Interface-Working Environment • Operational tasks demand



• ATM services personnel operating procedures and instructions • Operational ATC procedures • Other operational ATM service procedures • Engineering and maintenance procedures • Interface between ATM service units • ATM service infrastructure/facilities/technical systems • Hardware issues • Software issues • Integration issues • Aerodrome layout and infrastructure • Airspace structure • Route structure • Capacity • Sectorisation • ATS airspaces • Company structure and Management Policy • Operational Line management • Safety Management System • Institutional arrangements • Management/personnel policy • Regulatory activities • Regulation • Approval process

A-3.2.2 Safety recommendations, interventions and corrective actions shall be developed and recorded where necessary, and their implementation monitored. They can take various forms, including development and implementation of a Safety Regulatory Requirement, standards implementation, procedures development or improvement, changes to system architecture, revisions in the ATM training.



DCA –ATM Voluntary reporting scheme

The DCA CNS/ATM Division implements a Voluntary Reporting System with the objective of encouraging people to report incidents and unusual occurrences, which though they fall outside the scope of the mandatory reporting system, still, in the opinion of the reporters, have significance for safety. The events that are reported are determined by the individual safety concerns of the reporters. The objective of implementing a Voluntary Reporting System is to:

• Allow the capture of events, features and actions that have the potential to cause harm; • enable the understanding of the relationships between the many potential causes of

accidents, serious incidents and other incidents; and • facilitate the implementation of root cause solutions that prevent recurrence

Relationship Between Mandatory and Voluntary Reporting systems The DCA CNS/ATM Division Voluntary Reporting System is complementary to the Mandatory Reporting System( see MATS and Safety Management Manual). Mandatory and Voluntary Reporting Systems must be seen as having the “Same Vision with Different Views”. The Mandatory Reporting systems focuses on incidents and accidents to trigger investigations

of latent and active errors. The Voluntary Reporting System is aimed at obtaining information on a range of “undesirable” events so that these can be investigated for any links or associations with possible incidents or accidents. The purpose of the voluntary reporting system is therefore to establish whether undesirable events are or could be correlated with incidents. Legal framework ICAO Annex 13, Aircraft Accident and Incident Investigation, chapter 8 has published the following SARPs:

8.2 Recommendation. — A State should establish a voluntary incident reporting system to facilitate the collection of information that may not be captured by a mandatory incident reporting system. 1.1 A voluntary incident reporting system shall be non-punitive and afford protection to the

sources of the information.

Note 1. — A non-punitive environment is fundamental to voluntary reporting. Note 2. — States are encouraged to facilitate and promote the voluntary reporting of events that could affect aviation safety by adjusting their applicable laws, regulations and policies, as necessary. Note 3.— Guidance related to both mandatory and voluntary incident reporting systems is contained in the Accident Prevention Manual (Doc. 9422).



SYSTEM DESCRIPTION Scope

In principle there are no limitations to the type of undesirable events to be reported as long as they are outside the list of reportable occurrences of the Mandatory Reporting system. Confidentiality

The DCA CNS/ATM Voluntary Reporting System allows for anonymous reports. However reporters should bear in mind that the effectiveness of the system would be affected e.g. there is no possibility for feedback which is one of the required qualities of a reporting system. Reporting mechanism

Reports can be made in any form; including verbal reports to the Safety Manager (Divisional Head -ATM). However it is recommended that the free text form at Attachment A be used for this purpose. The Standard ATS Reporting Form may also be used whenever the report requires technical data to be included. Roles and responsibilities The responsibilities of the main parties involved in the Voluntary Reporting system shall be as follows: • Reporters - provide a clear concise report and be open and honest about their own actions

and reactions. • Supervisors – when applicable support the reporter and make an immediate assessment of

the safety implications, report the need for immediate action to the appropriate managers. • Managers - Encourage participation, provide sufficient resources for the system, ensure an

open reporting culture, and act on recommendations. • Safety Manager– Provide an unbiased assessment of reports, support and feedback

information to reporters via the appropriate management chain. Prepare safety recommendations, correlate data to identify patterns of undesirable events.

Handling of reports In principle reports shall be given the same attention as report originating from the Mandatory reporting system i.e. broadly the same steps as for safety occurrence report would be followed whenever that is feasible and pertinent.



Feedback Whenever possible feedback shall be provided to the reporter:

• At receipt of the report; and • After analysis of the report. •

Recommendations Should recommendations be felt desirable by the Safety Manager they would first be verified by the most suitable group of person/unit or department. Should they be retained by these review groups they would then either be submitted to the Safety Committee whenever costs beyond unit(s)/department budgets or directly implemented and their implementation shall be monitored by the Safety Manager/safety department.

Type or report submitted

No further investigation The issue will assessed for need to monitor the kind of occurrence or undesirable event (e.g. through surveys)

The report will be handled as if it was a mandatory report with the following Differences:

- No information to the Regulatory division whatever the severity may be (to avoid killing the system)

- Strict disidentification i.e. only the safety Manager would have known the name of the person reporting, which name is erased definitively from any records

Anonymous Confidential



Expectations from the system Here are some of the specifics of voluntary reporting systems.

• Voluntary reporting systems are prone to collect any kind of data; • Voluntary reporting systems should not be misused e.g. to complain about persons or

equipment; • Confidentiality may reduce the effectiveness of the reporting system; • Best value of reports will be when they will include suggestions for improvement; and • Voluntary reports are not limited to malfunctions. They can also proactive suggest

improvements to an already acceptable situation.

• Due to their specific and the inevitable misuse to some extent of reporting systems, expectations from management and reporters should remain reasonable.

