Aviation Training, Safety Management System

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SAMPLE
SAMPLE Recurrent Training
Safety Management
System (SMS)

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Unit 1
Review of Basic Safety
Concepts
Safety Management
System (SMS)

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Introduction
This course will help participants and organizations understand the
function, role and importance of developing and implementing
a Safety Management System (SMS).
• Location: Classroom course
• Duration: 1 days (7 hours)
• Recommended level: All
• Prerequisites: Completion of Initial SMS
• All Staff inclusive of operational personnel, management and the
Accountable Manager, shall attend recurrent training once every 12
months.

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Course Content
All Staff inclusive of operational personnel, management and the
Accountable Manager, shall attend recurrent training once every 12
months. The recurrent syllabus includes:
Unit 1 - Review of Basic Safety Concepts
Unit 2 - Update on Safety Reporting and Revised Procedures
Unit 3 - Review of Safety Risk Management
Unit 4 - Update of Safety Processes:
Unit 5 - Review of Company Safety Management
Unit 6 - Review of Safety Reporting

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Unit 1
Review of Basic Safety
Concepts
Safety Concepts
Safety Management
System (SMS)

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Unit Content
Review of Basic Safety Concepts:
• The concept of Safety
• Accident causation-the organizational accident
• People, context and safety – the SHELL Model
• Errors and violations
• Organizational culture / (Just Culture/Non-Punitive
Reporting)
• Definitions of Safety & SMS

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Basic Safety Concepts
Safety Explained
“The state in which the possibility of harm to persons or of
property damage is reduced to, and maintained at or below,
an acceptable level through a continuing process of hazard
identification and safety risk management.”
• There is no such thing as absolute safety!
• In aviation it is not possible to eliminate all risk.
• Risks can only be managed to a level
“As Low as Reasonably Practicable” (ALARP)

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Evolution of Aviation Safety
Undesired
cabin state
Accidents
Fragile System (1920’s to 1970’s)
• Individual risk management & intensive training
• Accident investigation
Safe System (1970’s to 1990’s)
• Technology & regulations
• Incident investigation
Ultra-Safe System (Mid1990’s onwards)
• Business management approach to
safety (SMS)
• Routine collection & analysis of
operational data
Less that one catastrophic
breakdown per million
production cycles
10
10
10-6
-5
-3

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The Evolution of Safety Thinking
Technical Factors
Human Factors
Organizational factors
TODAY
1950’s 1970’s 1990’s 2000’s

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The Essential is Invisible to the
Eyes
Number of Occurrences
1 – 5
30 – 100
100 – 1000
1000 – 4000 Latent conditions
Incidents
Serious incidents
Accidents

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Failures
The distinction between active and latent failures can be
summarized as follows:
Active failures - are the result of unsafe acts (errors and violations)
committed by those at the "sharp end" of the system (pilots, air traffic
controllers, AMTs, etc.). They are the people at the human-system
interface whose actions can, and sometime do, have immediate
adverse consequences.
Latent failures - are created as the result of decisions, taken at the
higher echelons of the organization. Their damaging consequences
may lie dormant for a long time, only becoming evident when they
combine with local triggering factors (e.g., errors, violations and local
conditions) to breach the system's defenses.

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ALARP
As Low as is Reasonably Practical:
• We know that as long as there are hazards, it is impossible to
eliminate risk. Therefore, we strive to systematically manage or
reduce risks to an acceptable level. The acronym “ALARP” is used to
describe a risk that has been reduced to a level that is as low as
reasonably practical.
• A determination that a risk is as low as reasonably practical means
that any further risk reduction is either technically impractical or
significantly outweighed by costs. A cost-benefit study is needed to
determine this!

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As Low as is Reasonably Practical
Unacceptabl
e Region
Tolerable
Region
Acceptable
Region
Negligible Risk
Technical Feasibility
Cost

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Accident Causation
The Swiss Cheese model of accident causation is a model used in risk
analysis and risk management, including aviation, engineering,
healthcare, and as the principle behind layered security, as used in
computer security and defence in depth.
It likens human systems to multiple slices of Swiss cheese, stacked side
by side, in which the risk of a threat becoming a reality is mitigated by the
differing layers and types of defences which are "layered" behind each
other.
Therefore in theory, lapses and weaknesses in one defence do not allow a
risk to materialize, since other defences also exist, to prevent a single
point of weakness. The model was originally formally propounded by
Dante Orlandella and James T. Reason of the University of Manchester,
and has since gained widespread acceptance.
It is sometimes called the cumulative act effect.

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Human Factors
James Reason’s model -
The Reason model of accident causation a useful framework to use when
considering human factors issues
Organizational Problems:
• Learning from warnings
• Refresher training
• Fatigue management
Local Problems:
• Procedures
• Refresher training
• Tools & equipment
• Skills & experience
• Communication
Unsafe Acts:
• Memory lapses
• Work a rounds
• Situational awareness
• Expertize errors
• Action slips
Safeguards:
• Error tolerance
• Error capture
Hazards

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Accident Prevention
Technica
l
Organizational People
Controls
Leadersh
ip
Vigilance
Resilience
Empowerment
& Accountability

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Mistakes Lapses Slips
When the
person does
what they
meant to, but
should have
done something
else
When the
person forgets
to do
something
When the
person does
something, but
not what they
meant to do
Human Failures
Unintended actions
Intended actions
Errors - Unintended consequences
When the person decided to act
without complying with a known rule
or procedure
Violation - Intended consequences
Human Failure Taxonomy

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ICAO SHELL Model
H L L
S
E
(E) Environment: Operating
circumstances in which the rest of
the L-H-S system must function
(H) Hardware:
Machines & equipment
(S) Software:
Procedures, training
& support
(L) Live ware:
Humans in the
workspace
SHEL(L) Model
Human interfaces with other
components

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Human Error Types
Definition
• Errors are the result of actions that fail to generate the
intended outcomes. They are categorized according to
the cognitive processes involved towards the goal of the
action and according to whether they are related to
planning or execution of the activity.

