SMS for Aviation–a Practical Guide

Safety policy and objectives 2

Safety Management Systems I
Contents
Management commitment and responsibility 01

Safety accountabilities of managers 04

Appointment of key safety personnel 05

Developing an SMS implementation plan 09

Gap analysis 10

Contractors/third party interfaces 10

Documentation 11

Coordination of the emergency response plan 13

Toolkit – Safety policy and objectives 15

© 2012 Civil Aviation Safety Authority

For further information visit www.casa.gov.au
This work is copyright. You may download, display, print and reproduce this material in unaltered form only (retaining this notice) for your personal, non-commercial use
or use within your organisation. Apart from any use as permitted under the Copyright Act 1968, all other rights are reserved. Requests for further authorisation should be
directed to: Safety Promotion, Civil Aviation Safety Authority, GPO Box 2005 Canberra ACT 2601, or email [email protected]
This kit is for information purposes only. It should not be used as the sole source of information and should be used in the context of other authoritative sources.
The case studies featuring ‘Bush Air’ and ‘Bush Maintenance Services’ are entirely fictitious. Any resemblance to actual organisations and/or persons is purely coincidental.
1105.1511

Safety policy and objectives

Management commitment and To successfully implement an SMS you need to:

responsibility »» Establish expectations. These must come from

senior management. What safety standards
Good safety management is not about having an does senior management want?
SMS manual on the shelf, outlining each of the
elements you have in place. »» Engage personnel (somebody to run the SMS)
with competence (some knowledge of the
Safety management needs context to be science of safety)
effective – you need to establish a few
fundamentals before you even consider things »» Get staff involved and committed to identifying
such as a manual. safety risks. That way you create a culture of
shared accountability and responsibility for
The ultimate responsibility for safety rests on the managing risks from the very start. The stage
shoulders of senior managers—those at the top. for a positive safety culture is set by the extent
You should demonstrate your commitment to, to which organisations accept the importance
and responsibility for, safety in a formal safety of proactive risk management.
policy, which then flows into safety objectives.
These safety objectives must be practical, »» Do a gap analysis of your existing SMS to see
achievable, regularly reviewed and reassessed, what is missing and develop a customised
and communicated to the staff with clear SMS implementation plan – one which is
endorsement of senior management. relevant and appropriate to your organisation.

Management commitment and responsibility checklist

SMS ITEMS
Management »» There is commitment of the organisation’s senior management to the
commitment and development and ongoing improvement of the SMS
responsibility »» There is evidence of decision-making, actions and behaviours that reflect a
more positive safety culture
»» There is a defined disciplinary policy clearly identifying when punitive action
would be considered (for example in cases of illegal activity, negligence or
wilful misconduct)
»» There is evidence that the organisation is applying its disciplinary policy

Safety Management Systems 01

Case study
The case study of Bush Air, a fictitious air
transport operator, illustrates how operators
might take these steps.

About Vision
Bush Air is a small, family-owned charter ‘We are all leaders in safety’
business operating from a regional airport. Safety leadership ultimately comes from the
The company employs four full-time pilots, a top, but everyone at Bush Air, regardless of
number of casual pilots on a seasonal basis, position, can make a significant difference
and two admin staff. The chief pilot owns the in reducing the number of near misses and
business and directs day-to-day operations, as accidents. Success in the future will depend
well as occasionally working as a relief pilot. on each one of us teaching, coaching and
The company owns and operates two single supporting others, so that no one is hurt, and
turbo-prop Cessna 208 Caravans and two no aircraft are damaged
Cessna 402s on statewide charters. A local Safety is the new economy
on-airport maintenance organisation provides
Safety is not just a priority, because priorities
maintenance.
change; rather, it is our core and ever-present
Safety is managed informally, with an open value. Our safety performance at Bush Air
communication policy and a written safety must continue to improve so we can lead
reporting policy. There is no dedicated resource our competition: in human performance,
for safety management. engagement and reduced worker turnover.
The chief pilot has identified an opportunity Think with both the heart and the head
to conduct regular public transport (RPT) Effective safety management is more than
services between three regional locations rules, training, safety meetings and a set
to meet increased mining industry activity in of posters – those are just the mechanics.
the area. The company intends to re-equip Everyone at Bush Air must believe that safety
progressively with larger twin-engine aircraft, is important, make it automatic, and embrace
taking on additional pilots and bringing aircraft it with all the energy, passion and personal
maintenance in house. He expects that this commitment it deserves.
growth will require 10 full-time pilots, eight
support staff, including maintenance personnel, The new team
and eight aircraft in the expanded fleet. Regardless of our role or professional
background at Bush Air, we are all equal when
it comes to safety responsibility – we are all
in this together. I hope that you will join me
in this exciting growth phase of Bush Air and
make a valuable contribution to our safety
system.
John Smith
Chief pilot and owner
Bush Air

02 Safety policy and objectives

Establish expectations
The CEO is ultimately accountable for safety. Regardless of the type of aviation business you are in,
the CEO must provide the resources necessary to implement and maintain an effective SMS. The CEO
should create a clear safety vision – their expectation of why safety is fundamental to their business
growth and sustainability.

About Bruce Jones has a meeting with the LAMEs

Bush Maintenance Services is a small aircraft and apprentice at smoko, and talks to them
maintenance organisation based at a regional about his plans, outlining his expectations of
airport. The company was founded by LAME, them and the business.
Bruce Jones, to service local GA and charter ‘At Bush Maintenance Services we have a
aircraft. It employs two LAMEs, an apprentice, proud safety record—not one of the aircraft we
and one admin staff member (Jones’ wife). maintain has had an engineering accident, or
They service Bush Air’s Cessna Caravans and even a serious incident. But that doesn’t mean
402s, as well as the local GP’s Beechcraft we can sit back—far from it. We’re only as
Bonanza, and privately-owned fixed wing and good as our as last job. And you all know what’s
rotary GA aircraft, some used by local station happening with the mining in our area; that’s
owners for mustering. where I think our future income is going to
Bush Maintenance Services is transitioning to come from. I have talked to some of the people
becoming a Part 145 maintenance organisation, at Outback Exploration, and they have very
with a view to meeting the future growth they demanding operational and safety standards.
see in the area with increased mining activity. Bush Air is in the process of putting a safety
Jones is aware that John Smith at Bush Air is management system in place, and has come
considering taking his maintenance in house, up with a vision and some procedures that
but feels that with a strengthened organisation, I think we can apply to Bush Maintenance
Bush Maintenance Services could offer Services. I know safety is ultimately my
competitive, safe, best-practice maintenance responsibility, but to maintain and improve our
for Bush Air’s expanded fleet. Like Bush Air, safety performance, so that we can grow as the
Bush Maintenance Services manages safety mining industry in our area grows, all of us have
informally, with an open communication policy to make safety the basis of everything we do.
and a written safety reporting policy. However,
with the transition to Part 145, they are Trevor has put his hand up to be our safety
implementing a formal SMS. officer, and we will be working together to put
down our safety objectives, how we are going
to get all this set up, and how we are going to
track how it’s working.’

Safety Management Systems 03

Safety accountabilities of
managers
The safety of operations rests with the relevant You should ensure that safety management
manager/s. The safety manager’s role is to assist is seen as an integral aspect of your business
these managers with safe operations. by giving it the highest priority. This level of
commitment is vital for the effectiveness of
As well as the safety manager, all managers and
your SMS.
supervisors are expected to show leadership,
and their responsibilities/accountabilities should
include their need to: On your organisational chart, clearly
detail the SMS roles and responsibilities
»» actively support and promote the SMS
of each person/manager.
»» ensure that they and their staff comply with
the SMS processes and procedures
»» ensure resources are made available to achieve
the outcomes of the SMS
»» continually monitor their area of responsibility,
as outlined in the SMS manual.

Safety accountabilities of managers checklist

SMS ITEMS
Safety »» The SMS roles, responsibilities and accountabilities of the positions outlined
accountabilities on the organisational chart are explicit.
of managers
»» All managers ensure that sufficient resources are made available to achieve
the outcomes of the SMS.
»» The safety manager has established working arrangements with the local
management team to meet SMS objectives.
»» The structure of the organisation is documented so that everyone understands
their roles and responsibilities.
»» The safety manager reports to the CEO, with direct access to the CEO at all
times. This is formalised in the organisational structure.
»» To demonstrate their ongoing support for the SMS, managers:
-- have ensured due processes and procedures needed for safe operations are
in place
-- have made sufficient resources available to support the SMS
-- are continually monitoring their areas of responsibility, as outlined in the
SMS manual.