• Reporters may not expect that any suggestion they make will be implemented. • Management should not expect a too high degree of contribution to the voluntary

reporting system. • Management should not be surprised by any misuse of the reporting system.



Safety Occurrences Investigation

1. Purpose of the investigation

1.1 Annex 13- Chapter 3. GENERAL, states that the sole objective of the investigation of an accident or incident shall be the prevention of accidents or incidents. It is not the purpose to apportion blame or liability.

2. Rationale for investigations by DCA ATM Division

2.1 Although it is the DCA’s prerogative to appoint an independent investigation board to enquire into the reported safety occurrence. The advantages of having internal (ATM) procedures for the processing and investigation of safety occurrences are that:

a) An internal investigation can be started imme3diately after the incident

occurs, so that accounts of what occurred can be obtained while it is still fresh in the minds of those involved; and

b) Prompt internal investigation may enable the identification of areas where immediate risk mitigation measures should be introduced, in advance of the conclusion of the formal investigation.

2.2 There should be no conflict of interest between an internal and an external

investigation by professional investigators and in practice they should be mutually supportive as evidence gathered by the internal investigators can be used by the regulatory investigators. However the external investigators have precedence and evidence must not be tampered with in any way.

3. Scope of Investigations made by the DCA ATM Division

3.1 Investigations carried out by the DCA ATM Division shall cover:

• The ATM (ground component) aspects of incidents, including serious incidents

• The ATM (ground component) aspects of accidents

• The ATM (ground component) aspects of other occurrences, including

technical occurrences which may require support from technical staff

3.2 In line with the above, it is evident that the scope of the investigation processes and

procedures by the DCA ATM Division covers occurrences where no aircraft are actually involved as well as observations either with potential for negative effect on operations or that are considered to have potential to improve the system, avoid re-occurrence, or lead to the detection of latent conditions and individual weaknesses.



4. Decision to carry out an investigation

4.1 All stages of an investigation shall be conducted unless the Safety Manager, on his own volition or on receipt of a written justification from the Investigator in Charge decides to halt the process at any stage. In either case the reason why an investigation was not carried out or why an investigation was halted should be clearly documented. This should be an iterative process as the progress of the investigation may provide rationale for halting the process. Conversely, an occurrence that appeared of minor importance may turn out to contain prominent information for safety management. Great care should therefore be applied when assessing the need for investigation. The first steps e.g. data gathering should always be carried out even if on a soft mode before making a final decision

5. Action by Safety Manager on Receipt of ATS Occurrence Report

5.1 On receipt of a Safety Occurrence report, the Safety Manager shall:

a) Ensure that the Duty Supervisor has taken any action that may be necessary to restore safe operations and inform the Divisional Head accordingly.

b) Give instructions for the safeguarding of any data that will be required for the

ensuing investigation. These shall include:

1) EUROCAT recordings. 2) Radio recordings. 3) Copies of relevant Log books and roster sheets.

c) In consultation with the Divisional Head, appoint a team of investigators to:

1) Gather full and complete evidence through reports submitted, interviews of persons involved directly or indirectly, requests to other Departments if necessary (see note below)

2) Establish the circumstances of the incident 3) Carry out a detailed analysis 4) Formulate recommendations 5) Submit a formal report for submission to the Director of Civil Aviation

Note: Should the investigation team encounter difficulties it should report without delay to the Safety Manager who may report the matter to the Director of Civil Aviation

6. Written Reports

6.1 Re Mandatory Occurrence Reports

6.1.1 Such reports should normally be submitted by filling in a Safety Related Occurrence Form. Reporters may also submit on a separate sheet their personal account of the safety occurrence. All such reports should be signed by their authors and delivered to the Supervisor.



6.2 Re Voluntary Occurrence Report

6.2.1 Such reports may be submitted by filling in an ATM Voluntary Report Form.

6.3 Persons to submit Reports

6.3.1 Usually safety occurrence reports are submitted by persons occupying operational positions at the time of the occurrence such s the ATCO’s, ATC Supervisors, Air Traffic Control Assistants, Technical Officers etc. However the Safety Manager may request any other person that may have a link with the occurrence to produce such a report. This includes persons who were not present but should have been present.

6.4 Purpose of reports 6.4.1 The reports are meant for:

• Providing for an official account of the events by each staff concerned. In

this respect it is important for staff to understand that these reports should not be used for attempting to cover-up colleagues or hide facts. This might well lead to inconsistencies which would reveal these attempts. The Department of Civil Aviation top management has committed to conduct safety occurrence investigation in accordance with the principles of a “fair culture” and in return expects staff members to make honest accounts of the events related to an occurrence with the sole purpose of taking reliable and valuable lessons from a safety occurrence; and

• Providing further “background” understanding to the investigator in charge.

7 Interviewing procedure

7.1 Staff members concerned with a safety occurrence shall be interviewed in compliance with the following provisions. Such interviews should be well prepared by the interviewers so as to give an opportunity for the investigator(s) to clarify points that are either unclear at that stage or totally incomprehensible.

7.2 Results of interviews shall be recorded on an Air Safety Report – Interview Report Form so as to enable both the interviewer and the interviewee to subsequently review the products of the meeting. Findings from an interview shall be documented in a formal way and communicated to the interviewee.



7.3 At the Chief Investigator’s discretion interviews can take any of the following formats:

• Individual interviews (one to one) • Interviews panels (many to one) • Team-based Interviews (one to many) • Group discussion (many to many)

Note: In the case that the interview format permits specify whether the interviewee(s) are

allowed to be accompanied by either:

o a colleague; o a staff representative; o a trade union representative; o a lawyer; or etc..