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Human Error Types
Description
Actions by human operators can fail to achieve their goal in
two different ways:
• The actions can go as planned, but the plan can be
inadequate, or the plan can be satisfactory, but the
performance can still be deficient (Hollnagel, 1993).
• Errors can be broadly distinguished in two categories:
1
2

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Slip, Lapse, Mistake & Violations
Unintended
Action
Slip
Performance
Management Process
Attention failure when
actions are largely
automatic
Violation
Lapse
Mistake
Intended
Action
Typically memory
related
Rule based mistake
Knowledge based
mistake
Routine
Exceptional
Deliberate
Discipline Process
Human Action
Error
Types
Management Process

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Human Error Types
Description
Actions by human operators can fail to achieve their goal in
two different ways:
• The actions can go as planned, but the plan can be
inadequate, or the plan can be satisfactory, but the
performance can still be deficient (Hollnagel, 1993).
• Errors can be broadly distinguished in two categories:
1
2

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Errors
• Skill-Based Errors: Errors which occur in the operator’s execution
of a routine, highly practiced task relating to procedure, training or
proficiency and result in an unsafe a situation (e.g., fail to prioritize
attention, checklist error, negative habit).
• Decision Errors: Errors which occur when the behaviours or actions
of the operators proceed as intended yet the chosen plan proves
inadequate to achieve the desired end-state and results in an
unsafe situation (e.g. exceeded ability, rule-based error,
inappropriate procedure).
• Perceptual Errors: Errors which occur when an operator's sensory
input is degraded and a decision is made based upon faulty
information.
1
2
3

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Violations
• Routine Violations: Violations which are a habitual action on the
part of the operator and are tolerated by the governing authority.
• Exceptional Violations: Violations which are an isolated departure
from authority, neither typical of the individual nor condoned by
management.
1
2

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HFACS Level 2
Preconditions for Unsafe Acts:
• The Preconditions for Unsafe Acts level is divided into three
categories - Environmental Factors, Condition of Operators, And
Personnel Factors - and these three categories are then divided
into subcategories.
• Environmental factors refer to the physical and technological
factors that affect practices, conditions and actions of individual
and result in human error or an unsafe situation.
1
2

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Environmental Factors
• Physical Environment: Refers to factors that include both the
operational setting (e.g., weather, altitude, terrain) and the
ambient environment (e.g., heat, vibration, lighting, toxins).
• Technological Environment: Refers to factors that include a
variety of design and automation issues including the design of
equipment and controls, display/interface characteristics,
checklist layouts, task factors and automation.
1
2

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Condition of Operators
• Adverse Mental State: Refers to factors that include those mental
conditions that affect performance (e.g., stress, mental fatigue,
motivation).
• Adverse Physiological State: Refers to factors that include those
medical or physiological conditions that affect performance (e.g.
medical illness, physical fatigue, hypoxia).
• Physical/Mental Limitation: Refers to when an operator lacks the
physical or mental capabilities to cope with a situation, and this
affects performance (e.g. visual limitations, insufficient reaction
time).
1
2
3

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Personnel Factors
• Crew Resource Management: Refers to factors that include
communication, coordination, planning, and teamwork issues.
• Personal Readiness: Refers to off-duty activities required to
perform optimally on the job such as adhering to crew rest
requirements, alcohol restrictions, and other off-duty mandates.
1
2

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HFACS Level 3
Unsafe Supervision:
The Unsafe Supervision level is divided into four categories:
• Inadequate Supervision: The role of any supervisor is to provide
their staff with the opportunity to succeed, and they must provide
guidance, training, leadership, oversight, or incentives to ensure
the task is performed safely and efficiently.
• Plan Inappropriate Operation: Refers to those operations that can
be acceptable and different during emergencies, but unacceptable
during normal operation (e.g., risk management, crew pairing,
operational tempo).
1
2

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HFACS Model
• Fail to Correct Known Problem: Refers to those instances when
deficiencies are known to the supervisor, yet are allowed to
continue unabated (e.g. report unsafe tendencies, initiate
corrective action, correct a safety hazard).
• Supervisory Violation: Refers to those instances when existing
rules and regulations are wilfully disregarded by supervisors (e.g.
enforcement of rules and regulations, authorized unnecessary
hazard, inadequate documentation).
3
4

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Slip, Lapse or Mistake?
Involuntaryor non-
intentional action
Was there prior
intention to act?
Did the actions
proceed as
planned?
Did the actions
achieve their
desired end?
Successful action
Was there
intention in the
action?
Spontaneous or
subsidiary action
Unintentional
action (slip or lapse)
Intentional but
mistaken action
Yes
Yes
Yes
Yes
No
No
No
No
Human
Action

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Safety Culture?
Safety culture is the set of enduring values and attitudes regarding
safety issues, shared by every member at every level of an
organization.
Refers to the extent to which every individual of the organization is
aware of the risks and unknown (?) hazards induced by their activities
Objective: Raising and maintaining the level of awareness
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Safety Culture
• A construct
• An outcome, not a process
• The introduction of “Safety Management” concepts lays the
foundation upon which to build a safety culture
• Safety culture cannot be “Mandated” or Designed”, it
evolves.
• It is generated “Top-down”
1
2
3
4
5

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Safety Culture
National Culture - recognizes and identifies the national
characteristics and value systems of particular nations
Professional Culture - recognizes and identifies the behaviour and
characteristics of particular professional groups (e.g. the typical
behaviour of pilots vis-à-vis that of ATCOs or AMEs)
Organizational Culture - recognizes and identifies the behaviour
and values of particular organizations (e.g. the behaviour of members
of one company versus that of another company, or government
versus private sector behaviour).