04 Safety policy and objectives

Appointment of key safety The safety manager is responsible for:

personnel »» drafting the SMS manual

»» implementing, maintaining, reviewing and
Safety manager revising the SMS
Appointing the right safety manager is critical. »» providing safety advice to management and
This role can make or break an SMS. staff
A large organisation might have a dedicated »» promoting safety awareness and a positive
safety department, led by a head of safety safety culture
management.
»» investigating incidents and accidents
A medium-sized organisation might have a
separate safety manager, possibly with a small »» maintaining an appropriate reporting system to
number of staff, whereas a small organisation identify and manage hazards,
might just appoint a part-time safety manager, or »» identifying ongoing safety training
add these duties to an existing role. requirements to support the SMS objectives
Depending on the size of the organisation, you »» overseeing internal and external SMS audit
should ensure that the safety manager has programs
operational management experience and an
adequate technical background to understand the »» maintaining the emergency response plan
systems supporting your operations. Operational (ERP).
skills alone will not be sufficient. The safety The safety manager needs certain knowledge
manager should have a sound understanding of for the role. You would not expect anybody to
safety management principles, typically acquired service one of your aircraft simply using common
through both formal training and practical sense to operate the controls, or to maintain
experience. its avionics. Similarly, safety management is
underpinned by basic scientific principles and
personal skills, which safety managers need
to learn.

Safety Management Systems 05

Bush Air Safety Officer | case study Bush Air safety committee
The chief pilot drafts a position description Armed with the training Bush Air has
for a part-time aviation safety officer, with provided, the safety officer establishes a
the expectation that the role will grow with safety committee, comprising the chief pilot/
the business. CEO, one of the full-time pilots, the safety
officer, and one of the administration staff.
The chief pilot appoints one of the line
pilots to the role, and decides to send the They also invite a representative from the
newly appointed aviation safety officer to local on-airport maintenance organisation
two training courses as a quick way to to meetings.
improve their safety management knowledge
and skills:
Before you appoint someone, develop a position
1. Safety incident investigation training
description for the safety manager outlining
– two-day course
their specific duties. A safety manager needs
2. Human factors and error management to have (or be given the opportunity to develop)
– two-day course knowledge of the following:
These courses cost $4,000, but the chief pilot »» safety management principles and practices
feels this is a good investment in the future of
»» human factors
his company.
»» written and verbal communication skills
The aviation safety officer arranges for one
of CASA’s aviation safety advisors (ASAs) to »» interpersonal skills
visit and provide further advice on SMS. Bush
»» computer literacy
Air’s safety officer receives some free CASA
safety promotion products to further build the »» the ability to relate to people at all levels, both
Bush Air SMS. The safety officer also attends inside and outside the organisation
free workshops and seminars on safety
»» training – instructional qualifications and
management hosted by CASA in the region.
experience such as a Certificate IV in Training
and Assessment.
Ideally, the safety manager should be a person
who is approachable, convincing, reliable,
able to stay cool under pressure, and above
all, tenacious.
Your safety manager might need formal
training in:
»» integrating human factors into an SMS
»» familiarisation with different fleets, types
of operations, routes
»» developing, implementing, operating and
maintaining an SMS
»» investigating accidents and incidents.

06 Safety policy and objectives

Safety committee and action groups Regardless of the number of sub-groups, a safety
committee’s job usually includes:
If your organisation is large and complex, you are
likely to need more than one group to support »» making recommendations or decisions about
your SMS. Typically, you would have a high-level safety policy and objectives
safety committee to oversee the SMS program,
»» defining safety performance indicators and
and one or more safety action groups that take
setting safety performance targets for the
strategic direction from the safety committee.
organisation
Smaller and less complex organisations may only
need to establish a safety committee. »» directing and monitoring the initial SMS
implementation process
»» reviewing safety performance and outcomes
»» evaluating safety training effectiveness.

Appointment of key safety personnel checklist

SMS ITEMS
Appointment »» There is a dedicated safety department, led by a head of safety management
of key safety (large organisations).
personnel
»» There is a separate safety manager, possibly with a small number of staff
(medium organisations).
»» There is a part-time safety officer (who is supported through safety training)
(small organisations).
»» The safety manager has operational management experience and enough
technical background to understand the systems that support operations
(operational skills alone will not be sufficient).
»» The safety manager has a sound understanding of safety management
principles, typically acquired through formal training and practical experience.
»» The role and responsibilities of the safety manager are specified in the
SMS manual.
»» The safety manager reports directly to senior management (ideally the CEO).
»» The organisation recognises that the safety manager is not the sole person
responsible for safety. Specific safety activities and functional or operational
safety performance are the responsibility of the relevant operational or
functional managers. The safety manager monitors all cross-functional or
departmental SMS activities to ensure appropriate integration.
»» The safety manager is approachable, remains cool under pressure and has
credibility with staff.
»» Regardless of the size of the organisation, there is a safety committee which
provides a forum for discussing safety issues and the overall health and
direction of the SMS.

Safety Management Systems 07

SMS implementation plan Safety objectives should be SMART:
»» Specific
Safety objectives
»» Measurable
The most effective SMS objectives are those
which provide a call to action and develop »» Achievable
commitment from, and engagement of, staff. »» Realistic; and have a specified
Safety objectives are broad directions that help »» Timeframe within which they
to establish specific safety goals or desired are to be achieved.
targets for relevant aspects of your organisation’s
safety vision, senior management commitment,
realistic safety milestones and desired outcomes.
You should make them clear and review them
regularly.

SMS implementation plan checklist

SMS ELEMENT ITEMS
SMS »» The SMS implementation plan details all aspects of developing and
implementation implementing your SMS.
plan »» The implementation plan addresses all the areas covered in the SMS manual,
especially safety strategy, safety objectives, safety management processes
and activities, resource implications, training, safety promotion and timelines.
»» Current capabilities for safety management (including experience, knowledge,
processes, procedures, resources etc.) have been reviewed.
»» Shortcomings in safety management experience have been recognised and
resources to assist in development and implementation of the SMS identified.
»» Internal procedures for the investigation of incidents, hazard identification,
safety monitoring etc. have been reviewed and modified as required for
integration in the SMS.
»» A gap analysis of system/s has determined which parts of a safety
management system are in place, and which parts should be added or
modified to meet SMS and regulatory requirements (the review involves
comparing the SMS components and elements against the existing systems
in the organisation).
»» A checklist accounts for each component and its respective sub-elements.
‘Yes’ and ‘no’ responses show how the existing system complies with
SMS requirements. There are fields in which to report partial compliance or
deviations, as well as any actions needed to meet the criteria.
»» The gap analysis is complete and fully documented. Identified missing or
deficient items form the basis of the SMS implementation plan.

08 Safety policy and objectives

 Developing an SMS
implementation plan
Implementing your SMS will be more effective
Safety objectives with careful planning. This plan will be a detailed
1. To encourage reporting of all incidents, guide to how you are going to set up your SMS.
no matter how trivial they may seem Your SMS will change and grow – improving
(Measure: 20 per cent increase in continuously – so your implementation plan can
reporting for each of the next three years) be a living document, used throughout the life
of your SMS.
2. To build an accurate database of these
incidents, and give feedback to staff Your implementation plan should address
within two weeks of the initial report all the areas covered in the SMS manual,
especially safety strategy, safety objectives,
3. To set up a more formal rostering and
safety management processes and activities,
reporting system, so that we can track
resource implications, training, safety
and minimise fatigue-related mistakes.
promotion and timelines.
This system will take into account limits
on consecutive shifts, as well as the extra
time required for task completion if a
night shift is involved.

Safety Management Systems 09

Gap analysis Contractors/third party
To implement your SMS effectively, you need to interfaces
understand where your organisation is now,
As an aviation service provider you will often
where you want it to be, and how you are going
employ contractors in areas such as refuelling;
to get there.
catering; ground handling; aircraft maintenance;
A gap analysis provides valuable information crew training and flight planning/dispatch. These
about which parts of your SMS you already contractors will be referred to as ‘third party
have in place, and which parts you should add interfaces’ in your SMS. You have probably
or modify to meet both your company’s and always had contractual arrangements with your
regulatory requirements. providers. Your SMS provides both an opportunity
(and an obligation) to extend these contractual
(See the comprehensive gap analysis checklist on
arrangements to include safety performance.
pages 26-31 of this booklet for guidance.)
While a contractor provides you with a service,
Use a checklist to assess each component,
you still hold overall responsibility for the safety
marking off a ‘yes’, ‘no’ or ‘not applicable’
of services they provide. The safety standards
response. The results will show where you
specified in your SMS must not be eroded by
should focus your efforts.
any products and services provided by external
Once you have completed and fully documented organisations.
your gap analysis, the items you have identified
It is a good idea to investigate the third
as missing or deficient will form the basis of your
party’s previous safety record thoroughly and
SMS implementation plan.
establish whether they have ever breached any
regulations. Simply asking around – talking to
other organisations currently using their services,
or who have used them in the past—will quickly
give you a sense of how professional they are.

Contractor checklist
SMS ITEMS
Third-party »» Contracts or service level agreements specify the safety standards to be met.
interface
»» There are provisions to ensure that contractors comply with the prescribed
safety standards.
»» Processes/checks ensure that the level of safety is not adversely affected by
services and supplies provided by external organisations.
»» The previous safety record of, and any regulatory breaches by, the third party
are considered before engagement.
»» The third party understands your SMS and their responsibilities relating to it.
»» Decision to engage third parties considers their previous safety record,
any regulatory breaches, and their understanding of your SMS and their
responsibilities in it.