7.4 The final record of the interview should be recorded, communicated to the interviewee and signed by the latter.

8. Safety Occurrence Analysis

8.1 Establish the Circumstances of the Incident

8.1.1 Construct a draft narrative of the events leading to the incident, the incident itself and post incident actions, cross referencing the evidence. It should be borne in mind that the evidence gathering process is not a specific step but continues throughout the duration of an investigation. It is important to keep and open mind and change any conclusions drawn as new evidence comes to light.

8.1.2 The purpose of the above reconstruction is to put the events in a time sequence with

order and spacing between events. Consequently the reconstruction must provide for alternative scenarios when information is missing or unreliable to establish firmly the sequence and spacing of events.

8.2 Carry Out a Detailed Analysis – Findings and Diagnosis of the Causes

8.2.1 Having established the circumstances of the incident, the next step is to analyse the

events in order to identify the investigators findings and diagnose the causes.



Findings

Findings shall consist of a selection of data (salient facts either firmly established or suspected) extracted from: • factual data itself; • established circumstances of the incident; and • Analysis; • together with their established or suspected links. The selection is based on the prominence of these facts in the development of the occurrence. Causes

This is either a non-prioritised list of all the elements that are considered to have played a part in the emergence and development of the occurrence (ICAO).Or the causes may be classified as DIRECT and INDIRECT causes where:

1) DIRECT causes are those events which if they were not present, would have prevented the occurrence from happening.

2) INDIRECT causes do not influence the emergence of the occurrence but have played a part in it.

A list of causes (whether distinguished into direct/indirect categories or not) shall be elaborated for further inclusion in the final report.

9. Safety occurrence risk assessment

An assessment of the risk presented by the safety occurrence shall be made using an appropriate qualitative/quantitative Assessment scheme. ( See ICAO Doc 9859 , second edition – 2009 ) .



Safety Indicators and Targets for Reporting The purpose of this chapter is to provide for means to establish safety targets and for the improvement of reporting levels. The Department has established a reporting system and the reports received are recorded in a database. However before establishing safety targets there is a need to determine whether the number of reports received reflect the actual number of safety occurrences or whether they are the result of low reporting levels. If this were the case there would be a need to actually reported prior to setting safety targets and to initially encourage reporting so that this number is reached. Though this seems strange, as it looks as if one is calling for occurrences to get reports, in fact this is the other way round. If it is probable that there are more occurrences happening every year than are being reported, the organization needs to know about them so as to take appropriate remedial actions. This presents the following advantages:

• Allows for the setting for realistic targets.

• Avoids the “bad surprise” effect where top management may feel strange that as result of implementing a SMS the organization receives more report than before. Top Management needs to be briefed on two things:

- there are not more occurrences, we just know about them; and - the fact that more visibility on occurrences means more improvement on

safety can be achieved. Safety targets for reporting operational safety occurrences In line with the foregoing, there are indications that reporting system may not be operating efficiently. As the first objective for the implementation of a reporting system is to obtain maximum visibility on what actually happens, the first target should address this issue. Target No. 1: The fist target is therefore to achieve an increase of the number of reports to reflect the actual number of occurrence (Note: there may seem a paradox here as defining a target to obtain more safety occurrences reports. Remember Pr J. Reason “If you think you are safe because you do not have reports, you most probably mistaken.”) After a period of three years, the safety targets will be set on reducing the number of safety occurrences.



DCA/ATM Policy and Roadmap to a Just Culture The main objective of these procedures is the successful implementation of a “just culture” reporting environment within ATM Division. An effective reporting culture depends on how DCA/ATM handle blame and punishment. Only a very small proportion of human actions that are unsafe are deliberate (e.g. criminal activity, substance abuse, use of controlled substances, reckless noncompliance, sabotage, etc.) and as such deserve sanctions of appropriate severity. A blanket amnesty on all unsafe acts would lack credibility in the eyes of employee (workforce) and could be seen to oppose natural justice. A “no-blame” culture per se is therefore neither feasible nor desirable. What is needed is a “just culture”, an atmosphere of trust in which people are encouraged for providing essential safety-related information – but in which they are also clear about where the line must be drawn between acceptable and unacceptable behaviour. There is a need to learn from accidents and incidents through safety “investigation” so as to take appropriate action to prevent the repetition of such events. In addition, it is important that even apparently minor occurrences are investigated, in order to prevent catalysts for major accidents. Safety analysis and ‘investigation’ is a necessary and effective means of improving safety, by learning the appropriate lessons from safety occurrences and adopting preventative actions. It is therefore important that an environment exists where occurrences are reported, the necessary processes are in place for investigation and for the development of necessary preventative actions such as re-training, improved supervision etc. In recent years the concept of “Just culture” has become better understood and accepted by people employed in the aviation industry. Necessary action is currently being undertaken by DCA to create necessary regulation to foster open reporting of safety related incidents without fear of reprisal The DCA CNS/ATM Division Voluntary Reporting System is complementary to the Mandatory Reporting System( see MATS and Safety Management Manual). Mandatory and Voluntary Reporting Systems must be seen as having the “Same Vision with Different Views”. The Mandatory Reporting systems focuses on incidents and accidents to trigger investigations of latent and active errors. The Voluntary Reporting System is aimed at obtaining information on a range of “undesirable” events so that these can be investigated for any links or associations with possible incidents or accidents.The purpose of the voluntary reporting system is therefore to establish whether undesirable events are or could be correlated with incidents.

D E P A R T M E N T OF C I V I L A V I A T I O N

DCA – ATM VOLUNTARY REPORTING FORM

Name of Reporter : …………………… Designation : …………………… If Anonymous : Tick Here To: Safety Management ATM (Divisional Head ATM)

Air Traffic Services Safety Related Occurrence

Date of Occurrence ………………………….. Time:…………….. Description of occurrence

(Use an additional sheet if necessary)

Confidential

SAFETY MANAGEMENT - PROGRAM


Safety

Management Manual

Section 4

Safety Management

Program


DCA Mauritius Safety Management Manual l Effective 05 October 2009 Safe 4:2

Table of Contents Page Introduction................................................................................................. 4:3

Executive Responsibilities..........................................................................