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Organizational Safety Culture
SAFETY
CULTURE
Cooperation &
coordination between
team members (within
and across a team)
People are willing to report
occurrences, without fear of being
blamed and the organization
having the will and capability to
learn from safety occurrences
Vertical & horizontal channels are
efficient, and people have faith in the
processes, their peers and managers
The priority to safety in
organizational planning and day to
day operations, both at the
management and operational levels
Acceptance at the
organizational and
individual levels of the
responsibility for safety
Corporation & Employees &
Managers participate in
safety discussions, activities
and improvements
Commitment
Responsibility
Involvement
Communication
&
Trust
Just reporting
&
Learning
Teamwork

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Indications of a Positive Safety Culture
A positive safety culture demonstrates the following
attributes:
• Senior management places strong emphasis on safety as part of
the strategy of controlling risks (i.e. minimizing losses).
• Decision-makers and operational personnel hold a realistic view of
the short- and long-term hazards involved in the organization’s
activities.

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Positive Safety Culture
Positive
Culture
Flexible Culture
People can adapt
organizational processes
when facing high temporary
operations or certain kinds of
danger, shifting from the
conventional hierarchical
mode to a flatter mode.
Learning Culture
People have the willingness
and the competence to draw
conclusions from safety
information systems and the
will to implement major
reforms.
Informed Culture
People are knowledgeable about the human, technical,
organizational and environmental factors that determine the
safety of the system as a whole.
Reporting Culture
People are prepared to
report their errors and
experiences
Just Culture
People are encouraged (even rewarded) for providing
essential safety-related information. However, there is a
clear line that differentiates between acceptable and
unacceptable behaviour.

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Safety Culture Differences
Poor Bureaucratic Positive
Hazardous information
is:
Suppressed Ignored Actively sought
Safety messengers are: Discouraged
or punished
Tolerated Trained &
encouraged
Responsibility for
safety is:
Avoided Fragmented Shared
Dissemination of
safety information is:
Discouraged Allowed but discouraged Rewarded
Failures lead to: Cover – ups Local fixes Inquiries &
systematic reform
New ideas are: Crushed Considered as new
problems (not
opportunities)
Welcomed
Safety Culture
Characteristics

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Positive Safety Cultures are
Typically
Informed Cultures - Management fosters a culture where people
understand the hazards and risks inherent in their areas of operation.
Learning Cultures - Learning is seen as more than a requirement
for initial skills training; rather it is valued as a lifetime process.
Reporting Cultures - Managers and operational personnel freely
share critical safety information without the threat of punitive action.
Just Cultures - While a non-punitive environment is fundamental
for a good reporting culture, the workforce must know and agree on
what is acceptable and what is unacceptable behaviour.

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Proactive Approach
Each State or each service provider has to:
• Collect safety-related data and analyse them;
• Set up key safety indicators reflecting its activities;
• Define and target objectives;
• Monitor the system in place by evaluating the overall performance
of the system;
• Improve or maintain its safety performance;
• Eventually allocate the most-effective resources to meet these
objectives.
This is called the “proactive approach”.
In addition, the State will oversee the Safety Performance Indicators
(SPIs) of the services providers and share data.
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Definitions of Safety & SMS
State:
• Development/absence of primary aviation legislation or operating regulations
• Level of regulatory compliance – Lack of Effective Implementation (LEI – USOAP
ICAO indicator)
• Does the audit programme cover all activities?
State and Organisation:
• Incident rate or incidents reported
• Number of deviations to the SOPs (Standard Operating Procedures)
Organisation:
• Measurement of safety culture in an organisation or open climate in an
organisation for reporting
• MTBF for maintenance (Aircraft, ANS and Aerodrome)
• Dispatch or stabilized approaches (operations)…
• Deviations to the flight path or separation (Air Navigation Services)
• Bird strikes (Aerodrome)

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Definitions of Safety & SMS
Safety Assurance is based on effective safety data-driven processes
but not being entirely data-driven
Collecting information in an organized and standardized manner;
sharing and protecting information
Setting the right Key Safety Indicators (moving from concept towards
implementable / practical KSI’s)
Managing Properly (safety trends and effective decision making);
Collaboration between States and Service Providers (KSI’s)
Compliance with the rules remains a must
Develop performance-based oversight and performance – based rules
Enhancement of regional agencies (RSOO’s – oversight and RAIO’s –
Accident, incidents), eliminating duplication of efforts, fostering
cooperation (sharing information - databases) and independency

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Safety Management System (SMS)
Safety
Management
System
Organizational
Components
Senior management
Commitment
Policy &
Objectives
Organization for
Safety, Accident
Prevention Advisor
Structure, Safety
Committee
Risk
Management
Hazard Identification
Systems
Investigation
Capabilities
Safety Analysis
Capabilities
Safety Promotion
Training & Education
Safety Information
Management
Safety Oversight &
Programme
Evaluation

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Definition of a Safety (SMS) Program?
An integrated set of regulations and activities aimed at
improving safety.
States are responsible for establishing a Safety Programme:
o Safety Regulation
o Safety Oversight
o Accident/Incident Investigation
o Mandatory/Voluntary Reporting Systems
o Safety Data Analysis And Exchange
o Safety Assurance
o Safety Promotion
1
2
3
7
4
5
6

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Safety Management System
The operator shall implement a safety management
system acceptable to the Authority that is based on the
ICAO Doc 9859 Safety Management Manual:
a. Identifies safety hazards and assesses, controls and mitigates risks;
b. Ensures the implementation of remedial actions necessary to
maintain the agreed safety performance;
c. Provides for continuous monitoring and regular assessment of the
safety performance achieved; and
d. Aims to make continuous improvement to the overall safety
performance of the safety management system; and
e. Quality management system and emergency response planning

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Unit 2
Update on Safety Reporting
and Revised Procedures
Safety Management
System (SMS)
Reporting

Unit Content
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Update on Safety Reporting and Revised Procedures:
• Hazards
• Importance of reporting hazards and incidents
• Procedures of reporting hazards
• Types of Hazard Reporting forms (Mandatory Reports, Incident
Reports, Hazard Reports)
• Specific Safety Initiatives (e.g. FDMP/CRM) if applicable

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Management
Team Training
Procedure
Training /Environment, Device, Material
Physical & Physiological Circumstances
Actions, Readiness to Assume Risk
Organization Process
Active Failure
Hazards
Hazards

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Importance of Reporting Hazards & Incidents
Experience in other industries and lessons learned from the
investigation of aircraft accidents have emphasized the importance
of managing safety in a systematic, proactive and explicit manner:
• Systematic means that safety management activities will be conducted in
accordance with a predetermined plan and applied in a consistent
manner throughout the organization.
• Proactive means the adoption of an approach which emphasizes
prevention through the identification of hazards and the introduction of
risk mitigation measures before the risk-bearing event occurs and
adversely affects safety performance.
• Explicit means that all safety management activities should be
documented, visible and performed independently from other
management activities.

