Advisory Circular. Safety Management Systems Development Guide for Small Operators/Organizations

Transcription

1 Advisory Circular Subject: Safety Management Systems Development Guide for Small Operators/Organizations Issuing Office: Civil Aviation Activity Area: Oversight AC No.: File No.: Z Issue No.: 01 RDIMS No.: Effective Date: TABLE OF CONTENTS 1.0 INTRODUCTION Purpose Applicability Description of Changes REFERENCES AND REQUIREMENTS Reference Documents Cancelled Documents Definitions and Abbreviations BACKGROUND What is this guide for and who should use it? What is a SMS? Key Generic Features of the SMS Approach SMALL OPERATORS/ORGANIZATIONS GUIDE Determining Complexity Appendix A: Safety Management Plan Appendices B to E CONTACT OFFICE... 7 APPENDIX A SAFETY MANAGEMENT PLAN...8 APPENDIX B OCCURRENCE REPORT AND HAZARD IDENTIFICATION FORM...49 APPENDIX C INCIDENT/ACCIDENT ANALYSIS...50 APPENDIX D CORRECTIVE/PREVENTATIVE ACTION PLAN...51 APPENDIX E RISK MANAGEMENT WORKSHEET...52 APPENDIX F RISK MATRIX...54

2 1.0 INTRODUCTION This Advisory Circular (AC) is provided for information and guidance purposes only. It may describe an example of an acceptable means, but not the only means, of demonstrating compliance with regulations and standards. On its own, this AC does not change, create, amend or permit deviations from regulatory requirements, nor does it establish minimum standards. 1.1 Purpose The purpose of this document is to provide additional guidance on the practical application of the regulations pertaining to Safety Management Systems (SMS). This guide provides examples of SMS processes suitable for small operators/organizations operating under the Canadian Aviation Regulations (CARs) Parts IV, V and VII. 1.2 Applicability This document is applicable to the aviation industry, delegates, individuals and organizations and all Transport Canada Civil Aviation (TCCA) employees when they are exercising privileges granted to them under an External Ministerial Delegation of Authority. 1.3 Description of Changes Not applicable. 2.0 REFERENCES AND REQUIREMENTS 2.1 Reference Documents It is intended that the following reference materials be used in conjunction with this document: (a) (b) (c) (d) (e) (f) Part I, Subpart 7 of the Canadian Aviation Regulations (CARs) Safety Management System Requirements; Part V, Subpart 73 of the CAR Approved Maintenance Organizations; Part VII, Subpart 5 of the CAR Airline Operations; Staff Instruction (SI) SUR-001, Issue 01, dated Safety Management System Assessment and Program Validation Procedures; Transport Publication (TP) 14135, dated Safety Management Systems for Small Aviation Operations A Practical Guide to Implementation; and TP 14343, Revision 1, dated Safety Management System Implementation Procedures Guide for Air Operators and Approved Maintenance Organizations. 2.2 Cancelled Documents Not applicable. 2.3 Definitions and Abbreviations The following definitions and abbreviations are used in this document: (a) (b) (c) (d) (e) (f) AC means Advisory Circular. AMO means Approved Maintenance Organization. COM means Company Operations Manual. MCM means Maintenance Control Manual. MPM means Maintenance Policy Manual. Policy means a guiding principle used to set direction in an organization. It is a high-level overall plan that outlines goals and objectives of 54 AC Issue 01

3 (g) (h) (i) (j) (k) Procedure means a group of interrelated activities (procedures) that convert inputs to outputs. Process means a specified way to carry out an activity (e.g. a series of steps). SMS means Safety Management System. System means a group of inter-dependent processes and people that work together to achieve a defined result. Together, the policies, procedures and processes form the system. TCCA means Transport Canada Civil Aviation. 3.0 BACKGROUND 3.1 What is this guide for and who should use it? (1) In anticipation of the regulatory SMS requirements for small operators, this document has been developed to address organizations of minimum to moderate complexity. (2) This guidance material provides an interpretation of the intent and application of the SMS regulatory requirements in small operators. It contains practical examples of how the components that make up a SMS might be implemented; however, it is not meant to be a list of prescriptive requirements or a template to be used verbatim. Each organization is required to develop policies and procedures in accordance with their unique operating requirements. (3) Depending on the size and complexity of the organization, the tools that make up a SMS will vary. As such, the material contained herein is not intended as a formula for meeting the regulatory requirements, but rather is offered as an information source for interpreting the regulatory requirements, and is intended to pave the way forward for the successful implementation of a SMS in an organization. (4) Whether an organization has chosen to develop an overarching SMS manual or has incorporated their SMS program into their existing manuals, such as the Maintenance Control Manual (MCM), Maintenance Policy Manual (MPM) or Company Operations Manual (COM), Transport Canada requires adequate document control in order to avoid any potential discrepancies on policy or procedures, omissions or conflicts that could result from having multiple manuals. The format used to document the SMS program must allow end users to promptly locate required information to enable them to execute their functions. (5) Amendments to the SMS manual will be treated as an amendment to the actual MCM, MPM or COM and hence need to follow the established approval process. (6) Users of this AC should consult the CARs and SI SUR-001, Safety Management System Assessment and Program Validation Procedures to ensure that their SMS meets all regulations, applicable expectations and measurement criteria. Although the expectations outlined in SI SUR- 001 vary, all SMS regulations must be met regardless of the organization s complexity. (7) The information and examples provided in this document were developed by applying the applicable CARs, relevant SI SUR-001 expectations and level 3 measurement criteria to models representing small aviation operations. 3.2 What is a SMS? (1) In technical terms, a SMS is an explicit, comprehensive and proactive process for managing risks that integrates operations and technical systems with financial and human resource management, for all activities related to a Canadian aviation document. (2) Practically speaking, a SMS is a business-like approach to safety. In keeping with all management systems, a SMS provides for goal setting, planning, and measuring performance. It deals with organizational safety rather than the conventional health and safety concerns in the of 54 AC Issue 01