4:4

The National Airways System.....................................................................

4:5

SAFETY MANAGEMENT SYSTEM - PROGRAM

Executive Management Responsibility..................................................................... 4:6

Safety Accountabilities......................................................................................................

4:7

Safety Management...........................................................................................................

4:8

Change Management........................................................................................................

4:11

Documentation.....................................................................................................................

4:13

Training...................................................................................................................................

4:14

Interfaces...............................................................................................................................

4:17

Air Traffic Services, Aeronautical Radio Navigation & Aeronautical Telecommunications...............................................................................

4:19

Abnormal Operations.......................................................................................................

4:23

Emergency Operations...........................................................................................

4:24

Interruptions to Level of Operational Service...................................

4:26

Incident and Occurrence Procedures..............................................................

4:27

Aeronautical Information Service...............................................................................

4:28

ATS Personnel Licensing..............................................................................................

4:30

ATS Message Recording..............................................................................................

4:32

Airspace Design................................................................................................................ 4:33

Runway Safety Program................................................................................................

4:35

GAP Analysis......................................................................................... 4:35

Safety Risk Management....................................................................... Annex A – Runway Incursion Form Annex B – BirdStrike Reporting Form

4:36




The purpose of this document is to:

• Identify the elements of DCA’ business which address the requirements of DCA Safety Management System; and

• Enhance staff awareness in the many aspects of Safety Management by making the links between Safety Management and DCA business elements visible.

Scope

This document is applicable to DCA staff, and contractors working for or on behalf of DCA, who undertake activities which may directly or indirectly affect the safe operation of the National Airways System.

Note

This document provides a listing of the relevant Program in place within DCA safety management system at the time of document issue. As such, this document should be considered a transitional document, and will be reviewed as the safety management system is further developed and implemented.

SAFETY MANAGEMENT SYSTEM – PROGRAM

SMS Strategy

Document Details

Status


Runway Safety Programme

Establishment of a Runway Safety Team

ICAO DOC AN/463 – 1st Edition 2007

The Aerodrome operator has set up an Apron Safety Committee since 2001. The ATC participates actively in this committee. The reports of this committee are filed in the ATM Safety Report file. Awareness Training is implemented at ATC Level. The following Reporting Forms are enclosed : Annex A – Runway Incursion

Reporting Form.

Annex B – Bird Strike Reporting form

GAP Analysis

DCA- ATM conducts GAP analysis of its system to determine which components of the SMS are currently inplace and which components and elements must be added or modified to meet the implementation requirements.

Guidance principles and Materials :

• ICAO SMM – Doc 9859, 2nd Edition 2009

Checklist of ICAO Doc 9859 ICAO SMM 7 APP 2.2 to be used


SMS Strategy

Document Details

Status


Safety Risk Management

ATM main objective is primarily geared to the Management of safety risks.

Guidance principles and Materials :

• ICAO SMM – Doc 9859, 2nd Edition 2009

DCA ATM to conduct safety risk Assessment as a process and the notion of safety as an outcome.



Executive Responsibilities Executive Management Responsibility

DCA management is responsible for the establishment, implementation and ongoing maintenance of the DCA Safety Management System. In discharging these responsibilities executive management has: • Developed the Safety Management Manual, including: Section 1, DCA “Safety Management System; Policy”, Section 2, DCA “Safety Management System; Document Management”, Section 3, DCA “Safety Management System; Strategy”, Section 4, DCA “Safety Management System; Program”, • Developed various supporting documentation that are listed in the

above as safety Program, AND, • Tasked specific staff with the continuing development, implementation and maintenance of the DCA Safety Management System.

Note

This document should be considered a transitional document, and will be reviewed and amended as the safety management system is further developed and implemented.



The National Airways System Introduction

DCA is committed to providing the highest reasonable standard of safety within the Airways System which it plans, provides and operates the Safety Management System is designed to provide this assurance. The National Airways System consists of the facilities, equipment, personnel and procedures, which, in combination, DCA uses to provide an airways service to the aviation industry.

The National Airways System is shown below:

Linking Program to business

The following tables link the Program of DCA business which addresses the Strategy of the DCA Safety Management System.

National Airways System

Surveillance Comm’s Navaids Information

Support

Engineers

Air Traffic

Air Traffic

Equipment

People Procedures


SMS Strategy

Document Details

Status


SAFETY MANAGEMENT SYSTEM - PROGRAM

Executive Management Responsibility A policy indicating DCA’ safety objectives and its commitment to safety is defined, documented and promulgated

• DCA Safety Management Manual; Section 1; Policy

In Place

This policy is understood, implemented and maintained at all levels of the organisation

• DCA Safety Management Manual;

o copies available throughout ATS

Ongoing

A Safety Management System (SMS) is established, documented and maintained as a means of ensuring that the services delivered meet DCA’ own performance standards, and as a minimum, conform with safety regulatory requirements and standards

• DCA Safety Management Manual; Section 1; Policy • DCA Safety Management Manual; Section 3; Strategy • DCA Safety Management Manual; Section 4; Program • Supporting documentation and Manuals

In Place

Procedures for SMS preparation, maintenance, approval, ownership and update are in place


Section 2; Document Management

In Place

The SMS is reviewed at defined intervals sufficient to ensure its continuing suitability and effectiveness


Section 2; Document Management

In Place

The SMS is embedded in all levels of the organisation


o copies available throughout ATS o controlled copies at all levels

In Place


SMS Strategy

Document Details

Status


Safety Accountabilities The responsibility, authority and the interrelation of staff who manage, perform and verify work affecting safety must be defined and documented.