10 Safety policy and objectives

It is also important to take the time to explain to »» All agreements should detail how any noted
the contractor all about your SMS and particularly safety hazards and deficiencies will be
what they need to do under it. When you are addressed, and the time frame in which to
making a decision about using their services, do this
whether they are willing to comply with your
»» Where a service being provided is CASA-
SMS is as important as factors such as price,
licensed or certified, the written agreement
quality and on-time delivery.
should require the third party to advise you,
The following minimum standards should apply as the contracting organisation, of any CASA
when engaging third-party contractors: regulatory action that may affect their ability
to provide the required services.
»» Any agreement for the provision of services
should be supported by a written contract prior
to these services commencing Documentation
»» All third-party providers should hold the One of the formal ways to communicate
appropriate qualifications/credentials or your safety approach effectively to all
approvals for the work being carried out employees and third parties is through clear
»» All third parties should understand your SMS, safety management documentation.
and their responsibilities within it This safety documentation demonstrates to
»» All third-party organisations should be able to your managers, staff and third parties that
demonstrate their ability to provide trained and you always conduct business based on safety
competent staff (training may be provided by management principles.
your organisation, where relevant) If your procedures are in separate manuals
»» All written service-level agreements should (as can happen in larger more complex
contain a schedule of oversight to monitor the operations), you must make this clear, so
third party’s performance on a regular basis your staff have simple, effective access to
the detailed information about your safety
management procedures.

Documentation checklist
SMS ITEMS
Documentation »» Safety management documentation means management can effectively
communicate the organisation’s approach to safety to the entire organisation.
»» Key components and elements, as per the CASA SMS framework,
are documented.
»» The documentation reflects the intent and processes of the SMS.
»» The SMS manual is updated to reflect any changes to the SMS.
»» The SMS manual is concise and to the point.
»» Information that changes regularly (e.g. names of personnel assigned
specific safety responsibilities) is recorded in annexes/appendices at the
back of the SMS manual.
»» Amendment and distribution of SMS documentation is controlled.

Safety Management Systems 11

 Minimum SMS components to be documented
COMPONENT ELEMENTS
Safety policy, »» Management commitment and responsibility
objectives and
»» Safety accountabilities of managers
planning
»» Appointment of key safety personnel
»» SMS implementation plan
»» Third-party interfaces/contractor activities
»» Coordination of the emergency response plan
»» Documentation*
-- describes the SMS
-- is regularly reviewed and updated
-- is available to all personnel
-- details where and how any other SMS-related records are kept
-- has a table of contents
Safety risk »» Hazard identification processes
management
»» Risk assessment and mitigation processes.
Safety assurance »» Safety performance monitoring and measurement
»» Internal safety investigations
»» Change management
»» Continuous improvement of the safety system.
Safety training and »» Training and education
promotion
»» Safety promotion.
* The SMS manual is a working document. While there is a need for some policy statements, your manual should be largely procedural.

SMS components you should document Any information you expect to change regularly
(e.g. the names of personnel with specific safety
Your documentation should reflect the intent and
responsibilities) should be presented as annexes/
processes of the SMS. Therefore, if you change
appendices at the back of your manual.
your SMS, you will probably need to update your
SMS manual. Above all, make sure that when you amend and
distribute SMS documents they are controlled. In
To make it easy to use and understand, keep
other words, make sure that the approved person
your SMS manual concise and to the point.
authorises them, they are distributed to all the
places where they wil be needed, and that old or
obsolete versions are removed/replaced.

12 Safety policy and objectives

Coordination of the emergency »» Planned and coordinated action to manage
and minimise the risks associated with an
response plan accident/incident
An emergency response plan (ERP) is an integral Consider also the role of contractors/third parties
part of your SMS, and is activated in the event of in a remote airport emergency.
a major occurrence, such as an accident or major
in-flight incident. The ERP sets out what you will You can either document the ERP in a separate
do in the case of an emergency and importantly, manual, incorporate it into your organisation’s
how you return to normal operations. It lists SMS manual, or a combination of both.
procedures for: Emergency situations create unique pressures
»» Orderly and efficient transition from normal – they are complex and unfamiliar. Accident
to emergency operations investigations consistently show how important
regularly rehearsed emergency procedures and
»» Delegation of emergency authority scheduled refresher training are in preventing or
»» Assignment of emergency responsibilities minimising harm.

»» Authorisation by key personnel for actions Approved maintenance organisations’ emergency

mandated by the plan response plans must focus on events which
can affect aircraft or components’ flight safety.
»» Coordination of efforts to handle the
emergency Aircraft maintenance organisations’ ERP
scenarios should include, as required:
»» Safe continuation of operations, or return to
normal operations, as soon as possible »» emergency response to a major aircraft
occurrence during maintenance, such as
an oxygen fire, or major engine failure
during a ground run

Safety Management Systems 13

»» response to requests for expert advice from Both aircraft and component maintenance
aircraft and/or aerodrome operators during organisations should also consider including
an occurrence personnel-related considerations in their
ERP, such as:
»» response to requests for expert emergency
aircraft recovery assistance from aircraft and/or »» appropriate during-and post-incident personal
aerodrome operators behaviours
The ERP will be less involved for component »» welfare and deployment of affected personnel
maintenance organisations. A small component immediately following a major occurrence.
organisation’s ERP might only include:
You can document your ERP in a separate
»» quarantine of components and/or maintenance manual, incorporate it into your SMS manual,
documents related to the occurrence or do a combination of both. You may find it
effective to have relatively stable information
»» where an AMO finds measurement tool(s)
(ERP policies, roles and responsibilities,
are out of calibration limits and urgently
succession plans, training requirements, etc.)
needs a documented and formally agreed
in your SMS manual and put response
process to inform operators of at-risk installed
information required immediately (such as
components.
procedures, checklists, phone numbers,
locations, etc.) in separate, easily accessible
booklets.

Emergency response plan (ERP) checklist

SMS ITEMS
Coordination »» The SMS documents include an emergency response plan which can be
of the emergency activated in the event of a major occurrence.
response plan
»» The ERP covers:
(ERP)
-- Orderly and efficient transition from normal to emergency operations
-- Delegation of emergency authority
-- Assignment of emergency responsibilities
-- Authorisation by key personnel for actions included in the plan
-- Coordination of efforts to handle the emergency
-- Safe continuation of operations, or return to normal operations, as soon
as possible
-- Planned and coordinated action to manage and minimise the risks
associated with an emergency.
»» The ERP is either documented in a separate manual, or incorporated into
the SMS manual.

14 Safety policy and objectives

To o l kit
Safety policy and objectives

Safety Management Systems 15

Index of toolkit items »» Appendix A – Workflow process for
This is your safety toolkit with some best-practice applying the just culture procedures
tips and practical tools that can be adapted »» Appendix B – Bush Air counselling/
to meet your organisation’s needs. We hope discipline decision chart
you find them useful, whether you are further
developing your SMS, starting an SMS from Booklet 3 - Safety risk management tools
scratch, or simply looking for some ideas to »» Error prevention strategies for organisations
improve your existing SMS.
»» Risk register
This list summarises the checklists/templates
»» Sample hazard ID
you will find at the back of each of the respective
booklets. »» Guidance on job and task design

This is not an exhaustive list of resources. »» A six-step method for involving staff in safety
hazard identification
There are many systems and products across
various industries, so this toolkit can only include »» Hazard reporting form
a very small sample of practices and/or tools
Booklet 4 - Safety assurance tools
for information.
»» Generic issues to be considered when
Inclusion of materials does not imply monitoring and measuring safety performance
endorsement or recommendation. Each
organisation must select the most appropriate »» Audit scope planner
products for its individual and specific needs. »» Basic audit checklist
Booklet 1 – Basics »» Information relevant to a safety investigation
»» Jargon busters »» Event notification and investigation report
»» References
»» Aviation safety incident investigation report
Booklet 2 - Safety policy and objectives tools
»» Corrective/preventative action plan
»» SMS organisation checklist
»» Checklist for assessing institutional resilience
»» Safety policy statement against accidents (CAIR)
»» Safety manager’s job description
»» Practical safety culture improvement strategy
»» Role of the safety committee
»» Safety culture index
»» SMS implementation plan
Booklet 5 - Safety promotion tools
»» Ten steps to implementing an SMS
»» How to conduct a training needs analysis
»» SMS gap analysis checklist
»» Sample safety information bulletin on fatigue
»» An effective emergency response
plan (ERP) »» How to give a safety briefing/toolbox talk
»» Language and layout of procedures/ »» Aviation safety toolbox talk
documentation
»» Safety briefing/toolbox meeting
»» Document register attendance form
»» Sample safety leadership rules
»» Aviation safety lifesavers policy
»» Just culture procedure

16 Safety policy and objectives

 SMS organisation checklist
SMS ITEMS
Safety »» The SMS roles, responsibilities and accountabilities of the positions outlined
accountabilities on the organisational chart are explicit.
of managers
»» All managers ensure that sufficient resources are made available to achieve
the outcomes of the SMS.
»» The safety manager has established working arrangements with the local
management team to meet SMS objectives.
»» The structure of the organisation is documented so that everyone understands
their roles and responsibilities.
»» The safety manager reports to the CEO, with direct access to the CEO at
all times. This is formalised in the organisational structure.
»» To demonstrate their ongoing support for the SMS, managers:
-- have ensured due processes and procedures needed for safe operations
are in place
-- have made sufficient resources available to support the SMS
-- are continually monitoring their areas of responsibility, as outlined in the
SMS manual.

