Implementing Safety

1
Implementing Safety Management Systems The
Canadian Perspective
2
Agenda

• SMS - the Canadian Model
• Lessons Learned 1-10
• There are many more!
• Questions

3
What is SMS?

• The Definition (CAR 101.01)
• Safety management system means a documented
  process for managing risks that integrates
  operations and technical systems to ensure
  aviation safety or the safety of the public
• In practice what does this actually mean?

4
Transport CanadasSMS Components Elements

• 1. Safety Management Plan
• Safety Policy
• Non-punitive Safety Reporting Policy
• Roles, Responsibilities Employee Involvement
• Communication
• Safety Planning, Objectives Goals
• Performance Measurement
• Management Review

• 2. Document Management
• Identification Maintenance of Applicable
  Regulations
• SMS Documentation
• Records Management

• 3. Safety Oversight
• Reactive Processes
• Proactive Processes
• Investigation and Analysis
• Risk Management

4. Training
5. Quality Assurance
6. Emergency Preparedness
5
SMS COMPONENTS

• Safety Management Plan
• Documentation
• Safety Oversight
• Training
• Quality Assurance
• Emergency Response Plan

6
COMPONENT 1 SMS Plan

• The Safety Management Plan should include
• Company safety policy
• Roles and responsibilities
• Description of safety management system processes
• Safety performance targets
• Management review

7
COMPONENT 2 - Documentation

• Processes for
• Identifying applicable aviation safety
  regulations, including standards and exemptions,
  and where required, procedures for demonstrating
  compliance with them
• Implementing changes to company documentation as
  required due to amendments to aviation safety
  regulations, standards and exemptions.

8
COMPONENT 2 - Documentation

• Consolidated documentation describing the systems
  for each component of the safety management
  system
• Maintenance of current applicable and
• Maintenance of effective documentation.
• Note Documentation includes all types of
  printed material including manuals, bulletins
  and safety reports.

9
COMPONENT 3 Safety Oversight

• Subcomponents of Safety Oversight are
• Reactive processes of occurrence/ hazard
  reporting and event investigation and analysis
• Proactive safety assessments and
• Common elements to both reactive and proactive
  processes.

10
COMPONENT 3 Safety Oversight

• Reactive Processes
• Occurrence/hazard reporting and
• Event investigation and analysis
• Proactive Processes
• Hazard Identification
• Hazard Register
• Safety Risk Profile
• Safety Case

11
COMPONENT 4 Training

• Training for SMS should be commensurate with the
  individuals function in the System and might
  include
• Investigation and analysis techniques
• Human and organizational factors
• Business processes
• Reporting techniques
• Auditing Techniques
• LOSA/FOQA

12
COMPONENT 5 Quality Assurance

• An effective QA system should encompass
• Well designed and documented procedures for
  product and process control
• Inspection and testing methods
• Internal and external audits, as applicable
• Corrective and preventive action and,
• The use of appropriate statistical analysis, when
  required.

13
COMPONENT 6 Emergency Response Preparedness

• Emergency planning should aim where possible to
  prepare an organization in the event that an
  emergency situation occurs.
• This preparation should through good planning,
  reduce, control or mitigate the effects of the
  emergency.
• The ERP should
• be monitored and changed as the operation changes
• be subject to regular exercises
• address all interested parties

14
Safety Management System Process Flow

• (REACTIVE)
• REPORTS
• Hazards
• Incidents
• Accidents
• Data base
• Risk Analyses
• (PRO-ACTIVE)
• SAFETY ASSESSMENT
• Audits
• Policy and Procedures Assessment
• Hazard Identification

Initial Risk Assessment
Database

• Information
• Dissemi-
• nation
• Trend analysis
• Safety bulletins
• Report distribution

No Action
Further Investigation
Second Risk Assessment
No Action
Determine Contributing Factors
Determine and Implement Corrective Action
Monitor Corrective Action
Correct
Confirmation of Corrective Action Quality
Assurance
System Evaluation
15
The CARs vs ICAO Requirements