• DCA Safety Management Manual; Section 3; Strategy • DCA Safety Management Manual; Section 4; Program • Operational Administration Manual • Manual of Air Traffic Services • Supervisor Manual • Degraded Modes Manual • IFER & AEP Manuals

In Place

Managers must detail key safety accountabilities for staff, for actions relating to system design, system acceptance, system operation, or restoration of a service or facility.

• All Manuals containing ATS procedures • Operational Administration Manual

o ATS Structure o Job Descriptions

• Manual of Air Traffic Services • Supervisor Manual • Degraded Modes Manual • IFER & AEP Manuals

In Place

The safety accountabilities structure must be compatible with DCA’ general management structure. Safety accountabilities should be included in job descriptions and safety performance included in personnel appraisals.

• DCA Safety Management Manual; Section 3; Strategy • DCA Safety Management Manual; Section 4; Program • Operational Administration Manual

o ATS Structure o Job Descriptions o Training & assessment records

• Manual of Air Traffic Services • Supervisor Manual • Degraded Modes Manual • IFER & AEP Manuals

In Place

Staff identified with key safety accountabilities must have appropriate qualifications and competencies to enable them to fulfil their organisational roles.

• Operational Administration Manual o Training & assessment records

• Supervisor Manual

In Place


SMS Strategy

Document Details

Status


Safety Management All managers must ensure that the necessary level of vigilance is in place to enable the early detection of deviation from practices and procedures which may degrade the level of safety.

• Operational Administration Manual

o Training & assessment procedures • Manual of Air Traffic Services

o Documents Control processes • Supervisor Manual • Degraded Modes Manual • IFER & AEP Manuals

In Place

Processes must be established which identify, assess and control operational safety implications and hazards. These processes must enable the monitoring of the effectiveness of such controls on a periodic basis to ensure the ongoing integrity of operations.


o Training & assessment procedures • Degraded Modes Manual • IFER & AEP Manuals • Training & assessment procedures • Manual of Air Traffic Services

o Request for Change process o Document Control Processes

In Place

Processes must be established for monitoring and reviewing the effectiveness of the safety management procedures against key safety indicators.


o Training & assessment procedures

In Place

Wherever practicable, quantitative safety levels must be derived and maintained for operational systems. Overall system safety levels must be based on assessment of the levels of risk which is acceptable to the organisation and the community, and subject to regulatory and statutory obligations.


o Training & assessment procedures

• SMS: Safety Analysis • SMS: Risk Management Guidelines

In Place Pending


SMS Strategy

Document Details

Status


A system of safety reporting must be in place to ensure the timely reporting of all safety related issues, incidents and accidents. The reporting system must enable appropriate review, investigation, trend analysis and change to be effected, as necessary. Lessons learnt from safety occurrences must be given wide distribution. Investigation reports must be de-identified prior to dissemination for lessons learnt.


o Training & assessment procedures • Manual of Air Traffic Services

o Incident reporting procedures o Request for Change process

• SMS: Safety Analysis • SMS: Risk Management Guidelines • Recurrent Training program

In Place Pending

Remedial action must be taken to address identified hazards to safe operation. Due consideration of risks to safe operation must be taken to ensure that an appropriate course of action is adopted with a clear statement of reasons for decisions recorded. Following implementation, remedial action must be reviewed to assess effectiveness.

• Manual of Air Traffic Services

o Incident reporting procedures • Operational Administration Manual

o Remedial management processes


In Place Pending

Processes must be in place, which ensure capture and tracking of safety issues through to resolution.


o Request for Change process o Incident reporting procedures

• Operational Administration Manual o Remedial management processes


In Place Pending


SMS Strategy

Document Details

Status


Formally documented processes, procedures and where necessary audits, must demonstrate the overall safety of the Airways System. Audits may be of the following types:

• compliance; • effectiveness; and • efficiency.

• Document Control Processes • Operational Administration Manual

o Training & assessment processes o Remedial management processes

• Manual of Air Traffic Services o Incident reporting procedures o Request for Change process

• All procedures Manuals

• Documentation Audits


In Place Draft Pending

Processes must be established to assess the effects of environmental and other influences on safety.

Pending

Recommendations from statutory authorities and ICAO must be reviewed, and if agreed, implemented as quickly as possible.

• In compliance with Act, Regulations & ICAO SARPS. • Operational Administration Manual

o Chief Officer & Supervisor responsibilities

In Place Ongoing


SMS Strategy

Document Details

Status


Change Management Management must ensure that processes are in place to formally document:

• the identification of hazards to safe operation, • the analysis and assessment of these risks, and • the control of the resulting risk,

for any significant change to existing systems, processes or procedures. Any unacceptable risks must be eliminated or reduced to an acceptable level before a change is implemented.


o Incident reporting procedures o Request for Change process

• Operational Administration Manual o Job Descriptions o Training & assessment processes

• Audit processes



A Safety Case or analysis must be used to document the safety aspects of: all new Airways System components having operational safety implications; and major modifications or upgrades to the existing Airways System


Pending


SMS Strategy

Document Details

Status


The change management process must:

• describe the existing system in sufficient detail to allow an understanding of the safety issues;

• identify the impact of change on the existing system;

• detail the hazard identification methodology used; • describe the risk analysis and assessment

methodology used; • describe the risk control process for eliminating

or reducing risk factors which have been identified;

• describe the safety management arrangements for implementation of the change through to commissioning and ongoing safety monitoring;

• ensure that all changes are documented in such a way that all system users are informed of the change; and

• detail approval authority for the identified safety accountability.