4 workplace. An organization s SMS defines how it intends to manage air safety as an integral part of its business management activities. A SMS becomes part of the way people do their jobs. (3) An organization s structure, or set-up, and the activities that make up a SMS are found throughout the organization. Every employee contributes to the safety health of the organization. In some areas or sections, safety management activities will be more visible than in others, but the system must be integrated into the way things are done throughout the organization. This will be achieved by the implementation and continuing support of a safety program based on a coherent policy that leads to well-designed procedures. 3.3 Key Generic Features of the SMS Approach (1) There is no definitive meaning attached to the term SMS. Every organization, and industry, for that matter, has its own interpretation of what it is. From the Civil Aviation perspective, five generic features characterize a SMS. These are: (a) (b) (c) (d) (e) A comprehensive systematic approach to the management of aviation safety within an organization, including the interfaces between the organization and its suppliers, subcontractors and business partners; A principal focus on the hazards of the business and their effects upon those activities critical to flight safety; The full integration of safety considerations into the business, through the application of management controls to all aspects of the business processes critical to safety; The use of active monitoring and audit processes to validate that the necessary controls identified through the hazard management process are in place and to ensure continuing active commitment to safety; and The use of quality assurance principles, including improvement and feedback mechanisms. (2) When considering how to meet CARs requirements with respect to SMS, some organizations may choose to utilize a commercial off-the-shelf system. Whilst this might be appropriate for some organizations, the program should be tailored to meet the requirements of the individual organization rather than assuming that one size fits all. Attention should also be given to the need to ensure that linkages between the individual components are in place so that the system functions in a cohesive manner. (3) A SMS includes the following key components: (a) (b) (c) (d) (e) (f) Safety management plan; Documentation; Safety oversight; Training; Quality assurance; and Emergency preparedness. (4) A SMS can be divided into three principle parts, all interlinked and interdependent. The key point to remember is that if any one of these parts is missing, the system will be ineffective. The diagram below shows how each of the regulatory requirements (per the list above) fit into the SMS as a whole of 54 AC Issue 01

5 Diagram 1 Key Generic Features of an Effective SMS C D E A robust system for assuring safety An effective organization for delivering safety A B D F A comprehensive corporate approach to safety E A B 4.0 SMALL OPERATORS/ORGANIZATIONS GUIDE (1) Due to the size and complexity of the infrastructure required to support large air operations, this document is not applicable to: (a) (b) holders of an air operator certificate issued under CAR ; or holders of an Approved Maintenance Organization (AMO) certificate issued under CAR whose certificate includes ratings for an aircraft of a type that, if operated in commercial air transport, would be subject to CAR 705 Airline Operations. (2) Guidance for the large complex organizations indicated above can be found in TP Safety Management Systems Implementation Procedures Guide for Air Operators and Approved Maintenance Organizations. 4.1 Determining Complexity (1) To assist organizations in developing their SMS using the guidance provided in this document, it is necessary to determine the degree of complexity of the organization. In order to do so, various factors, such as the number of employees, number of certificates held, number of bases, different types of equipment operated as well as the operational environment, must be considered. (2) There is no overall complexity formula that takes all variables into account. Determining where an organization may fit in this guide is based on many factors and variables, including an understanding of the operation itself and its environment. Users should consider factors affecting their organization and then determine whether their operations are of minimal or moderate complexity, as identified in Appendix A of this document. For example, a small organization that operates a heli-ski service will have different challenges than a similarly-sized fixed-wing air taxi operation. 4.2 Appendix A: Safety Management Plan (1) This guide and its associated appendices are to be used for guidance purposes in conjunction with SI SUR-001. (2) SI SUR-001 separates SMS into distinct component parts. This separation is necessary to allow for an understanding of the components that make up the system. Organizations are free to keep of 54 AC Issue 01