This checklist also appears on page 4. You can use it and others in this kit as tools to check
your organisation’s health.

Safety Management Systems 17

Safety policy statement »» Ensure that no action will be taken against
any employee who discloses a safety
Safety policy statement#1 concern through the hazard reporting system,
Safety is one of our core business functions. unless such disclosure indicates, beyond
We are committed to developing, implementing, any reasonable doubt, an illegal act, gross
maintaining and constantly improving strategies negligence, or a deliberate or wilful disregard
and processes to ensure that all our aviation of regulations or procedures
activities take place under a balanced allocation »» Comply with and, wherever possible,
of organisational resources, aimed at achieving exceed, legislative and regulatory requirements
the highest level of safety performance and and standards
meeting national and international standards,
while delivering our services. »» Ensure that sufficient skilled and trained
human resources are available to implement
All levels of management and employees are safety strategies and processes
accountable for the delivery of this highest level
of safety performance, starting with the [chief »» Ensure that staff are provided with adequate
executive officer (CEO) /managing director/or as and appropriate aviation safety information and
appropriate to the organisation]. training, are competent in safety matters, and
are only allocated tasks in line with their skills
Our commitment is to:
»» Establish and measure our safety performance
»» Support the management of safety through against realistic safety performance indicators
the provision of all appropriate resources that and safety performance targets
will result in an organisational culture that
fosters safe practices, encourages effective »» Continually improve our safety performance
safety reporting and communication, and through management processes that
actively manages safety with the same ensure that relevant safety action is taken
attention to results as the attention to the and is effective
results of the other management systems »» Ensure externally supplied systems and
of the organisation services to support our operations are
»» Enforce the management of safety as delivered, and meet our safety performance
a primary responsibility of all managers standards.
and employees (Signed) CEO/Managing Director/or as
»» Clearly define for staff, managers and appropriate
employees alike, their accountabilities
Safety policy statement #2
and responsibilities for the delivery of
the organisation’s safety performance Safety is the first priority in all our activities. We
and the performance of our safety are committed to implementing, developing and
management system improving strategies, management systems and
processes to ensure that all our aviation activities
»» Establish and operate hazard identification uphold the highest level of safety performance
and risk management processes, including and meet national and international standards.
a hazard reporting system, in order to
eliminate or mitigate the safety risks of the Our commitment is to:
consequences of hazards resulting from our a) develop and embed a safety culture in all our
operations or activities to a point which is aviation activities—one that recognises the
as low as reasonably practicable (ALARP) value of effective safety management and
acknowledges that safety is paramount

18 Safety policy and objectives

b) clearly define all personnel’s accountabilities Safety policy statement #3
and responsibilities for developing and Management is committed to providing safe,
delivering aviation safety strategy and healthy, secure work conditions and fostering
performance positive safety attitudes. The organisation’s
c) minimise the risks associated with aircraft owner/CEO is committed to:
operations to a point that is as low as »» ongoing pursuit of an accident-free workplace,
reasonably practicable/achievable including no harm to people and no damage
d) ensure that externally supplied systems to equipment, the environment, or property
and services affecting the safety of our »» a culture of open reporting of all safety hazards
operations meet appropriate safety standards
»» an open reporting culture in which
e) develop and improve our safety processes to management will not initiate disciplinary action
conform to world-class standards against any personnel who, in good faith,
f) comply with, and, wherever possible, exceed disclose a hazard or safety occurrence resulting
legislative and regulatory requirements and from unintentional conduct
standards »» support for safety training and awareness
g) ensure that all staff have adequate and programs
appropriate aviation safety information and »» conducting regular audits of safety policies,
training, are competent in safety matters, procedures and practices
and are only allocated tasks in line with their
skills »» monitoring industry activity to ensure best
safety practices are incorporated into the
h) ensure there are enough skilled and trained organisation
personnel to implement safety strategy and
policy »» providing the necessary resources to support
this policy
i) establish and measure our safety
performance against realistic objectives »» requiring all employees to maintain a safe
and/or targets work environment through adherence to
approved policies, procedures, and training;
j) achieve the highest levels of safety and familiarising themselves, (and complying),
standards and performance in all our aviation with safety policies and procedures
activities
»» all levels of management, starting with the
k) continually improve our safety performance owner/CEO, being accountable for safety
l) conduct safety and management reviews performance. To be a good leader, you must
and ensure we take relevant action be a good safety leader

m) ensure that an effective SMS is integral to all »» the principle that the organisation is
our aviation activities. strengthened by making safety excellence
an integral part of all activities.

Safety Management Systems 19

Safety manager Ambassador

—job description »» Represents the organisation in government

and industry activities.
1. Overall purpose
Analyst
»» The safety manager is responsible for
providing guidance and direction for the »» Analyses technical data for trends relating to
planning, implementation and operation hazards, events and occurrences.
of the organisation’s safety management
Process manager
system (SMS).
»» Effectively utilises applicable processes and
2. Key roles procedures to fulfil roles and responsibilities.
Safety advocate
»» Investigates opportunities to increase the
»» Demonstrates excellent safety behaviour and efficiency of processes.
attitude, follows regulatory practices and rules,
»» Measures the effectiveness of processes and
recognises and reports hazards, and promotes
seeks to continually improve their quality.
effective safety reporting.
Leader 3. Responsibilities
These responsibilities will include, but not be
»» Models and promotes an organisational culture
limited to:
that fosters safety practices through effective
leadership. »» Managing the audit program/performing
a gap analysis
Communicator
»» Operation of the safety committee
»» Promotes two-way communication:
brings safety issues to the attention of »» Managing the investigation of incidents
management, and delivers safety information »» Maintaining the hazard register
to the organisation’s staff, contractors and
stakeholders. »» Day-to-day operation of the SMS.

»» Provides and articulates information regarding 4. Nature and scope

safety issues within the organisation. The safety manager must interact with
Developer operational personnel, senior managers and
departmental heads throughout the organisation.
»» Assists in the continuous improvement of The safety manager should also foster positive
hazard identification, safety risk assessment relationships with regulatory authorities,
and the organisation’s SMS. agencies and outside organisations. Other
Relationship builder contacts will be established at a working level
as appropriate.
»» Builds and maintains an excellent working
relationship with the organisation’s safety
action group (SAG) and across the organisation.

20 Safety policy and objectives

5. Qualifications 6. Authority
Attributes and qualifications include: The manager has the following authorities:
a) broad operational knowledge and experience a) Direct access to the accountable executive
in the functions of the organisation (e.g. and appropriate senior and middle
training management, aircraft operations, air management on safety matters.
traffic management, aerodrome operations
b) To conduct safety audits, surveys and
and maintenance organisation management)
inspections of any aspect of the operation,
b) sound knowledge of safety management and direct other areas to provide information.
principles and practices, preferably with
c) To conduct investigations of internal safety
completion of a recognised SMS course e.g.
events in accordance with the procedures
investigator’s course
specified in the organisation’s safety
c) good written and verbal communication skills management systems manual.
d) being responsible for providing information d) Liaise with regulatory authorities on behalf
and advice to senior management and to the of the organisation.
accountable manager on matters relating to
safe operations. Tact, diplomacy and a high
degree of integrity are prerequisites
e) computer literacy
f) ability to relate to people at all levels, both
inside and outside the organisation
g) flexibility to undertake assignments with
little or no notice, and outside normal
working hours
h) ability to cope with changing circumstances
and situations with little supervision.
The safety manager acts independently
of other managers within the organisation
i) good analytical skills
j) leadership skills and an authoritative
approach
k) worthy of respect from peers and
management.

Safety Management Systems 21

Role of the safety committee Minutes and agenda
»» Minutes: all committee meetings should
Safety committees should focus on action, as
be minuted. As soon as possible after the
opposed to talk. The safety committee’s role
meeting, each committee member should
may include:
receive a copy of the minutes with a clear
a) acting as a source of safety expertise and indication of actions and timelines for
advice for senior management completion. Display copies of the minutes
for employees.
b) reviewing progress on hazards identified
and actions taken following accidents and »» Agenda: a committee member, usually the
incidents safety manager, drafts the agenda, after
adequate notice of any discussion items.
c) making safety recommendations to address
The safety manager should distribute the
safety hazards
agenda one week before the meeting.
d) reviewing internal safety audit reports
A typical agenda might include some or all of
e) reviewing and approving the audit response the following items:
and any resulting actions
»» Review outstanding issues from previous
f) encouraging lateral thinking about safety meetings
issues
»» Review safety action plans
g) helping to identify hazards and defences
»» Review accident investigation reports
h) preparing and reviewing safety reports to be
»» Review the effectiveness of previous safety
presented to the CEO
recommendations
i) reviewing progress against
»» Notify members of committee activities
- safety objectives
- safety performance indicators »» Assess and resolve identified hazards
- safety targets
»» Review safety audits and action plans
Safety committees do not normally have the
»» Monitor and promote safety involvement
authority to direct individual departments, as this
would interfere with the formal lines of authority. »» Carry out risk assessments on any new
Rather, they make recommendations for action equipment, routes or procedures
by the responsible managers. However, because
»» Plan and organise staff training
of accountability issues, some organisations have
introduced safety committees at the Board level, »» Plan for the safety impact of operational
thus ensuring that corrective actions are taken. changes.