Pending


SMS Strategy

Document Details

Status


Documentation Management must ensure that DCA has a document management system defined, documented and in place to record policies, procedures, actions and results of its operations, and which facilitates analysis and review.

• Manual of Air Traffic Services o Request for Change process

• ALL ATM Manuals o Document Control Process

• Operational Administration Manual o Training & assessment process o Forms

• Documentation Audits

• SMS: Document Management


Document control processes must: • ensure that the authority for issue and/or amendment is appropriate to the management and accountability structures; • ensure that the latest version of all documentation is readily available to all users requiring provision; • ensure that a master copy of all operational and technical documentation is secure; • ensure that a copy of obsolete documentation is archived and all other versions are destroyed promptly; • check that operational and technical instructions conform with agreed policy and internal documentation standards; • encourage all operational areas to confine like type documentation to standard presentation formats; and • ensure document review on a periodic basis.

• ALL ATM Manuals

o Document Control Process • Operational Administration Manual

o Supervisory Job Descriptions o Supervisor – Document Control

• SMS: Document Management

In Place Pending


SMS Strategy

Document Details

Status


Training

Management must ensure that processes are defined, documented, in place and maintained which ensure staff are trained, qualified and competent to perform their tasks. The processes must allow for monitoring the continuing competence of these personnel on a periodic basis.


o ATS Structure o Job Descriptions o Remedial management processes o Training & assessment processes

• Supervision Manual

• Recurrent Training program

In Place Ongoing Pending

Training courses must be provided on the basis of a training needs analysis or other equivalent method. Legislative and/or ICAO training requirements are accepted.

• In compliance with Act, Regulations & ICAO SARPS.


Ongoing In Place

A process for maintaining and updating records of staff qualifications, certifications, licenses and competencies must be in place.


o Licensing & Certification Database o Job Descriptions Assessment Officers o Remedial management processes o Training & assessment processes o Chief Officer & Supervisor responsibilities

In Place


SMS Strategy

Document Details

Status


The training programs for each course must facilitate achievement of the training goals through:

• a curriculum, or synopsis for courses with a short life;

• method of delivery; • method of assessment; • remedial process; and • recency criteria.

In Compliance ICAO defined curriculum used for internal and external ATS training. Instruction is by qualified Air Traffic Services staff. Recurrent Training

Ongoing Pending

The curriculum must ensure compliance with national and International requirements and any relevant competency based training standards.

In Compliance ICAO defined curriculum used for internal and external ATS training. Instruction is by qualified Air Traffic Services staff. Recurrent Training

Ongoing Pending

The method of delivery must utilise facilities and instructors with current expertise and identified competencies appropriate to achieving the goals of the course.

Contemporary instructional facilities available and used. Instruction by qualified Air Traffic Services staff.

Ongoing

The method of assessment must utilise qualified assessors and appropriate facilities; The assessment process must include a record keeping process which records all progress and completed assessments.

In Compliance Instruction and assessment is by qualified Air Traffic Services staff. Operational Administration Manual

Training & assessment processes Chief Officer & Supervisor responsibilities Document archiving

Ongoing In Place


SMS Strategy

Document Details

Status


The training program must employ a remedial process which ensures that deficiencies in technique, application or knowledge are identified and rectified. The process must ensure that staff in need of remedial training are afforded the appropriate level of assistance.

Operational Administration Manual

Remedial management processes Training & assessment processes Chief Officer & Supervisor responsibilities

In Place

Processes must be in place to evaluate courses to ensure that learning outcomes continue to satisfy training needs.

Management Review

Ongoing

Emergency training specifically to prepare the candidate for abnormal operations must be provided, either as stand alone training or as part of relevant operational training courses.

Included in operational training and assessment. Recurrent Training including IFER, Degraded Modes, etc

In Place Pending

Transition training to ensure efficient integration into new systems or environments must be provided.


Job Descriptions Training & assessment processes Chief Officer & Supervisor responsibilities Examination processes

In Place


SMS Strategy

Document Details

Status


Interfaces Management must ensure that interface arrangements between DCA’ organisational elements are defined and consistent with safety accountabilities. Management must ensure that interface arrangements are in place with external agencies, which address requirements to accept and provide data and services. Processes must be put in place to ensure the effective management of these interfaces.

Interface arrangements are identified in numerous documents such as Memoranda of Understanding (MOU), Letters of Agreement (LOA), Contracts and Service Level Agreements (SLA), Regional Agreements (eg;IOOM).

In Place Ongoing

The interface arrangements must seek to ensure: • the integrity and reliability of the data or service being accepted; • internal/external service providers have processes in place which support the services provided at a defined level of performance; • internal/external service providers have processes in place to detect any change in their operation affecting the data and/or services provided and will rectify.

As above

Ongoing

DCA must ensure that interface arrangements exist with neighbouring FIR’s, which ensure efficient, effective and unambiguous communications between organisations. A process must be in place to ensure resolution of any area of dispute or conflict arising from both organisations carrying out their respective statutory functions

LOA IOOM Regional Agreements

In Place & Ongoing


SMS Strategy

Document Details

Status


DCA must ensure that arrangements exist which ensure the clear communication of operational information and procedures to the aviation industry (e.g. NOTAM, AIC etc).

In compliance with LOA’s, Regional Agreements & ICAO SARPS. AIS utilising ATALIS System. Regular Industry, ICAO/IATA, Regional, CNS/ATM meetings

In Place & Ongoing


SMS Strategy

Document Details

Status


Air Traffic Services, Aeronautical Radio Navigation & Aeronautical Telecommunications

Management must ensure that processes are defined, documented, in place and maintained which ensure continuous safe operation of the Airways System.