6 components separate, or to combine them in any way that suits their operations, as long as the system contains all of the required component parts. To illustrate one way components might be grouped within the system, this guide combines the following elements: (a) (b) 1.6 Performance Measurement and 1.7 Management Review; and 2.2 SMS Documentation and 2.3 Records Management. (3) The column of Appendix A is based on a oneperson, single-certificate type air operator or AMO, as are the examples provided. Organizations that fall between minimal and moderate complexity must review any additional SMS element expectations outlined in SI SUR-001 for applicability. (4) The column is based on a five- to ten-person, multiple-certificate type air operator or AMO, with individuals identified as accountable executive, operations manager, person responsible for maintenance and SMS manager. When an organization s complexity increases beyond the moderately complex, SI SUR-001 must be used. (5) Each section of the SMS element detailed in this guide has three distinct components: (a) (b) brief description of the SMS element; SMS element criteria requirements based on: (i) (left-hand column of Appendix A) Score 3 element criteria (Appendix B of SI SUR-001) are used as the basis for this component, and are identified by a hollow square bullet in the attached Appendix A. (ii) (right-hand column of Appendix A) (iii) Bullets (A) (B) Score 3 element criteria (Appendix B of SI SUR-001) are used as the basis for this component, and are identified by a hollow square bullet in the attached Appendix A. Organizations may incorporate additional expectations as identified in Appendix B of SI SUR-001, where such expectations are considered to be relevant to the complexity of the organization s systems. Examples of additional expectation from SI SUR- 001 Appendix B are identified by arrow-shaped bullets in the attached Appendix A. Elements that are common to both minimal and moderate complexity are represented with the following symbol: (see example below); and Items found in the column that are deemed as additional requirements to those indicated in the Minimal Complexity column will be identified with the following symbol: (see example below) of 54 AC Issue 01

7 (c) Safety Management Systems Development Guide for Small Operators/Organizations SMS manual examples: 3. Safety Oversight 3.4 Risk Management (Item a) When a hazard has been identified, and the requirement for a risk assessment determined (Item b) Risk management should: include a process for include criteria include a process (Item c) 4.3 Appendices B to E (Item a) When a hazard has been identified, and the requirement for a risk assessment determined (Item b) Risk management should: include a process for include criteria include a process include a description (Item c) Appendices B through E are provided as examples of different recording and reporting methods in a SMS. 5.0 CONTACT OFFICE For more information, please contact the: Chief, Technical & National Programs (AARTT) Phone: Fax: CAIRS_NCR@tc.gc.ca Suggestions for amendment to this document are invited, and should be submitted via the Transport Canada Civil Aviation Issues Reporting System (CAIRS) at the following Internet address: or by at: CAIRS_NCR@tc.gc.ca Original signed by Don Sherritt on June 17, 2008 D.B. Sherritt Director, Standards Civil Aviation of 54 AC Issue 01

8 APPENDIX A SAFETY MANAGEMENT PLAN 1. Safety Management Plan 1.1 Safety Policy The safety policy is a valuable tool for informing clients, third-party subcontractors, TCCA and other stakeholders of the organization s commitment to safety. It establishes an overall sense of direction, states the commitment to safety and sets the principles of action for the organization. The safety policy should ensure that: a safety policy is in existence, followed and understood; the organization has based its safety management system on the safety policy and there is a clear commitment to safety; the safety policy is agreed to and approved by the accountable executive; and the safety policy is reviewed periodically for continuing applicability. SAFETY POLICY Safety is a corporate value. The ultimate responsibility for providing a safe and healthy environment to our clients and organization rests with myself as the accountable executive. To prevent accidents and to eliminate damage or injury, I have implemented and maintain an active safety management system (SMS). My objective is the proactive management of identifiable hazards, the reduction of risk to a level as low as reasonably practicable, and the sharing of safety information with my stakeholders. Signed: Accountable Executive The safety policy is a valuable tool for informing personnel, clients, third-party subcontractors, TCCA and other stakeholders of the organization s commitment to safety. It establishes an overall sense of direction, states the commitment to safety and sets the principles of action for the organization. In addition, the safety policy will ensure all personnel are aware of their safety-related obligations. The safety policy should ensure that: a safety policy is in existence, followed and understood; the organization has based its safety management system on the safety policy and there is a clear commitment to safety; the safety policy is agreed to and approved by the accountable executive; the safety policy is promoted by the accountable executive; the safety policy is reviewed periodically for continuing applicability; the safety policy is communicated to all employees with the result that they are made aware of their safety obligations; and the policy is implemented at all levels of the organization; it describes the organization s safety objectives, management principles and commitment to continuous improvement in the safety level. SAFETY POLICY Safety is a core business value, and a fundamental component of our competitive advantage. Our organization is strengthened by making continuous safety improvements and excellence an integral part of all our activities of 54 AC Issue 01