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Description of Roles
Accountable
Executive
Senior
Management
Managers &
Supervisors
Operational
Personnel
Manager CRM
Manager SEP
Fleet Chief
Supervisors
Post Holder
Training
Post Holder
Flight OPS
Manager Cabin
Flight
Crew
Cabin
Crew
Dispatch
Staff
Ground
Personnel
Maintenance
Staff
Safety Responsibilities
Station Manager Part 145/CAME
Post Holder
Maintenance
Post Holder
Ground OPS
Accountable Manager

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Reporting Hazards
Hazards exist at all levels in the organization and are
detectable through use of reporting systems, inspections or
audits. Mishaps may occur when hazards interact with
certain triggering factors. As a result, hazards should be
identified before they lead to accidents, incidents or other
safety-related occurrences.
The most important mechanism for hazard identification is
a voluntary hazard/incident reporting system.
Company’s Safety Reporting and Non- Punitive Reporting
Policy provide guidance on the methods of reporting safety
hazards, incidents and accidents within a Just Culture
System.

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Why is it Important to Report?
• Effective safety reporting is the cornerstone of SMS.
• Once reported, data on hazards is turned into safety
information.
• Effective safety reporting is therefore the Gate for Safety
Data Acquisition.

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About the reporting system…
It must:
• Be voluntary;
• Be anonymous;
• Identify the hazards and better understand the latent failures
• Should not lead to any blaming except in the case of malicious act
or gross negligence (this is called “just culture”)
• Be supported by a statement / commitment of the accountable
manager (no blaming)
Just culture (definition): an atmosphere of trust in which people are
encouraged for providing essential safety-related information, but in
which they are also clear about where the line must be drawn
between acceptable and unacceptable behavior.

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Mandatory Reporting
ICAO requires that States establish a mandatory incident reporting
system to facilitate the collection of information on actual or potential
safety deficiencies. In addition, States are encouraged to establish a
voluntary incident reporting system and adjust their laws, regulations
and policies so that the voluntary programme:
• Facilitates the collection of information that may not be captured
by a mandatory incident reporting system;
• Is non-punitive; and
• Affords protection to the sources of the information
a
b
c

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• MANDATORY - Reports
• People are required to report certain types of incidents. This
necessitates detailed regulations outlining who shall report
and what shall be reported.
• VOLUNTARY - Reports
• The reporter, without any legal or administrative
requirement to do so, submits a voluntary incident report.
• CONFIDENTIAL - Reports
• Confidential reporting systems aim to protect the identity of
the reporter. They allow for the disclosure of human errors,
without fear of retribution or embarrassment, and enable
others to learn from previous mistakes.
The 3 types of Reporting Systems
1
2
3

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Hazards and incidents should be reported if it is believed
that:
• Something can be done to improve safety;
• Other aviation personnel could learn from the report;
• The system and its inherent defenses did not work as expected.
If in doubt as to an event’s significance, it should be reported.
Some events or incidents are required to be reported in accordance
with state laws or regulations (Mandatory Occurrence reports).
What Shall be Reported?
1
2
3

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Share your experience:
Beyond the obligation of reporting accidents, incidents and
reportable occurrences, all staff shall also contribute to the “share
your experience” concept and report all events which could effect
safety or the quality of the operation.
What Shall be Reported?

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Mandatory Reports
All occurrences which must be reported mandatorily are defined in
the different manuals of the operator:
• Personnel involved in Operations > OM Part A
• Personnel involved in Maintenance > GMM
Example: Bird strike, TCAS
What are Mandatory Reports?
1

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Voluntary Reports
In order to implement an effective SMS in your organization every
occurrence which might have and influence on safety should be
reported.
Example: Recommendations concerning SOP’s
What are Voluntary Reports?
2

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Confidential Reports
Confidential reporting systems aim to protect the identity of the
reporter.
Confidentiality is usually achieved by :
• De-identification (of the reporter) and
• Any identifying information about the reporter is known
only to “gatekeepers” in order to allow for follow-up in the
reported event(s).
Confidential Reporting facilitates the disclosure of hazards
leading to human error, without fear of punishment or
embarrassment and enable wide acquisition of information
related to hazards.
What are Confidential Reports?
3

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What is the Safety Reporting
Policy?
• A written statement that ensures and encourages all
employees to report occurrences without fear of
punishment from the organization.
• A policy signed by the accountable executive, describing
under which circumstances an employee may be
disciplined.