Manual of Air Traffic Services

Incident reporting procedures Request for Change process

Supervisor Manual ATM Contingency Plans Degraded Modes Manual IFER & AEP Manuals Operational Administration Manual Fault Reporting Process PCR request process

In Place & Ongoing

Reporting processes must capture: • critical system failures; • system defects; • equipment faults; • deficiencies in processes, procedures, or standards; • aircraft accidents or incidents; and • potential safety hazards.



ALL ATM Manuals Request for Change process

Operational Administration Manual Training & assessment processes Examination processes

Fault Reporting Process PCR request process Audit processes

In Place & Ongoing Pending


SMS Strategy

Document Details

Status


Processes for corrective and preventive maintenance must be defined, documented, in place and maintained to assure that ongoing operations are in accordance with performance standards.

Manual of Air Traffic Services Incident reporting procedures Request for Change process

Operational Administration Manual Remedial management processes Training & assessment processes Examination processes

Fault Reporting Process PCR request process Recurrent Training program


Processes for monitoring and control that assure the ongoing operation of the system is in accordance with its performance standards must be defined, documented, in place and maintained.

DCA Safety Management Manual; Section 3; Strategy Manual of Air Traffic Services


ALL ATM Manuals Document Control Process

ATM Contingency Plans Degraded Modes Manual Operational Administration Manual

Job Descriptions Remedial management processes Training & assessment processes

Fault Reporting Process PCR request process Systems Review Group Documentation Audits Audit processes

In Place & Ongoing Draft


SMS Strategy

Document Details

Status


Processes for reliability and maintainability of data analysis, to confirm performance standards and/or safety level assessment must be defined, documented, in place and maintained.

Eurocat Volume & Performance Reports Supervisor Manual Operational Administration Manual

Chief Officer & Supervisor responsibilities Licensing & Certification Database

Fault Reporting Process PCR request process Documentation Audits Audit processes Systems Review Group

In Place & Ongoing Draft Pending

Potential hazards identified either through data analysis, performance monitoring or other sources must have mitigating strategies developed and implemented, which are commensurate with the level of risk associated with the hazards.

Eurocat Volume & Performance Reports Manual of Air Traffic Services


Operational Administration Manual Remedial management processes Training & assessment processes Licensing & Certification Database

Fault Reporting Process PCR request process Documentation Audits Audit processes Systems Review Group SMS: Safety Analysis SMS: Risk Management Guidelines

In Place & Ongoing Draft Pending


SMS Strategy

Document Details

Status


Defect reporting processes must ensure the equipment and procedures meet an ongoing performance standard equal to its performance expectation at design, and as refined during acquisition, acceptance, and after modification.

Eurocat Volume & Performance Reports Manual of Air Traffic Services


Fault Reporting Process PCR request process Systems Review Group


Critical airways system failure reporting procedures must link the performance of the National Airways System to management safety accountabilities.

???

Pending

Air safety incident and equipment fault reporting processes must ensure there is a method for monitoring the level and safety of service provision against that required by the users.

???

Pending


SMS Strategy

Document Details

Status


Abnormal Operations Management must ensure that business continuity plans, encompassing contingency plans, business resumption plans and emergency procedures, are defined, documented and in place which minimise the impact of any abnormal event on those utilising the Airways System.

ATS Contingency Plans ATS Degraded Modes Plan In Flight Emergency Response checklists Manual of Air Traffic Services

In Place

Contingency plans, business resumption plans and emergency procedures must be subject to regular testing and review. Testing and review must also be undertaken following significant change to existing systems, processes or procedures. Results of testing and revision must be documented.

All documents are “New Issue” at this time.

Pending

Processes must ensure the satisfactory operation of procedures and equipment in situations arising from abnormal occurrences, in particular: • emergency operations; • interruptions to level of operational service; and • incidents and occurrences.

SEE BELOW

SEE BELOW


SMS Strategy

Document Details

Status


Abnormal Operations, Emergency Operations

Recognition and response procedures must be available to ensure that staff are prepared, ready and able to respond appropriately to an emergency situation.


In Place

Reporting processes must ensure that all occurrences of emergency operations are reported promptly and relevant information reaches the appropriate authority.


In Place

Checklists of procedures which assist in the provision of an appropriate response to any given situation must be available to all operational staff.


In Place

Exposure to and training in procedures, must be utilised, (which may include simulation) to ensure that staff are experienced in responding to emergency situations.

Required in Initial training Operational Administration Manual

Remedial management processes Training & assessment processes Examination processes

Recurrent Training program

In Place Pending


SMS Strategy

Document Details

Status


Post-occurrence review processes must ensure that emergency situations are reviewed and assessed for the appropriateness of the reaction and response, and documentation, procedures and training are appropriately revised.



Operational Administration Manual Remedial management processes Training & assessment processes Chief Officer & Supervisor responsibilities

Audit processes Systems Review Group SMS: Safety Analysis SMS: Risk Management Guidelines Recurrent Training program



SMS Strategy

Document Details

Status


Abnormal Operations, Interruptions to Level of Operational Service

Contingency procedures must describe in detail, requirements for operational staff in the event of any interruption to the level of service provision.


In Place

Processes must be in place which ensure all affected and interested parties are promptly notified of the interruption to the operational service and its consequences. The notification processes will address both internal and external needs.


In Place

Procedures for the re-establishment of normal service must ensure the safe and orderly transition back into full operational service.

ATS Contingency Plans ATS Degraded Modes Plan In Flight Emergency Response checklists Supervisor Manual

In Place


SMS Strategy

Document Details

Status


Abnormal Operations, Incident and Occurrence Procedures

Incident and occurrence reporting procedures must include appropriate timeframes for reporting. Reports must be investigated to determine causal factors. Appropriate strategies must be put in place to minimise the potential for re-occurrence.