9 1. Safety Management Plan 1.1 Safety Policy All managers and employees are responsible and accountable for their actions and safety performance, starting with myself as CEO and accountable executive. I endorse all personnel to think and work safely at all times, regardless of any real or perceived pressures to do otherwise. To prevent accidents and to eliminate damage or injury, we have implemented and maintain an active safety management system (SMS). Our objective is the proactive management of identifiable hazards, the reduction of risk to a level as low as reasonably practicable, and the sharing of safety information with our stakeholders. Signed: CEO and Accountable Executive of 54 AC Issue 01

10 1. Safety Management Plan 1.2 Non-Punitive Safety Reporting Policy The non-punitive aspect of a reporting policy in a one-person operation is unnecessary, as it adds no value to the process. By removing the threat of disciplinary action, a non-punitive safety reporting policy encourages a healthy reporting culture. The non-punitive safety reporting policy should ensure that: immunity from disciplinary action for employees that report, hazards, incidents or accidents is provided; conditions under which punitive disciplinary action would be considered (e.g. illegal activity, negligence or wilful misconduct) are clearly defined and documented; the policy is widely understood within the organization; and there is evidence that the organization is applying the policy; the policy is applied throughout certificated and non-certificated areas of the organization. NON-PUNITIVE SAFETY REPORTING POLICY Our organization fully supports and encourages a culture of openness and trust between all personnel. This cannot be achieved unless employees feel able to report occurrences or hazards without the fear of unwarranted retribution. Reporting occurrences or hazards should become a priority for all employees. Only with full awareness can management rectify deficiencies in a timely manner. Employees are encouraged to identify and report unsafe conditions without fear of recrimination. The organization s primary goal is identification of any unsafe condition that exists within, or may affect, the organization. Personnel reporting safety-related issues to the organization will not be subject to punitive discipline, regardless of whether they were personally involved in the observation giving rise to of 54 AC Issue 01

11 1. Safety Management Plan 1.2 Non-Punitive Safety Reporting Policy the safety concern. The only cases where disciplinary action will be taken are for: negligence; wilful or intentional disregard; criminal intent; and use of illicit substances of 54 AC Issue 01

12 1. Safety Management Plan 1.3 Roles and Responsibilities An effective system must ensure that roles and responsibilities are identified and documented. The accountable executive maintains the responsibility to provide the necessary resources and to ensure the SMS is performing properly. Roles and responsibilities should ensure that: there are documented roles and responsibilities and accountabilities for the accountable executive and evidence that the SMS is established, maintained and adhered to. In a one-person operation, safety roles and responsibilities can be expressed in the safety policy statement. ROLES AND RESPONSIBILITIES I will ensure that SMS roles and responsibilities are identified, documented and periodically evaluated to ensure they are appropriate and functioning within this organization. The accountable executive is responsible for: establishing and implementing the SMS; ensuring the required safety resources are available; establishing and adhering to the safety policy; ensuring that the SMS remains effective; managing the operation of the SMS; collecting and analyzing safety information in a timely manner; monitoring and evaluating the results of corrective actions; ensuring that risk assessments are conducted when applicable; and monitoring the industry for safety concerns that could affect the program. An effective system must ensure that roles and responsibilities are identified, communicated and documented. The accountable executive maintains the responsibility to provide the necessary resources, and to ensure the SMS is performing properly. In addition to individual safety responsibilities, some personnel will have additional responsibilities associated with positions they hold within the organization, e.g. accountable executive, SMS manager, operations manager and person responsible for maintenance. These responsibilities need to be documented within the SMS. Roles and responsibilities should ensure that: there are documented roles and responsibilities and accountabilities for the accountable executive and evidence that the SMS is established, maintained and adhered to; the accountable executive demonstrates control of the financial and human resources required for the proper execution of his/her SMS responsibilities; a qualified person has been appointed, in accordance with the regulation, and has demonstrated control of the SMS; the person managing the operation of the SMS fulfils the required job functions and responsibilities; safety authorities, responsibilities and accountabilities are transmitted to all personnel; and all personnel understand their authorities, responsibilities and accountabilities in regards to all safety management processes, decision and actions; safety authorities, responsibilities and accountabilities are reviewed prior to any significant organizational change; of 54 AC Issue 01

13 1. Safety Management Plan 1.3 Roles and Responsibilities safety authorities, responsibilities and accountabilities of all personnel and third parties are defined and documented in job descriptions. ROLES AND RESPONSIBILITIES We ensure that all SMS roles and responsibilities and employee involvement are identified, communicated, documented and periodically evaluated to ensure they are appropriate and functioning within all levels of the organization. In addition to safety responsibilities associated with our day-today operations, the accountable executive, safety manager and employees have additional responsibilities associated with the operation and maintenance of our SMS. The accountable executive is responsible for: establishing and implementing the SMS; ensuring the required safety resources are available; establishing and adhering to the corporate safety policy; promoting and supporting the SMS; and ensuring that the SMS remains effective. The SMS manager is responsible for: managing the operation of the SMS; collecting and analyzing safety information in a timely manner; monitoring and evaluating the results of corrective actions; ensuring that risk assessments are conducted when applicable; of 54 AC Issue 01