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Safety Reporting
• Verbally / Phone call: to Supervisor or Safety
Representative,
• Written Safety Report: to Safety and Security or,
• Email:
• Anonymous reporting: on URL
• Physical box
• Reporting hotline:
1
2
3
4
5
6

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Hazard Identification
Methodologies
The three Company methodologies for identifying hazards
are:
Reactive Method
The Reactive Method
responds to the events
that already happened,
such as incidents and
accidents
Proactive Method
The Proactive Method
looks actively for
identification of safety
risks through the analysis
of Company’s activities
Predictive Method
The Predictive Method
captures system
performance as it happens
in real-time normal
operations to identify
potential future problems
1
2
3

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Unit 3
Review of Safety Risk
Management
Safety Management
System (SMS)
Safety Risk
Management

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Review of Safety Risk Management:
• What is a Hazard?
• Hazard identification
• Risk Severity, Consequences, Tolerability
• Risk Matrix
• Risk mitigation measures

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Risk Management Model
Establish the
Context:
Objective
Stakeholders
Criteria
Define key
elements
Identify the
risks:
What can
happen?
How can it
happen?
Analyze the
risks:
Review
controls
Likelihoods
Consequences
Level of risk
Evaluate the
risks:
Evaluate risks
Rank risks
Treat the risks:
Identify
options
Select the best
responses
Develop risk
treatment
plans
Implement
Communicate and Consult
Monitor and Review

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SAMPLE
Risk Management Process
Establish the Context:
• Establish the external, internal and risk management context in
which the rest of the process will take place. Criteria against which
risk will be evaluated should be established and the structure of
the analysis defined.
Identify the Risks:
• Identify where, when, why and how events could prevent, degrade,
delay or enhance the achievement of the objectives.

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SAMPLE
Analyze the Risks:
• Identify and evaluate existing controls. Determine consequences
and likelihood and hence the level of risk. This analysis should
consider the range of potential consequences and how these could
occur.
Evaluate the Risks:
• Compare estimated levels of risk against the pre-established
criteria and consider the balance between potential benefits and
adverse outcomes. This enables decisions to be made about the
extent and nature of treatments required and about priorities.

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SAMPLE
Treat the Risks:
• Develop and implement specific cost-effective strategies and action
plans for increasing potential benefits and reducing potential costs.
Monitor and Review:
• It is necessary to monitor the effectiveness of all steps of the risk
management process. This is important for continuous
improvement. Risks and the effectiveness of treatment measures
need to be monitored to ensure changing circumstances do not
alter priorities.

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SAMPLE
Risk Management Standard
Risk Management Standard was developed by the major risk
management organisations in the UK: The Institute of Risk
Management (IRM),The Association of Insurance and Risk Managers
(AIRMIC), and ALARM The National Forum for Risk Management in the
Public Sector. The risk management process flow consists of the
following elements:
• The Organisation's Strategic Objectives: All risk management
activities finally have to meet the strategy of the organisation.
• Risk Identification: As first of three elements of risk assessment
risk identification is the step to uncover risks.
• Risk Description: The second element of risk assessment is risk
description. Its objective is to display the identified risks in a
structured format.

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SAMPLE
• Risk Estimation: The third element of risk assessment is risk
estimation. It provides values for probability of a risk and
consequence in case of risk occurrence.
• Risk Evaluation: Risk Evaluation is about preparing for responding
to risks. The risk estimation is compared against risk criteria to
analyse whether the risk is accepted or requires any treatment.
• Risk Reporting: There are different requirements on reporting
depending on the level inside (internal reporting) or outside
(external reporting) the organisation.
• Decision: In this step a decision is made about whether and how to
respond to a risk.

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SAMPLE
• Risk Treatment: Risk treatment is about selecting and
implementing treatments against risks.
• Residual Risk Reporting: A specific part of risk reporting is residual
risk reporting. It reports the progress made by mitigating the risk.
• Monitoring: The monitoring step loops back via modifications to
the previous steps. It is the loop of improvement and update.
The 'Risk Management Standard' adds a formal audit to ensure that
the risk management process is performed as planned.

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SAMPLE
Establish the Context:
• The internal context
• External context
• The risk management context
• Develop criteria
• Define the structure
Identify the risks:
• What can happen?
• How can it happen?
• How and why
Treat the risks:
• Identify options
• Assess the options
• Prepare and implement treatment plans
• Analyze and evaluate residual risk
Analyze the risks:
Identify existing controls
Determine level of risk
Determine
consequences
Determine
likelihood
Analyze the risks:
YES
Communicate
and
Consult
Monitor
and
Review
NO
• Compare against criteria
• Set priorities
Treat
Risks

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SAMPLE
Managing Risk & SMS
• The elimination of accidents (and serious incidents) is
unachievable.
• Failures will occur, in spite of the most accomplished prevention
efforts.
• No human endeavour or human-made system can be free from
risk and error.
• Controlled risk and error is acceptable in an inherently safe
system.

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SAMPLE
Risk Management Elements
Risk management consists of three essential elements:
• Hazard Identification
• Identification of undesired or adverse events that can lead to the
occurrence of a hazard
• Analysis of mechanisms by which these events may occur and
cause harm.
Both reactive and proactive methods and techniques should be used
for hazard identification.
1
2
3

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SAMPLE
Risk Management
Definition
• “Risk Management - The identification, analysis and
elimination (and/or mitigation to an acceptable or tolerable level)
of those hazards, as well as the subsequent risks, that threaten the
viability of an organisation.” (ICAO Doc 9859).
• “Safety risk management (SRM) - a formal process within
the SMS composed of describing the system, identifying the
hazards, assessing the risk, analysing the risk, and controlling the
risk. The SRM process is embedded in the processes used to
provide the product/service; it is not a separate/distinct process.”
(FAA AC120-92, Introduction to SMS for Air Operators).

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SAMPLE
Risk Management
Description:
• The complete elimination of risk in aviation operations obviously is
an unachievable and impractical goal (being perfectly safe means
to stop all aviation activities and to ground all aircraft). As not all
risks can be removed, nor are all possible risk mitigation measures
economically practical. In other words, it is accepted that there will
be some residual risk of harm to people, property or environment,
but this is considered to be acceptable or tolerable by the
responsible authority and the society.

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SAMPLE
Risk Management
Description Cont:
• Risk management, being a central component of the SMS, plays
vital role in addressing the risk in practical terms. It requires a
coherent and consistent process of objective analysis, in particular
for evaluating the operational risks. In general, Risk Management is
a structured approach and systematic actions aimed to achieve the
balance between the identified and assessed risk and practicable
risk mitigation.