• 1. Safety Management Plan
• Safety Policy
• Non-punitive Safety Reporting Policy
• Roles, Responsibilities Employee Involvement
• Communication
• Safety Planning, Objectives Goals
• Performance Measurement
• Management Review
• 2. Document Management
• Identification Maintenance of Applicable
  Regulations
• SMS Documentation
• Records Management
• 3. Safety Oversight
• Reactive Processes
• Proactive Processes
• Investigation and Analysis
• Risk Management
• 4. Training
• 5. Quality Assurance

• PLAN Safety Policy and objectives
• Management commitment and responsibility
• Safety accountability of managers
• Appointment of key personnel
• SMS implementation plan
• PLAN Safety Assurance -
• Safety performance and measurement
• Management of change
• PLAN Safety Promotion - safety communication
• DOCUMENTATION -Documentation
• SAFETY OVERSIGHT
• Safety Hazard Identification Risk Management
• Hazard identification process
• Risk assessment and mitigation
• Internal safety investigation
• TRAINING Safety Promotion - Training and
  Education
• QUALITY ASSURANCE Safety Assurance - Audits and
  surveys
• Safety performance measurement

15
16
What Have weve learned (as a regulator) about
SMS Implementation?
17
1. - Implementing SMS

• Draft the (a) regulations and appropriate (b)
  standards
• Consult with the industry on (a) and (b)
• Get the industry involved from the outset

18
Effectivity Regulatory Requirement

• Effective May 31, 2005, Large Air Carriers and
  their Approved Maintenance Organizations were
  required to implement Safety Management Systems
• Effective January 2, 2008 Large international
  airports were required to implement Safety
  Management Systems
• An exemption was issued to enable structured,
  phased in, implementation

19
Why a phased in approach to SMS?

• Issuance of regulatory exemption to the CARs
• Provides a manageable series of steps for
  organizations to follow.
• Four implementation phases were identified each
  phase involves the introduction of specific SMS
  components and elements.
• Provides for continuous improvement through
  lessons learned

20
Common Problems

• In many cases the procedures supporting the
  policies are weak or non existent.
• Training is weak. Organizations do not have a
  plan or syllabus for SMS training.
• Management review is weak. Everyone says they
  will do a management review on a regular
  schedule, but they do not have any details on how
  this will be done.
• Investigation and Analysis generally do not have
  any detail on how to conduct these processes.
• On a positive note... Risk Management is strong.
  Organizations seem to have a good understanding
  of the requirements and have good procedures
  documented.

21
Regulations should define the Accountability
Framework

• The Accountable Executive
• The Person Responsible for Maintenance
• The Director of Flight Operations
• The Person Responsible for the SMS

22
Transport Canadas Philosophy
A three layered approach
Accountability- responsibility upper management
Accountable Executive
Safety Management System
Systemic Approach to Safety
23
The Accountable Executive

• "Accountable executive" means the person having
  financial and executive control over an entity
  that is subject to these regulations.
• The accountable executive is the certificate
  holder or the certificate holders
  representative.
• Single executive for all certificates held by
  organization (AOC, FTU, AMO, AEO, ATO etc..).

24
Safety responsibilities An example
Source ICAO
25
2. Implementing SMS

• 2. Organizations need to develop the
  implementation/project plan (ask yourself)
• What?
• who?
• Why? (performance targets)
• When?
• Where?

26
3. Implementing SMS

• 3. Develop your guidance material you need to
  assist in the interpretation and implementation
  of SMS
• SI-001 Safety Management Systems for Flight
  Operations And Aircraft Maintenance Organizations
  - A Guide to Implementation
• Safety Management Systems for Design
  Organizations
• Safety Management Systems for Small Aviation
  Operations A Practical Guide to Implementation
• Introduction to Safety Management Systems TP
  1373
• Continuously improve the material

27
4. Implementing SMS

• 4. Develop your communication plan
• Communicate with stakeholders on SMS
• Outreach programs, Information sessions
• seminars, conferences,
• group meetings
• Publications/website. Advertise what you hope to
  achieve with SMS
• Inform the industry
• Consult on the regulations
• Talk about your implementation plan

28
5. Implementing SMS

• 5. Develop and apply your SMS training for
  inspectors
• Initial what knowledge do I need to provide to
  the inspectorate in order to do their jobs?
• Recurrent what are the additional skills
  required
• Who to train?
• Over 900 inspectors trained in Canada so far.