14 1. Safety Management Plan 1.3 Roles and Responsibilities determining the adequacy of training; authority to delegate specific SMS tasks/roles to persons within the organization; ensuring that periodic reviews are conducted to determine the effectiveness of the system; monitoring the industry for safety concerns that could affect the program; and ensuring safety-related information, including organization goals and objectives, are made available to all personnel through established communication processes. Employees are responsible for: following established safe working practices; immediately dealing with any unsafe condition, as practical; identifying and reporting all occurrences, hazards, operational irregularities, unsafe conditions or practices in a timely manner; and being familiar with the organization s SMS of 54 AC Issue 01

15 1. Safety Management Plan 1.4 Communication Effectively communicating safety information is as important in a oneperson operation as it is in a larger organization. For example, a oneperson operation will be in regular communication with their industry peers, clients and TCCA. Communications should ensure that: there are communication processes in place within the organization that permit the safety management system to function effectively; information is established and maintained in a suitable medium, e.g. simple paper records or entries in a readily available black book is one method that could be employed when records of safety communications are required; and there is a process for the dissemination of safety information (e.g. signage, passenger briefing cards or a bulletin board) throughout the organization and a means of monitoring the effectiveness of this process. COMMUNICATION To facilitate the operation and maintenance of our SMS, we will communicate, share, review and document safety-related information through the following process: TCCA: o participation in relevant and accessible safety-related forums, etc. Industry groups: o participation in relevant and accessible safety-related forums; o other operators/associations, etc. Effective communication encourages all personnel to participate in the SMS, and builds a safety culture where issues are openly identified and addressed. As the organization grows in size and complexity, the processes required to communicate and record information will become more involved and formalized. An organization may choose to develop a binder where all employees are required to review and sign as having read safety-related information each time they come to work. Other techniques, such as staff instructions, memos, meetings, posters or newsletters may also be employed at the organization s discretion. Communications objectives and goals should ensure that: there are communication processes in place within the organization that permit the safety management system to function effectively; communication processes (written, meetings, electronic, etc.) are commensurate with the size and complexity of the organization; information is established and maintained in a suitable medium; and there is a process for the dissemination of safety information throughout the organization and a means of monitoring the effectiveness of this process. COMMUNICATION To facilitate the operation, maintenance and effectiveness of our SMS, we will communicate, share, and review safetyrelated information through meetings, electronic and written documentation with the following: of 54 AC Issue 01

16 1. Safety Management Plan 1.4 Communication Clients: o safety briefings, safety cards and customer feedback, etc. I document communications by keeping simple paper records or making entries in the organization s black book. All records are stored in a secure location. Internal: o quarterly (or as required) safety meetings to review reports; o face-to-face on an individual or group basis; o organization memos; o safety bulletin board; and o amendments to documentation. TCCA: o participation in relevant and accessible safety-related forums. Industry: o participation in relevant and accessible safety-related forums; o other organizations and associations; and o manufacturers. Clients: o safety briefings; o safety cards; and o customer feedback of 54 AC Issue 01

17 1. Safety Management Plan 1.5 Safety Planning Minimal Complexity One-Person Operation Safety objectives and goals help identify and prioritize issues, measure safety performance, allocate resources where they are needed the most, and ensure continuous safety improvement. For our purposes, objectives are broad statements that provide the overall context for what the organization s safety plan is trying to accomplish. To meet an objective, goals should be established. Goals should be specific targets and tasks that support the achievement of the stated objectives. Goals should be evaluated to see whether they have been achieved. Goals should be specific, measurable, achievable, realistic and time-bound (SMART). Safety planning objectives and goals should ensure that: safety objectives have been established utilizing a safety risk profile that considers hazards and risks; objectives and goals are consistent with the safety policy and their attainment is measurable; safety objectives and goals are reviewed and updated periodically; there is a documented process to develop a set of safety goals to achieve overall safety objectives; and safety objectives and goals are documented and publicized. SAFETY PLANNING OBJECTIVES AND GOALS The aim of establishing attainable objectives and goals is to ensure the effectiveness and continuous improvement of safety. My annual process for establishing, measuring and updating goals includes a review of results of the SMS quality assurance audit and of occurrence and hazard reports. These reviews will Safety objectives and goals help identify and prioritize issues, measure safety performance, allocate resources where they are needed the most, and ensure continuous safety improvement. Regardless of whether the organization is a one-person operation or moderately complex, the process for setting safety goals and objectives is similar. As the operation increases in complexity, the objectives and goals may become more detailed. For our purposes, objectives are broad statements that provide the overall context for what the organization s safety plan is trying to accomplish. To meet an objective, goals should be established. Goals should be specific targets and tasks that support the achievement of the stated objectives. Goals should be evaluated to see whether they have been achieved or not. Goals should be specific, measurable, achievable, realistic and time-bound (SMART). Safety planning objectives and goals should ensure that: safety objectives have been established utilizing a safety risk profile that considers hazards and risks; objectives and goals are consistent with the safety policy and their attainment is measurable; safety objectives and goals are reviewed and updated periodically; there is a documented process to develop a set of safety goals to achieve overall safety objectives; and safety objectives and goals are documented and publicized; the organization has a process for analyzing and allocating resources for achieving their objectives and goals; Safety objectives have been established utilizing a safety risk profile that considers: of 54 AC Issue 01