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SAMPLE
Risk Management Elements:
• Risk Assessment - Identified hazards are assessed in terms of
criticality of their harmful effect and ranked in order of their risk-
bearing potential. They are assessed often by experienced
personnel, or by utilising more formal techniques and through
analytical expertise. The severity of consequences and the
likelihood (frequency) of occurrence of hazards are determined. If
the risk is considered acceptable, operation continues without any
intervention, if it is not acceptable, risk mitigation process is
engaged.

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SAMPLE
Risk Management Elements:
• Risk Mitigation - If the risk is considered to be unacceptable,
then control measures are taken to fortify and increase the level of
defences against that risk or to avoid or remove the risk, if this is
economically feasible.

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SAMPLE
A
L
A
R
P
Risk Mitigation at a Glance
Does the mitigation
address the hazard?
Does it address the
risk(s)?
Is it appropriate?
Is it effective?
R R
R
H H H H
Is additional or different
mitigation warranted
EACH HAZARD
Do the mitigation
strategies generate
additional risk(s)
EACH RISK
Feedback (Safety Assurance)
Hazard
Identification
&
Risk Management
Assessment of the
defenses within
the Safety System
Control &
mitigation of the
risk (s)
Accepting the
mitigation of the
risk
Intolerable Region
Tolerable
Region
Acceptable
Region
Regulations
Training
Technology

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SAMPLE
Identify the hazards to equipment, property,
personnel or the organization
Evaluate the seriousness of the consequences
of the hazard occurring
What are the chances of it happening?
Is the consequent risk acceptable and within
the organization’s safety performance criteria?
Accept the risk
Take action to
reduce the risk to
an acceptable level
Hazard
Identification
Risk Assessment
Severity / Criticality
Risk Assessment
Probability of occurrence
Risk Assessment
Acceptability
Risk Mitigation
1
2
3
4
5

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SAMPLE
Risk Categorization
Probability
Severity
A
Catastrophic
B
Hazardous
C
Major
D
Minor
E
Negligible
5
Frequent
5A 5B 5C 5D 5E
4
Occasional
4A 4B 4C 4D 4E
3
Remote
3A 3B 3C 3D 3E
2
Improbable
2A 2B 2C 2D 2E
1
Extremely
Improbable
1A 1B 1C 1D 1E
Unacceptable region – Mitigation of risk is necessary
Tolerable region – Acceptable based on risk assessment & mitigation (if necessary). It may
require a management decision.
Acceptable region
Risk Mitigation: Risks should be managed to be as low as reasonably practicable. Risk must
be balanced against time, cost and difficulty of taking measures to reduce or eliminate the
risk. The level of risk can be lowered by reducing the severity of the potential consequences,
reducing the probability of occurrence or by reducing exposure to risk.

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SAMPLE
2/6/2024 84
Unit 4
Update of Safety Processes
Safety Management
System (SMS)
Processes

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SAMPLE
Update of Company Safety Processes:
• Audit principles and methodology
• Communication techniques
• SMS implementation, analysis and continual
improvement
• Safety promotion and information dissemination.

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SAMPLE
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Unit 5
Review of Company Safety
Management
Safety Management
System (SMS)
Review SMS

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SAMPLE
Review of Safety Management:
• Communication & Leadership
• Just culture Application Flow Chart
• Reporting accidents, incidents and perceived hazards
• Introduction to ERP
• Management accountability

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SAMPLE
SMS Framework Elements - AOCR 5.1
Safety Policy & Objectives
Establishes senior management’s
commitment to continually improve
safety; defines the methods, processes,
and organization structure needed
to meet safety goals
Safety Risk Management
Determines the need for, and adequacy
of, new or revised risk controls based
on the assessment of acceptable risk
Safety Assurance
Evaluates the continued effectiveness
of implemented risk control strategies,
support the identification of new
hazards
Safety Promotion
Includes training, communication, and
other actions to create a positive
safety culture within all levels of the
workforce
Polic
y
SRM SA
SP

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SAMPLE
Communication & Leadership
Safety promotion based on:
• Internal and external training
• Communication and dissemination of safety information
Train (initial and continuous) your staff, educate, inform, increase
the level of safety awareness, promote your policy and your
objective, communicate, instruct, share…
• Develop and maintain the level of “Safety Culture” among the
States, the organisations or any stakeholders playing a role in
safety
• It includes senior management, front-line management, staff in
the field, decision-makers etc

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SAMPLE
Just Culture
Senior management promotes a non-punitive working
environment. Some organizations use the term “just
culture” instead of “non-punitive”.
• There is an awareness of the importance of communicating
relevant safety information at all levels of the organization (both
within and with outside entities).
• There are realistic and workable rules relating to hazards, safety
and potential sources of damage.
• Personnel are well trained and understand the consequences of
unsafe acts.
• There is a low incidence of risk-taking behaviour, and a safety ethic
that discourages such behavior.

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SAMPLE
Company Safety & Security
Structure
Title Name Email Phone
Managing Director
Director of Corporate Safety
& Security
Security Manager
Flight Safety Manager
Cabin Safety Manager

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SAMPLE
Roles & Responsibilities
Safe operations can only be achieved with a balanced and realistic
allocation of resources between protection and production goals. All
personnel within Company are responsible for the safety of operations
under their control.
Company therefore recognizes that for SMS, each member of
management and every employee are accountable irrespective of
their other functions, with respect to the safety performance of the
SMS. This therefore means that “safety is everyone’s business”.

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SAMPLE
All management personnel are responsible for the safety of
operations in their respective departments.
Managers also have responsibilities of conducting the review of
identified hazards within their operational areas and conducting the
analysis to ensure that the identified substandard will not reoccur.
All management and non-management personnel have
responsibilities for making decisions that relate to the safety of
operations that are under their control.