Who should chair the safety committee? How often should the safety committee meet?
The senior manager, or the safety manager, can How often your committee meets depends on
chair the meetings. the size of your organisation and the number
and severity of identified hazards. Some safety
committees will meet weekly, while others will
need to meet less frequently, for example once
every two months. You should hold meetings
at least once every three months.

22 Safety policy and objectives

SMS implementation plan An SMS implementation plan typically includes:

The SMS implementation plan defines your a) safety policy and objectives
organisation’s approach to implementation of b) system description
your safety management system. It is a realistic
plan for implementing an SMS that both meets c) gap analysis
the organisation’s safety objectives and supports d) SMS components
efficient delivery of services.
e) safety roles and responsibilities
The plan, which may consist of more than
one document, describes how an organisation f) hazard reporting policy
will achieve its corporate safety objectives, g) means of employee involvement
how it will meet any new or revised safety
h) safety performance measurement
requirements, regulatory or otherwise, and
details the actions to be taken, by whom, and i) safety communication
in what time frame.
j) safety training
The organisation’s business plan will
k) management review of safety performance.
normally include significant items in the SMS
implementation plan. Once completed, senior management must
endorse the SMS implementation plan.
Depending on the size of the organisation and
the complexity of its operations, one person, or Note: The ICAO Safety Management Manual
a planning group with an appropriate experience provides a detailed implementation plan,
base, can develop the SMS implementation plan. including guidance on a phased approach.
The planning group should meet regularly to
assess the progress of the implementation plan,
and have the necessary resources (including
time for meetings) to do the job.

Safety Management Systems 23

Ten steps to implementing Step 3: Organisation
A company’s way of conducting business and
an SMS managing safety influences its resilience. To
An SMS allows an organisation to monitor and support the efficient implementation of an
improve its safety culture. The International Civil SMS, the company safety manager should
Aviation Organization recommends implementing be appointed by, and have direct access to,
a safety management system in a ten-step the CEO. Your safety committee should be
sequence to ensure you build it efficiently. structured to support safety management,
have a clear statement of responsibilities and
Step 1: Planning
accountabilities, and should oversee training
Logically, the SMS process starts with careful and competency, and management of aviation
planning, including a gap analysis. Creating a safety risk.
planning group of appropriately experienced staff
and managers is an important aspect of this. Step 4: Hazard identification
Setting up the group involves designating In a good safety culture, hazard identification
a safety manager (if you haven’t already done is proactive and non-punitive. When humans
so) and developing a realistic safety strategy, operate in fear of being punished for making
including your SMS implementation plan. normal mistakes, errors and unsafe actions
will remain hidden, and organisations will lose
Step 2: Senior management’s commitment
opportunities for improvement and prevention.
to safety
Proactive hazard identification processes such
The ultimate responsibility for safety rests on the as the line operations safety audit (LOSA) or the
shoulders of senior management. The stage for maintenance error decision aid (MEDA) provide a
a positive safety culture is set by the extent to continuous commitment to safety. Management
which company leaders accept the importance must provide adequate resources to
of safety management. Safety objectives must systematically record and store data on identified
be practical, achievable, regularly reviewed and hazards, as well as to competently analyse data
reassessed, and communicated to the staff with on such hazards.
a clear endorsement by senior management.
Step 5: Safety risk management
The CEO should sign and support safety plans
and program documents. They should include After you have identified the hazards, risk
a reasonable reporting chain for safety issues management focuses safety efforts on those
that goes through the safety manager and hazards posing the greatest risks. Assess all
ends at the CEO, if necessary. The CEO should risks critically and rank them according to their
allocate, and be seen to allocate, appropriate accident potential, taking into account both
resources to support your safety manager and their likelihood of occurrence and the severity
the safety program. of consequences. If you decide the risks are
acceptable, the company’s operations may
continue unchanged, at least for the present.
However, even ‘acceptable’ risks can be
the focus of SMS efforts to reduce overall
accident exposure. If you consider the risks to
be ‘unacceptable’, you must stop, or change,
operations until you can remove or avoid the
identified hazards.
Safety management is a closed-loop process:
residual risks are assessed and cost-benefits
analysed after each risk-reduction step. Staff
feedback on actions taken and the success of
procedures put into place is vital in this process.

24 Safety policy and objectives

Step 6: Safety investigation Step 9: Safety information management
Safety lessons are more beneficial when they Operating an SMS generates a large amount of
include a focus on root causes (the why?) data. If you do not properly record, store and use
rather than on a description of the accident or this data, it can be a waste of time and money.
incident (the what?). Identifying root causes Your safety management manual is the way in
requires trained investigators who look which you document how the SMS relates to
beyond the obvious causes at other possible other functions in your organisation, and how
contributing factors, including, (but not limited SMS data should flow and be used. You need to
to), organisational issues. Key operational staff have appropriate ways of disseminating safety
must be properly trained to conduct safety information, (including necessary technical
investigations and have appropriate management support and equipment), at the same time
support. Their findings should be disseminated assuring the protection of sensitive safety and
throughout the organisation. The regulatory personal information.
authority might also need to be made aware
Step 10: Safety performance monitoring and
of causal findings so they can be communicated
measurement
to other operators, as appropriate.
This last step ‘closes the loop’. Feedback for
Step 7: Safety analysis continuous improvement relies on:
Solid analytical capabilities provide compelling »» safety oversight, through inspections and
evidence to steer cultural change, and analytical audits, documenting for staff and management
tools and up-to-date safety databases (used that the safety actions are performed properly.
by specialists) support the risk-management
process. Safety recommendations should be »» safety performance monitoring, to assess
proposed to senior management, and corrective if the SMS efforts remain effective and are
measures must be taken and tracked to verify meeting the organisation’s safety objectives.
their effectiveness. For this you must identify accepted safety
performance indicators.
Step 8: Safety promotion
»» safety communication – dissemination of
Keeping staff informed of current safety issues
findings and implementation of corrective
is vital for continuous improvement. You can
actions to improve the system.
accomplish this using appropriate training, safety
communication and participation in safety-related
seminars. Training is an investment in the future
of your organisation. All employees, regardless of
their role and experience, can benefit from safety
analysis feedback and lessons learned. Safety
communication is two-way: management and
employees give and receive feedback.

Safety Management Systems 25

Gap analysis checklist
Use the following checklist to determine which
safety management system elements may be
missing from your organisation. Answer the
questions frankly for your organisation, with a
‘yes’, ‘no’, or ‘NA’ (not applicable).
Any points for which you tick ‘no’ you need to
examine further.
Count the total number of checked ‘yes’
answers, divide by the number of total checked
items and multiply by 100 to get a positive
percentage assessment result.
For example, if there were 39 ‘yes’ responses
on the gap analysis checklist.
39 100
X
69 1
gives a 56 per cent positive assessment.
The 44 per cent negative assessment result
shows the SMS elements requiring attention.

26 Safety policy and objectives

 Gap analysis checklist
SMS element Check question Response
Safety policy, Management commitment and responsibility
objectives and
1. Is there a safety policy statement signed by the CEO? No £ Yes £ NA £
planning
2. Is the safety policy appropriate for the size, nature No £ Yes £ NA £
and complexity of the organisation?
3. Is the safety policy readily visible and accessible No £ Yes £ NA £
to all staff?
No £ Yes £ NA £
4. Are there clearly established safety objectives
compatible with the safety policy?
No £ Yes £ NA £
5. Are the safety objectives measurable?
No £ Yes £ NA £
6. Are the safety objectives periodically reviewed to
ensure ongoing validity?
Safety accountability of managers
7. Are the roles and responsibilities of management No £ Yes £ NA £
in the SMS documented?
8. Are the values of management identified as being No £ Yes £ NA £
safety oriented?
No £ Yes £ NA £
9. Are management aware of their SMS obligations?
Appointment of key safety personnel
10. Is there a safety manager/officer appointed to champion No £ Yes £ NA £
the SMS?
No £ Yes £ NA £
11. Is there a position description outlining the
responsibilities of the safety manager/officer?
No £ Yes £ NA £
12. Does the appointed safety manager/officer have the
required knowledge for the job?
No £ Yes £ NA £
13. Are there sufficient resources (financial, human,
hardware/software) to support the SMS?
SMS implementation plan
14. Is there an SMS implementation plan to target No £ Yes £ NA £
resource allocation?
No £ Yes £ NA £
15. Has a gap analysis been undertaken to identify
existing and missing SMS elements?
No £ Yes £ NA £
16. Are priorities for SMS implementation based on
identified risks?