18 1. Safety Management Plan 1.5 Safety Planning also confirm that the organization objectives and goals are linked. Our current objectives and goals are: Objective A: Reduce hazards and associated risks. o Goal 1: Identify a larger percentage of existing hazards annually through increased documentation of identified hazards. Objective B: Reduce occurrence-related losses. o Goal 1: Ensure documentation of occurrences. o Goal 2: Ensure risk management process has been implemented when applicable. Objective C: To prevent damage and injury to nonorganization personnel and property resulting from our operations. o Goal 1: Placement of new passenger information notices and signage in office and on ramp. o Goal 2: Standardized passenger briefings. hazards and risks; financial, operational and business requirements; views of interested parties; and industry-wide safety risk profile. SAFETY PLANNING OBJECTIVES AND GOALS The aim of establishing attainable objectives and goals is to ensure the effectiveness and continuous improvement of safety. Annually, objectives and goals will be reviewed and updated in accordance with our performance measurement and management review processes. These reviews will also confirm that the organization objectives and goals are linked. The process for establishing goals includes review of the following: business plan; results of internal audits; and occurrence and hazard reports. Our current objectives and goals are: Objective A: Reduce hazards and associated risks. o Goal 1: Receive an increased percentage (5 percent) of existing latent hazards annually through increased reporting. o Goal 2: Increase the number of occurrence reports received by 5 percent. Objective B: Continue to enhance trend monitoring and the development of effective corrective action plans of 54 AC Issue 01

19 1. Safety Management Plan 1.5 Safety Planning o Goal 1: Provide additional trend monitoring and root cause analysis training to SMS manager. o Goal 2: SMS manager will provide additional SMS training to other personnel. Objective C: To reduce losses through a reduction in the number and severity of accidents and incidents. o Goal 1: Increase the number of occurrence reports received by 5 percent. o Goal 2: Join the local aircraft maintenance engineer (AME) association. o Goal 3: Provide St. John s ambulance and fire extinguisher training to those who do not already have it of 54 AC Issue 01

20 1. Safety Management Plan 1.6 Performance Measurement and 1.7 Management Review Performance Measurement The identification of performance expectations is needed to evaluate whether or not objectives are being met, training has been effective, system failures are being repaired, and if efforts to mitigate risk are actually working, etc. An organization must decide on safety performance parameters to be measured. Identifying and measuring safety performance is a tool that can be used to assess the effectiveness of the SMS and verify continuous safety improvement progress. Management Review The purpose of management review is to evaluate how the SMS is working and assure continuous improvement in safety performance. This could be accomplished in a variety of ways, including: comparing performance with objectives and goals, and reviewing findings, incidents, audits and reports. Performance Measurement and Management Review Combined Many smaller organizations may choose to identify safety performance parameters and measure them in combination with the management review process. For example, the quality assurance audit (component 5) may be used as the basis for the safety performance measurement and management review process. Performance measurement should ensure that: there is a documented process to develop and maintain a set of performance parameters that are linked to the organization s goals and objectives; and procedures have been established and maintained to monitor and measure safety performance on a regular basis. Performance Measurement The identification of performance expectations is needed to evaluate whether or not objectives are being met, training has been effective, system failures are being repaired, and if efforts to mitigate risk are actually working, etc. An organization must decide on safety performance parameters to be measured. Identifying and measuring safety performance is a tool that can be used to assess the effectiveness of the SMS and verify continuous safety improvement progress. Management Review The purpose of management review is to evaluate how the SMS is working and assure continuous improvement in safety performance. This could be accomplished in a variety of ways, including: comparing performance with objectives and goals, reviewing findings, incidents, audits and reports, identifying trends, the risk-based allocation of resources and Emergency Response Plan updates. Performance Measurement and Management Review Combined Organizations may choose to identify safety performance parameters and measure them in combination with the management review process. For example, the quality assurance audit (component 5) may be used as the basis for the safety performance measurement and management review process. Performance measurement should ensure that: there is a documented process to develop and maintain a set of performance parameters that are linked to the organization s goals and objectives; and procedures have been established and maintained to monitor and measure safety performance on a regular basis; of 54 AC Issue 01