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SAMPLE
The safety accountability and responsibilities of Company, AOC Post
holders are described in the job descriptions in their respective
manuals. Post holders are accepted by the CAA and have
accountability for ensuring in their respective operational areas, the
management of safety risks and to ensure that operations are
conducted in accordance with the conditions of the AOC and
standards required by Company.
It must be recognized that the primary responsibility for safety
outcomes rests with line managers who “own” the production
process. It is here where the of majority hazards are directly
encountered, where deficiencies in processes contribute to safety
risks, and where direct supervisory control and resource allocation can
mitigate the safety risks to acceptable levels.

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SAMPLE
The key safety personnel and the accountabilities discussed here
pertain mainly to their role in the safety production or promulgation
of the respective areas.
The full terms of reference for the job scope are found in the
respective departmental manuals, the Operations Manual – Part A
and the Quality Assurance Manual.

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SAMPLE
THE ACCOUNTABLE MANAGER (MANAGING DIRECTOR, MD)
Accountability: The Managing Director is the Accountable Manager of
Company. The Accountable Manager is responsible for ensuring that
the safety management system is properly implemented and is
performing to requirements in all areas of the organization.
He shall hold the ultimate responsibility and accountability for the
implementation and maintenance of the SMS throughout the
organization.
Deputation: Director of Flight Operations, or Director of Ground
Operations

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SAMPLE
DIRECTOR OF CORPORATE SAFETY & SECURITY (DCSS)
Accountability: The DCSS reports directly to the Accountable Manager
and is responsible for the implementation and maintenance of the
SMS. He is the nominated post holder accepted by the CAA as
responsible for SMS.
The DCSS is a senior management position. He has overall
responsibility for the preparation, coordination, administration and
management of the safety management system. The DCSS must be an
aviation professional, with good understanding of the SMS and
knowledge of the organization’s operations, procedures and activities.
The DCSS must be independent of operational activities and not hold
any other responsibilities that may conflict or impair his roles and
performance.
Deputation: Security Manager and/or Flight Safety Manager

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SAMPLE
SAFETY MANAGER (SM)
Accountability: The Safety Manager reports to the DCSS.
The Safety Manager is accountable for the day to day operation and
implementation of the Company's Safety Management System,
Quality Management System, and Crisis Management Program
(Emergency Response Plan).
He is accountable for the Accident Prevention and Flight Safety
Program. He must ensure;
1. Acceptable level of safety are being maintained;
2. Development and maintenance of an effective SMS;
3. Processes needed for the SMS are established, implemented and
maintained;
4. Safety promotion throughout the organization.
Deputation: Flight Safety Manager

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SAMPLE
SECURITY MANAGER
Accountability: The Security Manager reports to the DCSS.
The Security Manager is accountable for Company’s Air Operator
Security Program including, the requirements of the civil aviation
security program of the State, applicable requirements of other states
where operations are conducted and the security standards of
Company.
Deputation: Safety Manager and/or Cabin Safety Manager

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SAMPLE
CABIN SAFETY MANAGER
Accountability: The Cabin Safety Manager reports to the DCSS, and is
responsible for the matters related to flight operations safety in the
cabin.
Responsibility:
Assist to ensure compliance with Safety Management System Provide
information and feedback to CSS for incidents that occur in the cabin
Assist in incident / accident investigation

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SAMPLE
DEPARTMENTAL SAFETY REPRESENTATIVES
Company values the involvement of all its personnel with a view of
improving both safety management and safety culture.
Each departmental head shall nominate Departmental Safety
Representative(s). The Departmental Safety Representative role is a
voluntary position.
The role of the Departmental Safety Representative will help safety
promotion and communication and involve all staff in the SMS roles,
functions and decision making.
Departmental Safety Representatives are members of the SAG.

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SAMPLE
OPERTIONAL PERSONNEL & ALL STAFF
All employees shall carry out their duties and responsibilities in a
manner that is safe and in accordance with statutory regulations of
the state of registration and the state of operation, Company
standards, policies and procedures, and recommended practices.

2/6/2024 10
SAMPLE
The employees’ duties include:
a. Each Company employee is required to support the SMS Program
through participation and reporting any item or circumstance in
the workplace that is likely to be hazardous to the health or safety
of the employee, his colleagues, or any other person; and
b. Taking all reasonable and necessary precautions, appropriate to
the situation, to ensure the health and safety of all who may be
affected by a hazard.
c. Each Company employee has responsibilities for making decisions
that relate to the safety of operations that are under their control.
d. Each employee shall make a decision to stop a task and seek
clarification from documented procedures, his supervisor or other
appropriately qualified persons for all safety related decisions.

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SAMPLE
Safety Communications
In accordance with SMS best practices and CAA guidance, Company
will maintain formal means for safety communication that ensures
that all personnel are fully aware of the SMS and that safety-critical
information are properly conveyed. Particularly, safety
communication processes will explain why particular safety actions
are taken and why safety procedures are introduced and changed.
Company will communicate the airline’s SMS objectives and
procedures to all operational personnel. The CSS will regularly
communicate information regarding the safety performance trends
and specific safety issues through bulletins and briefings. The CSS
will also ensure that lessons learned from investigations and case
histories or experiences, both internally and from other
organizations, are distributed widely.
1
2

2/6/2024 10
SAMPLE
Safety Communications
Safety performance will be more efficient if operational personnel
are actively encouraged to identify and report hazards. Safety
communications therefore aims to:
• Ensure that staff are fully aware of the SMS;
• Convey safety-critical information;
• Raise awareness on corrective actions;
• Provide information regarding new or amended safety
procedures.
• Explain why particular safety actions are taken
• Explain why safety procedures are introduced or changed.
• Convey any information that may advance the ideals of safety
(“nice to know information”).
3

2/6/2024 10
SAMPLE
SMS Formal Communication
Company utilizes a number of methods for communicating safety
information throughout the organization.
Dissemination of the SMS manual: The distribution list of this manual
includes all areas of operations within Company and easy availability on the
intranet IT platform.
Safety processes and procedures changes: Safety processes and procedures
changes may be noticed by formal revision of the SMS Manual or Notice.
Safety newsletters, notices and bulletins: The CSS of Company will issue
quarterly periodicals.
Minutes of Safety Meetings: The minutes of safety meetings shall be
circulated among the relevant safety personnel. Pertinent issues arising from
the meetings shall be communicated on a departmental level.
Emails: Company utilizes emails as a primary means of communicating
safety information. Safety information is sent and received via the individual
email address;