29
6. Implementing SMS

• 6. Measure where you are with your safety
  culture
• Internal measurement to determine where you are
  with your safety culture
• Develop tools to measure culture in the industry
  On-going monitoring of indicators to determine if
  the behaviours show you are moving in the right
  direction
• Its all about culture - Change the way you do
  things before you implement the infrastructure

30
7. Implementing SMS

• 7. Work in partnership with the industry on SMS
  implementation pilot projects

31
Working with the Industry on SMS Implementation

• Headquarters participation in implementation
  teams with the major airlines
• Air Canada
• WestJet
• Skyservice
• Air Transat
• Etc.
• Adjust your program to meet the reality of the
  industry
• You need industry champions who speak from
  experience and support the SMS vision (Dilollo,
  Ramkay, Plottel)

32
Small Operators Working Group

• What did we learn? We learned one size does not
  fit all
• A component of TCCAs continuous improvement
  approach to SMS. 
• Invitation sent to CARAC Technical Committee
  members in January 2005 to identify volunteers
  for the project.

33
Executive Summary

• Results from the project indicate that Safety
  Management Systems can be successfully
  implemented in, and become a positive addition
  to, small operations. However, the
  industry/Transport Canada project team identified
  the need to continue to develop and/or update
  infrastructure in the following areas
• implementation procedures
• guidance material
• data management, and
• training

34
(No Transcript)
35
SMS Guidance Material For Small Operators
Guidance for CAR 107.04 - A safety
management system shall correspond to the size,
nature and complexity of the operations,
activities, hazards and risks associated with the
operations Describes examples of acceptable
means, but not the only means, of demonstrating
compliance with regulations and standards.
Does not change, create, amend or permit
deviations from regulatory requirements nor does
it establish minimum standards.
36
Examples
37
Examples
38
8. Implementing SMS

• 8. Develop documentation in support of your SMS
• Implementation procedures
• Exemptions
• Enforcement policy

39
SMS Enforcement Policy Objectives

• We learned we needed internal change
• To promote the effective use of SMS
• To promote voluntary compliance with regulatory
  requirements, without necessarily resorting to
  punitive action and
• To nurture and sustain a safety culture, whereby
  employees can confidentially report safety
  deficiencies without fear of subsequent punitive
  action.

40
SMS Enforcement Policy General Statement

• The Civil Aviation Enforcement policy remains
• the same in that intentional contraventions of
  the
• Aeronautics Act and the Canadian
• Aviation Regulations will still be investigated.

41
SMS Enforcement Policy Pith Substance

• No punitive action will be taken against a
  certificate holder governed by an SMS, if

• The contravention appears to have been
  unintentional and
• The certificate holder is proposing corrective
  measures that are likely to address the event and
  prevent recurrence.

42
9. Implementing SMS

• 9. Define your SMS oversight program and develop
  tools to be used

43
Audits versus Assessment

• Past (Audit)
• Auditing to the procedures
• Focus is on records review
• Oriented mainly towards conformity to standard
• Documentation reflects front line employees and
  middle management

• Future (Assessment)
• Assessment of the processes
• Balances manual review, on-site interviews,
  observations and records review
• More oriented towards outputs and outcomes
• Documentation reflects more involvement with
  senior management

44
Example TC Protocol

• Typical protocol expectations include
• CARS TC standards
• Industry guidelines standards
• Permits approvals
• SMS expectations as defined in TP13881 E
• Generally accepted safety management practices

The CARS plus more!!!
45
Example of Assessment Criteria

• Assessment level 3 defines the minimum
  requirements for the SMS to meet the CARS and TC
  standards

46
10. Implementing SMS

• 10. Review other legislative requirements to
  determine if changes are required or conflicts
  exist e.g. the Aeronautics Act, OSH,
  Environmental requirements

47
Principle Messages

• Develop you regulatory framework with the
  industry. This may involve changing the way you
  do business.
• Produce and continuously improve guidance
  material at all stages of implementation
  Communication is key!
• Determine if your existing oversight framework is
  adequate to assess the SMS.
• Manage the transition this may involve resource
  allocations and changes in the traditional
  approach to safety oversight.

48
Questions?

• www.icao.int/anb/safetymanagement
• www.tc.gc.ca/CivilAviation/SMS/menu.htm