21 1. Safety Management Plan 1.6 Performance Measurement and 1.7 Management Review Management review should ensure that: there are periodic, planned reviews and reviews for cause of the company s safety management system to ensure its continuing adequacy and effectiveness as well as a review of company safety performance and achievement; the safety management system review includes: internal audit results; safety objective achievement results; hazards and occurrence investigation and analysis results; internal/external feedback analysis and results; status of corrective and preventive action(s); follow-up actions from previous management reviews; changes that could affect the SMS; and recommendations for improvement. there is a documented procedure defining responsibilities and requirements for planning and conducting internal audits of : management policies, controls and procedures concerning all safety critical activities; and the implementation and maintenance of SMS requirements established by the organization. there is a process to evaluate the effectiveness of corrective actions resulting from the first bullet in this list. the analysis and allocation of resources are based on outputs from the performance measurement; personnel at all levels are aware of the safety performance measures in their areas of responsibility and the results of performance measures are transmitted to them. Management review should ensure that: there are periodic, planned reviews and reviews for cause of the company s safety management system to ensure its continuing adequacy and effectiveness as well as a review of company safety performance and achievement; the safety management system review includes: internal audit results; activities to verify that employees understand the SMS and their role and responsibilities in it; safety objective achievement results; hazards and occurrence investigation and analysis results; internal/external feedback analysis and results; status of corrective and preventive action(s); follow-up actions from previous management reviews; changes that could affect the SMS; recommendations for improvement; and sharing of best practices across the organization. there is a documented procedure defining responsibilities and requirements for planning and conducting internal audits of: management policies, controls and procedures concerning all safety critical activities; and of 54 AC Issue 01

22 1. Safety Management Plan 1.6 Performance Measurement and 1.7 Management Review PERFORMANCE MEASUREMENT AND MANAGEMENT REVIEW Annually, I utilize aspects of the quality assurance self-audit to conduct my management review, measure safety performance, assess SMS effectiveness and verify continuous improvement in accordance with the following process: identifying trends; evaluating effectiveness of corrective actions; updating safety objectives and goals; monitoring and updating safety performance measures; allowing for risk-based allocation of resources; reviewing safety-critical functions; and reviewing the Emergency Response Plan. The safety performance measures for this year are: continued absence of serious injury and damage to nonorganization personnel and/or property; 50-percent reduction in minor injury and damage to nonorganization personnel and/or property; and 25-percent reduction in damage to organization property. the implementation and maintenance of SMS requirements established by the organization. there is a process to evaluate the effectiveness of corrective actions resulting from the first bullet in this list; The organization has established a structured committee or board, appropriate for the size and complexity of the organization, consisting of a full range of senior management representatives including certificated, non-certificated and third parties that review the management review report. PERFORMANCE MEASUREMENT AND MANAGEMENT REVIEW Annually, management reviews data from various sources to measure safety performance, assess SMS effectiveness and verify continuous improvement. Components of the process include: identifying trends through data analysis and information sharing; evaluating effectiveness of corrective actions; updating safety objectives and goals; monitoring and updating safety performance measures; allowing for risk-based allocation of resources; reviewing quality issues; and reviewing the Emergency Response Plan of 54 AC Issue 01

23 1. Safety Management Plan 1.6 Performance Measurement and 1.7 Management Review Minimal Complexity One-Person Operation Our safety performance measures for this year are: number of hazards identified this year vs. previous years; number of incident and accident reports received this year vs. previous years; provision of SMS training to organization personnel; reduction in minor injury and damage to non-organization personnel and/or property this year vs. previous years; and reduction in damage to organization property this year vs. previous years of 54 AC Issue 01

24 2. Documentation 2.1 Identification and Maintenance of Applicable Regulations The purpose of the identification and maintenance of applicable regulations within a SMS is to ensure the organization understands its legal responsibilities, not simply to maintain a library. Organizations currently have processes in approved documents such as the MCM, MPM or COM for the identification and maintenance of regulations. One method of addressing this issue is to reference the existing MCM, MPM or COM processes in the SMS document. Another option could include detailing the process in the SMS manual. Either of these methods will ensure that applicable regulations are identified, updated and dealt with as required. This could include other regulations such as occupational safety and health (OSH), environmental, U.S. Federal Aviation Regulations (FARs), etc. Identification and maintenance of applicable regulations should ensure that: a documented procedure has been established and maintained for identifying applicable regulatory requirements; and regulations, Standards and exemptions are periodically reviewed to ensure that the most current information is available. IDENTIFICATION AND MAINTENANCE OF APPLICABLE REGULATIONS I will review bi-annual CARs updates (via the summary) and act upon change as applicable. When received, additional safety regulations such as the Canada Labour Code, Workplace Safety and Insurance Act, 1997, and the latest revisions of manufacturer s technical information, will be reviewed and acted upon as applicable. The purpose of the identification and maintenance of applicable regulations within a SMS is to ensure the organization understands its legal responsibilities, not simply to maintain a library. Organizations currently have processes in approved documents such as the MCM, MPM or COM for the identification and maintenance of regulations. One method of addressing this issue is to reference the existing MCM, MPM or COM processes in the SMS document. Another option could include detailing the process in the SMS manual. Either of these methods will ensure that applicable regulations are identified, updated and dealt with as required. This could include other regulations such as occupational safety and health (OSH), environmental, U.S. Federal Aviation Regulations (FARs), etc. Identification and maintenance of applicable regulations should ensure that: a documented procedure has been established and maintained for identifying applicable regulatory requirements; regulations, Standards and exemptions are periodically reviewed to ensure that the most current information is available; and all pertinent technical and regulatory information is readily accessible by personnel. IDENTIFICATION AND MAINTENANCE OF APPLICABLE REGULATIONS The purpose of identifying and maintaining applicable regulations is to ensure that we understand our legal responsibilities. The person responsible for safety will ensure the following process is followed: of 54 AC Issue 01