Safety Management Systems 27

 Gap analysis checklist
SMS element Check question Response
Contractors (third party interfaces)
17. Does the organisation assess a contractor’s previous safety No £ Yes £ NA £
performance before procuring contracted services?
18. Does the organisation have contracts or service level No £ Yes £ NA £
agreements with contractors clearly specifying the
safety standards they must meet?
No £ Yes £ NA £
19. Does the organisation audit ongoing contractor
safety performance for compliance regularly?
Emergency response plan
20. Is there an appropriate emergency response plan No £ Yes £ NA £
for all workplace locations?
No £ Yes £ NA £
21. Has the organisation assessed which emergencies are
most likely and developed plans for each different type?
No £ Yes £ NA £
22. Is there documentation of all major hazards in the
No £ Yes £ NA £
work area?
23. Are there sufficient notices in the workplace advising
No £ Yes £ NA £
people what to do in the event of an emergency?
24. Does the organisation have regular emergency
exercises/drills?
Documentation
25. As part of SMS documentation, has the organisation No £ Yes £ NA £
developed a safety management manual?
26. Are there written policies, procedures and instructions No £ Yes £ NA £
covering all the SMS standards?
27. Are these written policies, procedures and documents No £ Yes £ NA £
authorised, current and available to all relevant personnel?
28. Is there a written policy for retaining and maintaining No £ Yes £ NA £
SMS documentation?
29. Are all documents maintained in accordance with No £ Yes £ NA £
established document control procedures?

28 Safety policy and objectives

SMS element Check question Response
Safety risk Hazard identification
management
30. Is there an effective ongoing hazard identification program? No £ Yes £ NA £
31. Does the hazard identification program include a No £ Yes £ NA £
confidential reporting system?
No £ Yes £ NA £
32. Are confidential reports properly de-identified?
No £ Yes £ NA £
33. Are hazards associated with contracted agencies
included in the hazard reporting system?
No £ Yes £ NA £
34. Is there a procedure for acknowledging safety-
No £ Yes £ NA £
related reports?
35. Are the results of hazard reports and safety suggestions
made available to the initiator?
Risk assessment and mitigation
36. Is the process for risk assessment and management No £ Yes £ NA £
fully documented?
No £ Yes £ NA £
37. Is there a process for continuously assessing hazards
for their risk potential (likelihood and severity)?
No £ Yes £ NA £
38. Does the organisation have a process for managing
risks to a tolerable level i.e. as low as reasonably
practicable (ALARP)?
Safety Safety performance monitoring and measurement
assurance
39. Are there key safety performance indicators to measure No £ Yes £ NA £
aviation safety performance?
40. Are the safety performance indicators monitored No £ Yes £ NA £
for achievement?
No £ Yes £ NA £
41. Do the safety performance indicators go beyond
reactive/lag indicator measurement?

Safety Management Systems 29

 Gap analysis checklist
SMS element Check question Response
Internal safety investigation
42. Is there a simple, user-friendly system for reporting No £ Yes £ NA £
safety occurrences?
No £ Yes £ NA £
43. Is there a standard procedure for incident/accident
No £ Yes £ NA £
investigation?
44. Is the approach to incident/accident investigation systemic
No £ Yes £ NA £
in nature i.e. focused on root causes? (the ‘why’)
45. Are both immediate causes (active failures) and
No £ Yes £ NA £
contributing factors (latent conditions) identified?
No £ Yes £ NA £
46. Are enough resources/time dedicated to conducting
investigations? No £ Yes £ NA £

47. Are recommendations/corrective actions tracked to

ensure completion? No £ Yes £ NA £

48. Are recommendations/corrective actions reviewed to

determine if they have been effective in reducing risk?
49. Is a just culture policy applied post investigation to
consistently manage at-risk behaviour?
Change management
50. Is there a documented change management procedure? No £ Yes £ NA £
51. Are changes carefully planned and staggered? No £ Yes £ NA £
52. Does the procedure require identification of (and No £ Yes £ NA £
consultation with) all stakeholders?
53. Does the change management procedure contain No £ Yes £ NA £
an appropriate risk management strategy to reduce

risks associated with the proposed change?
No £ Yes £ NA £
54. Is performance monitored after the change?
Continuous improvement
55. Are there regular internal and external audits to determine No £ Yes £ NA £
if the SMS is working?
56. Does the organisation have a written procedure specifying No £ Yes £ NA £
how and when the effectiveness of the SMS is evaluated?

30 Safety policy and objectives

SMS element Check question Response
Safety training Training and education
and promotion
57. Has the organisation done a training needs analysis No £ Yes £ NA £
and clearly defined competencies?
58. Is a supply of safety-related information (magazines, books, No £ Yes £ NA £
pamphlets, posters, videos, DVDs, online resources) readily
available to all employees who have safety responsibilities?
59. Are employees encouraged and assisted to attend safety- No £ Yes £ NA £
related training courses and seminars?
60. Are new employees given sufficient training and No £ Yes £ NA £
checking in their technical duties prior to being permitted
to operate either supervised or unsupervised?
No £ Yes £ NA £
61. Is the refresher training and checking of all employees
No £ Yes £ NA £
adequate?
No £ Yes £ NA £
62. Are employees given sufficient training in new procedures?
63. Are trainers and checkers adequately trained and checked,
No £ Yes £ NA £
both for competence and standardisation?
No £ Yes £ NA £
64. Are employees trained in the procedures and policies
of the SMS? No £ Yes £ NA £

65. Is there a training records register?

66. Are training initiatives evaluated to determine if they
are effective?
Safety communication
67. Are regular briefings/toolbox talks/newsletters etc used to No £ Yes £ NA £
communicate with staff about current safety issues?
68. Are there set standards for safety communication—the best No £ Yes £ NA £
method of communicating specific messages?
69. Does the organisation share safety-related information No £ Yes £ NA £
freely with all employees?
Results Total number of ‘yes’ responses ___________ Assessment result
(% of ‘yes’
Total number of ‘no’ responses ___________
responses)

______%
Number of check questions completed ___________

Safety Management Systems 31

An effective emergency e) gather essential passenger information
and ensure passengers’ safety
response plan (ERP)
f) establish mutual support arrangements
For your emergency response plan to be with other operators and agencies for
effective, you need to address some critical an emergency
issues. Ensure you have:
g) prepare and maintain an emergency
»» adequate training and competency communications kit containing:
arrangements
-- necessary administrative supplies, such as
»» well thought-out procedures (easily assessable, forms, paper, name tags, computers/laptops
understood and applied)
-- critical telephone numbers and contact
»» clear understanding of roles in emergency details, such as doctors, local hotels,
response situations translators/linguists, caterers, airline
»» clear lines of command and communication transport companies.
If there is an aircraft accident at or near the
»» realistic expectations of people’s abilities
airport, operators should:
in an emergency
a) report to the airport command post to
»» prepared/practised for an emergency.
coordinate the aircraft operator’s activities
Emergency response responsibilities b) assist in locating and recovering any
for operators flight recorders
The aircraft operator’s emergency response plan
c) assist investigators to identify aircraft
(ERP) should be coordinated with the airport
components and ensure that hazardous
emergency plan (AEP), so both operator and
components are made safe
airport management know who is responsible for
what. As part of emergency response planning, d) provide passenger and flight crew
aircraft and airport operators together must: information, as well as information about
any dangerous goods on board
a) provide training to prepare personnel
for emergencies e) transport uninjured people to the designated
holding area
b) make arrangements to handle phone queries
about the emergency f) make arrangements for any uninjured
passengers who wish to continue their
c) designate a suitable holding area for
journey, or who may need accommodation
uninjured people (‘meeters and greeters’)
or other assistance
d) outline duties for company personnel (the
g) with the airport public information officer and
person-in-command, receptionists for
police, inform the media
receiving passengers in holding areas)
h) remove the aircraft (and/or wreckage) when
the investigation authority authorises it.

32 Safety policy and objectives

Language and layout of »» Consistency
Use the same layout, language, font etc.
procedures/documentation for each procedure, job card and technical
When drawing up procedures, you should ensure document. Comply with established
that you: conventions (see below) and stick to
established design guidelines. Having
»» use terms the user will know
consistent procedures and documents is good
»» include a glossary of terms and abbreviations human factors practice, because it reduces
(use the term in full the first time it is ambiguity and uncertainty.
mentioned, and then abbreviate it). However,
»» Convention
be wary of over-use of abbreviations and
A convention is an agreed-upon way of
jargon – in many cases they do not help
doing things. Having a convention such as
understanding, and can often confuse rather
simplified technical English, or plain English,
than clarify
makes documents and procedures easier to
»» use short sentences understand. Conventions also ensure that what
is learned in one task card, for example, can be
»» write ‘actively’ (e.g. ‘train the appropriate
transferred to any other, without the error-prone
personnel’ rather than, ‘the appropriate
process of ‘unlearning’.
personnel should be trained’)
»» Feed forward/communicate widely
»» are clear and concise
Although this term is used frequently in
»» set out actions in the right order aviation maintenance, ‘feed outward’ might
be more accurate. Feeding forward means
»» emphasise any hazards, precautions or
communicating the lessons personnel learn on
warnings with bold text or other highlighting
the job more widely. If someone identifies an
»» avoid negatives where possible (e.g. ‘wait easier, more effective way of doing something,
until the person is competent, then assign then (subject to appropriate approvals) share
responsibilities’ rather than ‘do not assign this information/method with others.
responsibilities if competency has not
»» Template
been assured’)
A template is a formatted outline into which
»» include visual aids for keeping track of procedure writers place information for specific
where the reader is (tick boxes, markers tasks. A template typically contains sections
etc.), especially if the document is long with formatting, font types, indentation
rules etc.
»» avoid complicated or ambiguous language,
jargon and buzz words »» Validation
A valid procedure has been tested and shown
»» avoid using different terms for the same thing.
to work properly in the real world. It is quite
When producing SMS documentation (both possible to write a procedure that cannot
procedural and technical), you should take the actually be performed in any operations for
following into account: which it was intended. That is why you must
make sure your procedures are valid/work.
»» Accuracy
Your procedures and documents must be »» Verification
accurate, using, for example, correct location A verified procedure has been checked for
names and task sequences. accuracy and completeness. Verifying a
procedure does not mean it can actually be
performed (see validation), but it does at least
contain all the material it is supposed to, and
that material is accurate.