Incident reporting procedures Operational Administration Manual

Chief Officer & Supervisor responsibilities Systems Review Group Recurrent Training program

In Place Pending

Interface arrangements must be documented between DCA and other agencies for the exchange of information relating to incident and occurrence reports. Including the dissemination of the results of any investigations to interested parties. These processes must protect the legal rights of witnesses to investigations.

Operational Administration Manual Section 5: Administration Chief Officer & Supervisor responsibilities

Manual of Air Traffic Services Incident reporting procedures

ATM Contingency Plans Degraded Modes Manual IFER & AEP Manuals SMS: Release of Information

In Place Pending

Procedures must detail a requirement to record the state of facilities which may be implicated in incidents.

Manual of Air Traffic Services Incident reporting procedures Watchlog Procedures Handover/Takeover Procedures

Fault Reporting Process PCR request process Systems Review Group

In Place Pending


SMS Strategy

Document Details

Status


Aeronautical Information Service Management must ensure that processes are defined, documented, in place and maintained which ensure the integrity and quality of the aeronautical information and guidance material produced and distributed.

AIS processes must include the following aspects: • catalogue of services • proofing and data verification • error analysis and notification • consistency • promulgation and publication

SEE BELOW

SEE BELOW

A catalogue of services must be available. Services provided must be of a minimum level arising from a needs analysis.

Proofing methods must ensure the integrity of the data to be published. AIS must ensure that the data custodian for any input to their operation has authorised that data.


SMS Strategy

Document Details

Status


Error notification and analysis processes must be utilised, to facilitate timely rectification of identified errors.

AIS processes must ensure the consistency and compatibility of maps and charts and displayed operational information.

Promulgation processes must ensure the synchronisation and timely distribution of publications, in preference to short term amendments (NOTAMs).


SMS Strategy

Document Details

Status


ATS Personnel Licensing Management must ensure that processes are in place that: • ensure the control of entry of personnel into functions that require a licence; and • periodically monitor and endorse the competency of licensed personnel.


Remedial management processes Assessment and performance monitoring Training & assessment processes Examination processes Supervisor & Assessment officer responsibilities Licensing & Certification Database Document Archiving

Documentation Audits

In Place Pending

Effective processes must be utilised for setting performance guidelines and required competencies for licensed staff, consistent with ICAO SARPS.

Manual of Air Traffic Services complies with Doc 4444 Operational Administration Manual

Remedial management processes Assessment and performance monitoring Training & assessment processes Examination processes Supervisor & Assessment officer responsibilities Licensing & Certification Database Document Archiving

In Place


SMS Strategy

Document Details

Status


Effective processes must be utilised for the initial and ongoing assessment and endorsement of competencies and proven proficiency.


Remedial management processes Assessment and performance monitoring Training & assessment processes Examination processes Supervisor & Assessment officer responsibilities Licensing & Certification Database

In Place

Record keeping processes must ensure the accuracy, integrity and availability of licences and endorsements.


Training & assessment processes Examination processes Supervisor & Assessment officer responsibilities Licensing & Certification Database Document Archiving

In Place

Administrative processes must ensure the timeliness of receipt and processing of medical and competency information and the issue of associated licences or endorsements.


Training & assessment processes Examination processes Supervisor & Assessment officer responsibilities Licensing & Certification Database

In Place

A process must be utilised which identifies the authority for, and enables the temporary suspension of, an ATS licence, pending investigation of an incident or occurrence. This process must include the nomination of the appropriate authority for reinstatement of the licence.


Remedial management processes Examination processes Supervisor & Assessment officer responsibilities Delegation of Authority

In Place


SMS Strategy

Document Details

Status


ATS Message Recording Management must ensure that processes are defined, documented, in place and maintained which comply with ICAO requirements for ATS message recording, access and storage.

Processes must ensure the appropriate level of security for operational records and data is applied.

Arrangements for cooperation with authorised investigative bodies must ensure compliance with relevant regulations regarding the access to, and the release of, records and data.


SMS Strategy

Document Details

Status


Airspace Design Processes must ensure the integrity, validity and appropriateness of existing and proposed airspace configuration.

Compliant with ICAO

In Place

Processes must establish and administer the level of service to be provided in designated airspace.

Compliant with ICAO

In Place

DCA must ensure that interface arrangements exist with neighbouring FIR’s, which ensure communication and discussion between organisations, when necessary, for airspace and procedures design.

ICAO Representation Regional Coordination meetings Regional CNS/ATM meetings LOA’s

In Place

Processes must be utilised which ensure that procedures, existing and proposed for use in designated airspace are, whenever practical, in accordance with ICAO standards and recommended practices and conform to policy and format conventions

Compliance with ICAO Documentation Compliance with regional agreements ICAO Representation Regional Coordination meetings Regional CNS/ATM meetings LOA’s

In Place


SMS Strategy

Document Details

Status


The development and promulgation of recommendations on enhancing operational procedures must be facilitated through appropriate procedures



Fault Reporting Process PCR request process Compliance with ICAO Compliance with regional agreements ICAO Representation Regional Coordination meetings Regional CNS/ATM meetings LOA’s

In Place

The Airways System must be periodically reviewed to confirm its relevance to current aviation industry needs.



Fault Reporting Process PCR request process Compliance with ICAO Documentation Compliance with regional agreements ICAO Representation Regional Coordination meetings Regional CNS/ATM meetings LOA’s

In Place

sms

Documents

safety management program

aircraft safety

atm safety management

importance of safety

priority of safety atm

safety requirements

commitment safety policy

ats safety management2