25 2. Documentation 2.1 Identification and Maintenance of Applicable Regulations Bi-annual review of CARs and Standards (via the summary), including applicable exemptions, and act upon change as appropriate; When received, additional safety regulations, such as the Canada Labour Code and Workplace Safety and Insurance Act, 1997, will be reviewed and acted upon as applicable; and Pertinent regulatory and technical information is available to all personnel through their applicable departments of 54 AC Issue 01

26 2. Documentation 2.2 SMS Documentation and 2.3 Records Management Minimal Complexity One-Person Operation Documentation Processes should be documented to help ensure the SMS is effective and that personnel are aware of their roles, responsibilities and accountabilities. There are two types of SMS documentation: (a) the description of the policies, processes, and procedures to operate the SMS; and (b) the records or outputs from the SMS processes. The reports that are generated will be analyzed and stored as records. Records Management Records provide a historical reference and information for continuous safety improvement. They can detail such things as: (a) occurrences and hazards; (b) risk assessment and root cause analysis; (c) training; (d) corrective and preventative actions; (e) trend monitoring; (f) performance measurement; and (g) goals and objectives. Documentation and Records Management Combined In many small organizations, maintaining documents and records are so closely linked that they are parts of the same process. SMS documentation should ensure that: there is controlled documentation that describes the SMS and the interrelationship between all of its elements; Documentation Processes should be documented to help ensure the SMS is effective and that personnel are aware of their roles, responsibilities and accountabilities. There are two types of SMS documentation: (a) the description of the policies, processes, and procedures to operate the SMS; and (b) the records or outputs from the SMS processes. The reports that are generated will be analyzed and stored as records. Records Management Records provide a historical reference and information for continuous safety improvement. They can detail such things as: (a) occurrences and hazards; (b) risk assessment and root cause analysis; (c) training; (d) corrective and preventative actions; (e) trend monitoring; (f) performance measurement; and (g) goals and objectives. Documentation and Records Management Combined In many small organizations, maintaining documents and records are so closely linked that they are parts of the same process. SMS documentation should ensure that: there is controlled documentation that describes the SMS and the interrelationship between all of its elements; of 54 AC Issue 01

27 2. Documentation 2.2 SMS Documentation and 2.3 Records Management Minimal Complexity One-Person Operation there is a process to periodically review SMS documentation to ensure its continuing suitability, adequacy and effectiveness, and that changes to company documentation have been implemented; and the organization has a process to identify changes within the organization that could affect company documentation. Records management should ensure that: the organization has a records system that ensures the generation and retention of all records necessary to document and support the SMS; and the system shall provide the control processes necessary to ensure appropriate identification, legibility, storage, protection, archiving, retrieval, retention time, and disposition of records. SMS DOCUMENTATION AND RECORDS MANAGEMENT I maintain two types of SMS documents: description of SMS policies, processes, and procedures; and records or outputs from these processes. The following policy, process and procedure documents are kept in an easily-accessible location and are updated as required: SMS manual; maintenance control manual; and company operations manual. documentation is readily accessible to all personnel; there is a process to periodically review SMS documentation to ensure its continuing suitability, adequacy and effectiveness, and that changes to company documentation have been implemented; there are acceptable means of documentation, including but not limited to, organizational charts, job descriptions and other descriptive written material that defines and clearly delineates the system of authority and responsibility within the organization for ensuring safe operation; and the organization has a process to identify changes within the organization that could affect company documentation. Records management should ensure that: the organization has a records system that ensures the generation and retention of all records necessary to document and support the SMS; and the system shall provide the control processes necessary to ensure appropriate identification, legibility, storage, protection, archiving, retrieval, retention time, and disposition of records. SMS DOCUMENTATION AND RECORDS MANAGEMENT By documenting and managing associated records, we ensure all personnel remain informed and involved with our SMS. The person responsible for the SMS maintains two types of SMS documents and records: description of SMS policies, processes, and procedures; and records or outputs from these processes of 54 AC Issue 01