Safety Management Systems 33

 Doc. no. Document Date How document Website Person Document Risk register Retention Date
title and is maintained or supplier responsible for status cross-reference period withdrawn/

34
version on file reference maintaining (draft, current, disposal
document archived, action
(Hard copy, electronic,
destroyed)
web link) on file

List the
documents
used in your
Document register

operations.

Safety policy and objectives

Sample safety leadership rules
£ I will never walk past, or ignore, an unsafe act, or unsafe behaviour.
£ I will ensure that my people are using task risk assessments to manage
risk effectively.
£ I will ensure that all personnel, including new starters and contractors, are
familiar with existing safety systems and procedures, including the tools
for risk assessment.
£ I will verify that housekeeping/hazard inspections are conducted as required
and rectify all identified issues immediately.
£ I will conduct at least one safety observation per week.
£ I will communicate all site incidents and safety investigation reports and
immediately rectify all issues within my control.
£ I will ensure that none of my people is asked to do a task that they are not
competent to perform in a safe manner.
£ I will ensure daily and monthly safety meetings take place with all of my people,
including a weekly safety toolbox talk.
£ I will ensure issues raised in daily and monthly safety meetings are recorded,
followed up on, and feedback is given in a timely manner.
£ I will ensure that we thoroughly investigate all incidents and injuries, take
action on the findings, and close them out in the aviation safety database,
in a timely manner.
£ I commit to ensuring there is no distinction between casual employees,
contractors, and permanent employees in the treatment and communication
of safety matters.
£ I will be absolutely impartial in dealing with safety issues and apply the
‘just culture’ process to all incidents.

I ___________________ agree to live and work by these rules while I am working at

XXXXXX and to be a safety role model.

Signed:___________________________ Date:___________________________

Safety Management Systems 35

Aviation Safety Responsibility
All employees and contractors working for Bush
Lifesavers Policy Air and its associated operations must adhere to
Purpose the aviation safety lifesavers.
All personnel of Bush Air have a responsibility to Lifesavers are Bush Air’s standards for
themselves, their family and work colleagues to safeguarding safety and are key controls and
work safely. Accordingly, Bush Air has developed procedures.
a set of non-negotiable aviation safety rules for all
All managers/supervisors must ensure that all
personnel.
personnel know, understand and apply these
This set of aviation safety rules, called lifesavers, principles when working for Bush Air. New
is based on incident management system data, employees and contractors will be familiarised
and developed in consultation with managers with the standards in their induction programs
and employee representatives. The objective is and site-based safety training.
to target and reinforce crucial behaviours and
processes that ensure safety performance, Consequences of non-compliance
particularly in high-risk areas of the business. All personnel must work to comply with the
aviation safety lifesavers. Where someone is in
Aviation safety lifesavers are rules that, if broken,
breach of the lifesavers, an investigation will be
will cause serious safety breaches. If these rules
conducted and disciplinary action may be taken.
are not followed, there is the potential for serious
This action will be in accordance with the Bush
injury to employees, contractors and/or members
Air Just Culture Procedure, BA-AS-05.
of the general public, and even for fatalities.

Scope LIFESAVERS . . . Your safety depends on them!

This procedure, defining Bush Air’s aviation
1. Only operate equipment for which you are
safety lifesavers, applies to all personnel.
trained, competent and authorised.
2. Only commence a task after all appropriate
permits/authorisations are in place.
3. Always speak up if standard operating
procedures (SOPs) are not followed. Don’t
stand by and accept poor work standards.
4. Always report incidents, to ensure a good
learning culture.
5. Always use the appropriate personal
protective equipment (PPE) when working
around aircraft.
6. R
eport any hazards you notice in your
workplace.

36 Safety policy and objectives

JUST CULTURE Procedure
BA-AS-05
Responsible Officer: Aviation Safety Manager
Approved: CEO

Contents
1 Purpose X
2 Scope X
3 Responsibilities X
3.1 Chief executive officer X
3.2 Managers X
3.3 Aviation safety manager X
3.4 Employees X
3.5 Contractors X
4 Application X
4.1 Commitment to a just culture X
4.2 Just culture application X
4.3 Training X
4.5 Record keeping and documentation X
5 Definitions X
6 Reference documentation X
7 Appendix X
Appendix A: Workflow process for applying the just culture procedure X
Appendix B: Bush Air counselling/discipline decision chart X

Version history

Revision Description Originator Date

H Draft - Issued for implementation J Smith 24.08.11
G Draft - Changes following review by staff representatives. J Smith 18.08.11
B Draft - Review and amendments by CEO J Smith 16.07. 11
A Draft J Smith 25.06. 11

Safety Management Systems 37

1. Purpose 3.2 Managers

The purpose of this procedure is to provide Bush Managers are responsible for:
Air staff with guidance on: »» ensuring all employees and contractors comply
»» the application of just culture procedures to with this procedure by
incident management »» leading and modelling the just culture process
»» the management of incidents, near-misses, »» periodically reviewing the process (if used)
hazards, and risks involving people and reporting monthly on its effectiveness
»» Bush Air’s commitment to a just culture and application
approach that complements our values, zero »» providing appropriate training and support to
harm outcomes and the sustained delivery all personnel in applying this procedure.
of a healthy safety culture
3.3 Safety Manager
»» the recognition that exceptional, or above-
The safety manager:
and-beyond team and individual performance
should be acknowledged and rewarded. »» assists managers to implement and maintain
this procedure
2. Scope »» promotes and models the just culture
This procedure applies to all personnel across procedure
all Bush Air workplaces.
»» audits periodically to ensure the
It does not provide detailed advice regarding implementation of, and adherence to,
the disciplinary process but it will be used in this procedure
conjunction with existing company discipline
»» coordinates management level training/
procedures.
awareness about applying the procedure
The just culture procedure will also be integral
»» compiles and distributes statistics relating
to management processes following incident
to its effectiveness and application.
investigations, primarily where the contributing
factors involve human error. 3.4 Employees
Employees will:
3. Responsibilities
»» comply with the requirements of this
3.1 Chief Executive Officer procedure
The CEO is responsible for: »» attend appropriate training and awareness
»» implementing this procedure sessions, as directed by their manager.

»» providing sufficient resources to act upon 3.5 Contractors

this procedure Contractors will comply with the requirements
»» leading and modelling the just culture process. of this procedure.

38 Safety policy and objectives

4. Application 4.2 Just culture application
To ensure the development and sustainability
4.1 Commitment to a just culture
of the high trust levels necessary to create a
A just culture is applied knowing that: healthy safety culture at Bush Air, managers will
»» people make mistakes apply these principles in a consistent manner.
An incident does not always trigger the use of
»» people may develop unhealthy patterns this process.
of behaviour
The just culture procedure should only apply:
»» there is zero tolerance of reckless conduct
»» following a systemic investigation into an
»» people must be recognised and rewarded for incident, event or exceptional behaviour
doing a good job and promoting sound work
practices on an ongoing basis. »» after factual information or data has been
collected from a thorough investigation.
If there is an incident, near-miss or identified Investigations should focus predominantly on
risk to safety, the just culture approach creates identifying and addressing system/organisation
an alternative to the two extremes of punitive contributing factors and related causes.
or blame-free cultures. A just culture balances
the need to have a non-punitive reporting and Following the investigation of an incident/event
learning environment (an environment that is not or exceptional behaviour, managers should
focused on attributing blame and administering consult the workflow process in appendix A to
punishment), with the need to hold people guide their approach. This workflow process
accountable for their actions. provides a step-by-step approach to using the
just culture decision chart in appendix B. This
A just culture is an important part of a positive procedure cannot incorporate every possible
health and safety culture. It recognises that scenario or situation; however, it will help
behaviours may fall below expectation. managers and leaders to consider a broad range
However, the employee may not necessarily of issues so the final decision is consistent with
be in the wrong. company values, and with the sense of fairness
A just culture: and justice that ultimately leads to achieving
safe operations.
»» focuses attention predominantly on identifying
and addressing the system/organisation
factors (root causes) which affect reliability
and performance
»» provides an atmosphere of trust in which
people are encouraged to provide essential
safety-related information (e.g. incident, hazard
and near-miss reports) and build a healthy
reporting culture
»» clearly defines where the line is drawn
between acceptable and unacceptable
behaviour (see also the Bush Air procedure
for Aviation Safety Lifesavers BA-AS-06).