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SAMPLE
2/6/2024 10
Unit 6 Review of Safety
Reporting
Safety Management
System (SMS)
Reporting

2/6/2024 10
SAMPLE
The hazard identification processes are formalized,
coordinated and consistently applied on an on-going basis
throughout the whole organization and in particular in the
following areas:
• Flight Operations (including OCC and Dispatch);
• Cabin Operations;
• Aircraft Maintenance and Engineering;
• Ground Handling Operations;
• Cargo Operations;
• Security;
1
2
3
4
5
6
Company Safety Reporting
Procedures

2/6/2024 10
SAMPLE
Company Safety Reporting Procedures
The hazard identification processes are formalized, coordinated and
consistently applied on an on-going basis throughout the whole
organization and in particular in the following areas:
• Mandatory and voluntary (confidential, anonymous) reporting by all
operational personnel;
• Safety investigation of accidents, incidents, irregularities and other non-
normal events which could be precursors to incidents and accidents;
• Flight Data Monitoring Program (FDMP);
• Observation of flight crew performance in line operations and training;
• Observations of operational personnel conducting normal duties;
• Safety and quality auditing;
• Safety information gathering or exchange from external sources such
Flight Safety Foundation, Euro control etc.
1
2
3
4
5
6
7

2/6/2024 11
SAMPLE
Air Safety Reports (ASR)
CAA requires that an aircraft registered in (Country) for public
transport shall report incidents and accidents promptly so that the
proper investigation can be carried out to determine the cause and
action taken to prevent further recurrence. The following categories
of Company persons (or organizations) are required to report
occurrences:
a. Company and commanders of public transport aircraft;
b. Those concerned with the manufacture, repair, maintenance or overhaul
of such aircraft, or any part or item of equipment intended for use on
such an aircraft;
c. Those who sign Certificates of Maintenance Review or Release to Service
for such aircraft, or any part or item of equipment;
d. Airport licensees / managers; and
e. Civil air traffic controllers operating in circumstances requiring an air
traffic controller’s license.

2/6/2024 11
SAMPLE
Air Safety Reports (ASR)
• Company has 6 official methods that any member of the Company
organization can use to report Hazards and Risk. These reporting
methods are described in chapter 2 Section 2.1 of the latest
revision of the Safety Management System Manuals (SMSM),
Which is available on your SharePoint document Library. Below are
the 2 reporting methods related to SharePoint with a brief
description of each one:
• SharePoint Reporting Platform: All members of Company have
access to Microsoft Office 365, which is a cloud based system that
offers various productivity tools such as email and MS Word.
SharePoint is one of the tools available to all Company Airways
members and which can be reached using the following steps:

2/6/2024 11
SAMPLE
Corporate Safety Report / Anonymous
Reporting
There are two ways to access the electronic Company
Corporate Safety Report Form:
• Through the link at the bottom right hand corner of your Company
SharePoint Home page
• Through the “Safety Reports” link at the bottom of our website
www.flyjetasia.com
1
2

2/6/2024 11
SAMPLE
Corporate Safety Report / Anonymous
Reporting
• Both of these will lead you to our electronic Corporate Safety
Report with a URL of www.flyjetasia.com/reports. This page is
outside of the SharePoint platform and can be accessed by anyone
without Company Management or IT being aware of identity of the
visitor.
• This is done on purpose so that we can allow for Anonymous
Reporting as an option. While we encourage for people to disclose
as much information as possible, including their identity and
contact details you will notice that you are not required to provide
your name of contact details.

2/6/2024 11
SAMPLE
Corporate Safety Report/Anonymous Reporting
• For those who opt to remain anonymous this is one way to do so
while still passing on Safety and Security critical information
including attachments. You will also notice that you will not be able
to submit the form unless you enter a 6 digit pin code. This 6 digit
pin code is required to ensure that only Company members file the
reports and to avoid trolls or other unauthorized people from
accessing the Company reporting system.
• You can find the 6 digit pin code at the bottom right hand side of
your SharePoint homepage. The pin code changes every 24hours to
for security purposes. Once submitted the form will generate an
email which will then be forwarded to safety@flyjetasia.com for
assessment and action to be taken by our safety department.

2/6/2024 11
SAMPLE
One Crew
The Safety Management System Menu contains all of the critical
components of SMS, Among them the Hazard Event Register and
the Hazard Event Investigation links.
Members of the Corporate Safety and Security team will
be able to access the Hazard Event Register by clicking
on the “SMS Administration” Link on the Main Menu
which can be found on the far left of the Company
SharePoint homepage

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SAMPLE
Company Incident Reporting

2/6/2024 11
SAMPLE
• Every safety or Security Report entered into SharePoint will be
displayed in the Hazard Event Register.
• This Register be seen in 3 different views, My Report, All Reports,
and New or Unprocessed Report.
• It is very important that every report that is received through any
method is eventually processed through the SharePoint platform
for record keeping and for data gathering purposes.

2/6/2024 11
SAMPLE
• When a safety or security report is received through SharePoint all
members of the Corporate Safety and Security team will receive a
notification email for their action

2/6/2024 11
SAMPLE
• The person who submits the safety or security report
will also get a receipt confirmation email for their record

2/6/2024 12
SAMPLE
Company hazard Investigation
• CSS must evaluate and review the initial report submitted and decided whether
it should continue to the investigation stage.
• Once it is decide to pursue an investigation CSS members must go to the
Operational Hazard Investigation Link on the Safety Management Systems Menu
• Click the New Item link on the Active Issues or My Issues view.

2/6/2024 12
SAMPLE
Company Risk Assessment (HIRA)

Aviation Training, Safety Management System

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