Safety Management Systems 39

4.3 Training 4.4 Record keeping and documentation
Managers, employees, aviation safety personnel Where the counselling discipline decision chart
and contractors (where necessary) will is used, the accountable manager will ensure
undergo just culture training to ensure quality that relevant actions are recorded on the incident
and consistency in using the model in the management database or on the employee’s
organisation. This training covers the following: file (only if discipline is taken). Use the decision
chart, detailed in appendix B, as a guide, ticking
1. Human factors and human error
the appropriate box to verify what action you
2. Systemic health and safety incident have taken.
investigation process (Incident Management
This process will follow the procedure for
BA-IM-01)
counselling, discipline and dismissal, BA-
3. Background to, and rationale for, just HR-01, including privacy and confidentiality
culture principles requirements, and use the appropriate form for
that procedure, such as the pro-forma counselling
4. Sample case studies on how to apply
and disciplinary interview forms.
the procedure
The relevant site/industrial instrument practices
5. Explanation of linkages to other procedures
will apply to records held on file.
such as:
-- aviation safety lifesavers, BA-AS-06
-- counselling, discipline and dismissal,
BA-HR 01

5. Definitions

At-risk behaviour The action increases the risk of an accident.

(unintentional)
Blame-free Not deserving of discipline/punitive action.
Culpable Deserving of discipline/punitive action.
Highly culpable Conscious disregard of a substantial and unjustifiable risk.
behaviour
Human factors A field of scientific knowledge that involves optimising the relationship between
the human operator and the environment.
Human error Occasions in which a planned sequence of mental or physical activity fails to
achieve its intended outcome.

40 Safety policy and objectives

Just culture Just culture is about understanding and effectively applying human factors
principles, and clearly defining acceptable and unacceptable/culpable behaviour
to ensure:
»» incidents that result from honest mistakes and failures in human reliability
are not punished, but acknowledged as organisational failures.
»» zero tolerance for reckless actions and violations, which are treated
appropriately.
»» ongoing support for reporting and learning as the basis of a healthy
safety culture
»» continuous improvement to reach, and then sustain, our zero harm objective.
Punitive Intended to inflict punishment.
Reckless Risk-taking, where the action constituted a significant and unjustifiable risk, and
(intentional) there was a conscious disregard of consequences.
Aviation safety Fundamental safety rules to ensure a safe workplace. A breach of any of these
lifesavers rules will result in disciplinary action.
‘Will’ Understood as mandatory.
‘Should’ Recommended, but not mandatory.

Safety Management Systems 41

6. Reference documentation Appendix
Bush Air Aviation Safety Policy
Appendix A: Workflow process for
Bush Air Procedure for Aviation Safety
applying the just culture procedure
Lifesavers, BA-AS-06
Understanding workplace behaviour
Bush Air Procedures for Incident Management,
BA-IM-01 Human error is a part of life and cannot be
entirely eliminated. Where someone makes
Bush Air Counselling/Discipline & Decision Chart a slip or lapse in following procedures, or a
BA-HR-01 mistake, disciplinary measures are not usually
appropriate. Even when someone violates
established procedures (an intentional act not
Errors: A Balance between learning and to follow established procedures), you should
accountability. Marx, David. Outcome examine the organisational context. For example,
Engineering (2004) is their violation a one-off, individual act, or is
Managing the Risks of Organisational Accidents, there a culture of workforce non-compliance?
Reason J. Ashgate, Brookfield (1997) The diagram below shows various types of error,
and the distinction between the unintentional
nature of human error, and the intentional nature
of violations.

Error types
When someone does something wrong, you
should look at the underlying cause/why they did
it, before deciding on a just consequence.

Workplace Behaviour

Human error Violation

Lapse or slip routine

Mistake situational

optimising

reckless

42 Safety policy and objectives

Applying the just culture procedure
Work flow process

Trigger Process step Required action

Incident or 1. Incident »» Has the incident investigation been completed?
event occurs investigation
Exceptional 2. Review relevant »» Has any human performance issue been identified as a
behaviour information & contributing factor?
occurs findings
3. Refer to »» Apply to only one action/behaviour at a time.
decision chart
»» If there are multiple actions by an individual, you should
treat each separately.
»» Use for the employee first, then repeat for the manager/
supervisor.
4. Move from left »» Locate the START point at the behaviour description
to right across column on the top left-hand side of the page.
decision chart
»» Determine the most accurate description of the behaviour
»» At each ‘yes’ or ‘no’ check point record the response.
Each subsequent ‘no’ identifies increasingly culpable
behaviour.
»» When you reach the appropriate ‘yes’, the manager moves
down the matrix to seek guidance on the most appropriate
consequence.
5. Determine »» If you identify a reckless violation or personal optimising
disciplinary action violation, consider disciplinary action for the employee,
referencing Procedure BA-HR-01
6. Documentation »» Document any actions and attach decision chart as a
record on employee/manager files.

Note: when team members intentionally break a well-known rule to gain a benefit or advantage, or simply disregard known risks and/or workplace standards, it is
reasonable that there should be a personal consequence of violation.

The consequence for unintentional human error must be different to that for violation. Errors may result from a lack of skill, training, or knowledge, whereas
violations are deliberate acts that knowingly contravene systems, processes and policies.

For very small organisations, internal

confidential reporting will be impossible.
Sharing lapses or mistakes with your
colleagues or peers is vital, as is building
a culture of openness and trust.

Safety Management Systems 43

Appendix B: Bush Air counselling/discipline decision chart

Recognition Coaching

Behaviour type Exceptional Expected Unintentional error Routine violation

behaviour behaviour (slip, lapse, or
mistake)
Team member Did the team Were all procedures Did the team member Do other team
behaviour member go and instructions think they were doing members
above & beyond followed? things the right way? normally not
START „
call of duty? follow safety
procedures in the
same way?
£ Yes £ No £ Yes £ No £ Yes £ No £ Yes £ No
‚ „ ‚ „ ‚ „ ‚ „
Team member £ Recognition or £ No action £ Does this happen £ Coach team
consequence reward required often? members on
(If yes, routine importance
£ Record on
error & record for of following
employee file
trend analysis) correct
£ Communicate procedures
£ Record type of
to wider team and not taking
error on incident
short cuts
management
database £ Record on file
£ Coach person on
taking more care
Supervisor/ Did the Does the Did the supervisor/ Does the
manager supervisor/ supervisor/ manager manager think the task supervisor/
behaviour manager lead by example, was being completed in manager normally
also exhibit by complying with the required manner? ensure work is
START „
exceptional procedures and completed in the
behaviour? instructions? appropriate and
correct manner?
£ Yes £ No £ Yes £ No £ Yes £ No £ Yes £ No
‚ „ ‚ „ ‚ „ ‚ „
Supervisor/ Recognition
£ No action
£ Does this happen
£ £ Coaching on
manager or reward required often? how to monitor
consequence (If yes, routine error & enforce
Record on
£
& record for trend procedures
employee file
analysis)
Safety
£
Communicate
£
Record type of
£ leadership
to wider team
error on incident skills training
Copy to
£ management
Record on file
£
supervisor database
Coach employee on
£
taking more care

44 Safety policy and objectives

 Initiate discipline

Situational violation Organisational Personal optimising Reckless violation

optimising violation violation

Did the team Did the team Did the team member Did the team member
member think the member think there deviate from the intentionally not follow
procedure was a was some benefit procedure to make it the procedure, without
for the company
barrier to getting the easier for themself? thinking or caring about
job done? by doing the job a the consequences?
different way?
£ Yes £ No £ Yes £ No £ Yes £ No £ Yes
‚ „ ‚ „ ‚ „ ‚
£ Coach the team £ Coach the team £ Formal disciplinary £ Formal disciplinary
member on member on action in accordance action in accordance
speaking up when balancing work with relevant with relevant
procedures cannot and time pressure procedures procedures
be followed, and with company
Consider suspension
£ Consider suspension £
delaying the job values. Consider
until further action until further
until it can be disciplinary
required action required
completed safely measures where
appropriate £ Record on Record on
£
£ Record on file
employee file employee file
£ Record on file

Did the supervisor/ Did the supervisor/ Did the supervisor/ Did the supervisor/
manager know the manager authorise manager manage the manager condone the
procedure was a shortcuts or other variance/behaviour actions of the team
barrier to getting the non-approved on this, or previous, member?
job done; however, methods, thinking occasions?
managed the matter this was a benefit for
appropriately? the company?
£ Yes £ No £ Yes £ No £ Yes £ No £ Yes
‚ „ ‚ „ ‚ „ ‚
£ Coaching on £ Consider health & Formal disciplinary
£ Formal disciplinary
£
how to monitor safety leadership action in accordance action in accordance
& enforce training with relevant with the relevant
procedures procedures procedures
Formal disciplinary
£
Safety leadership
£ action in Coaching on how
£ Consider suspension
£
skills training accordance to recognise and until further
with relevant deal with such action required
Record on file
£
procedures behaviour earlier
Record on
£
Record on file
£ Record on
£ employee file
employee file

Safety Management Systems 45

 www.casa.gov.au
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46 Safety policy and objectives