SMS For Small Organizations: March 2015
SMS For Small Organizations: March 2015
SMS For Small Organizations: March 2015
March 2015
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Table of Contents
Introduction................................................................................................1
Guidance to Small Organizations on Implementing SMS ................................................... 1
How Complex is the Small Organization? ......................................................................... 1
1 Safety Policy and Objectives ....................................................................3
1.1 Management Commitment and Responsibility ............................................................. 3
1.2 Safety Accountabilities .............................................................................................. 4
1.3 Appointment of Key Safety Personnel......................................................................... 4
1.4 Coordination of Emergency Response Planning .......................................................... 5
1.5 SMS Documentation ................................................................................................. 5
2 Safety Risk Management ..........................................................................6
2.1 Hazard Identification ................................................................................................. 6
2.2 Safety Risk Assessment and Mitigation ...................................................................... 9
3 Safety Assurance .....................................................................................9
3.1 Safety Performance Monitoring and Measurement....................................................... 9
3.2 The Management of Change ................................................................................... 12
3.3 Continuous Improvement of the SMS ....................................................................... 13
4 Safety Promotion ................................................................................... 14
4.1 Training and Education ........................................................................................... 14
4.2 Safety Communication ............................................................................................ 15
5 Dealing with Contractors and Other Organizations ................................ 15
5.1 People Contracting to You ....................................................................................... 15
5.2 Organizations That You Supply with Products or Services .......................................... 16
Appendix 1: A Step by Step Guide for Small Aviation Organizations —...... 17
Guidance for Implementation ................................................................... 17
Appendix 2: Example of a Very Small Organization SMS Manual ............... 21
Appendix 3: A Sample SMS Manual Format for a Small Organization ........ 23
Appendix 4: Sample Hazard Logs .............................................................. 24
Hazard Log for a Small Organization......................................................................................24
Hazard Log for Very Small Organization ................................................................................24
Appendix 5: Safety Report Form Template for a Small Organization ......... 25
Appendix 6: Safety Report Form Template for a Very Small Organization . 27
Appendix 7: The Five Whys Approach for Root Cause Analysis.................. 29
Appendix 8: Investigation Form Template for a Small Organization ......... 31
Appendix 9: Risk Management Procedures for a Small Organization......... 33
Appendix 10: Risk Management Procedures for a Very Small Org. ............ 35
Appendix 11: Safety Performance Indicators for a Small Organization ..... 36
Appendix 12: Corrective and Preventive Action Report Template.............. 37
Appendix 13: Management of Change Template........................................ 38
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Introduction
Guidance to Small Organizations on Implementing SMS
The introduction of safety management systems (SMS) across the aviation industry
brings some specific challenges for small organizations. Indeed, some small
organizations may feel that SMS is too complex or too costly to implement. This
guidance has been written for any small organization that operates or provides services
in civil aviation.
We hope to show that implementing an SMS is probably much simpler than you think;
many small organizations already have many of the elements of an SMS in place.
Throughout this guidance, we consider an organization with between five and twenty
staff as a Small organization, and one with less than five staff as Very Small. However,
your regulator may not define smaller organizations this way.
SMS can be boiled down to a very simple concept:
Actively look for safety issues in your operations, products, or services;
Develop corrective actions to reduce the risks those safety issues present; and
Monitor to be sure that you have appropriately controlled those risks.
An SMS does not have to be complicated to be effective.
Before starting to implement your SMS, talk to your regulator to find out what is required
for the size of your organization. Then carry out a gap analysis to compare what you
have already with what is required and see what is missing. As with any management
system, it is also important to remember that your SMS should be customized to reflect
your organization and the operating environment. But read the rest of this guide first!
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Example:
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and what type of behavior would attract disciplinary action. Then sign it, post it in a
prominent place – and live up to it!
Your Safety Policy should set out what you want to achieve and how you mean to
achieve it. In addition to your safety commitment statement and your safety reporting
policy, it should also include your key safety objectives.
It is important that everyone sees the Safety Policy. In a Small organization, you could
circulate it and have everyone sign as having read it, as well as posting it on the notice
board.
For a Very Small organization, the Safety Policy can be very brief, as demonstrated in
Appendix 2, Example of a Very Small Organization SMS Manual.
1.3.2 Responsibilities
The person responsible for the SMS will:
Ensure that the SMS processes are established, implemented, and maintained;
Promote safety awareness and a positive safety culture;
Liaise with the authorities on safety-related issues;
Exchange valuable lessons learned with other organizations;
Manage internal incident and accident investigations;
Ensure identified hazards and issues are being managed;
Maintain safety documentation; and
Organize safety training.
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Reporting of less significant incidents, which may not be subject to mandatory reporting,
should be actively encouraged. This will give you a better understanding of what is
going on and allow you to monitor your organization’s safety performance and help to
identify developing safety trends. Encourage all issues to be reported and then decide if
they need investigating.
For the reporting system to be effective, everyone connected to the organization,
whether internally or externally, needs to actively participate. Everyone needs to be
clear about how to report, what to report and who to report it to. Information from the
reports can then be used to identify safety risks so that appropriate action can be taken.
You can also ask organizations and customers that use your products or services to
report any safety issues that are related to what you have provided. Be sure to give
feedback to the person reporting an event so they can see that reports are taken
seriously and acted on; this will encourage further reporting.
The Safety Reporting Form is a good way to gather this vital information. The person
responsible for the SMS (described in Section 1.3.1) is the best person to manage
these reports and assign them to the appropriate person for action. Safety reporting in a
Very Small organization may be by word of mouth but it is important that it is still
documented so it is not lost or forgotten. Examples of templates for a Safety Reporting
Form can be found in Appendix 5, Safety Report Form Template for a Small
Organization, and Appendix 6, Safety Report Form Template for a Very Small
Organization.
Safety reports should be used to enhance safety rather than to apportion blame. To
encourage reporting without fear of repercussion, it is important that staff members
understand the open and just culture expressed in your reporting policy.
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2.1.3 Investigation
There are times when further investigation of a safety issue is necessary to determine
the exact cause and the contributing factors. You do not want to develop a corrective
action only to find you have not solved the underlying problem. Using a root cause
analysis method for investigations will help to get to the main issue that is causing your
problems.
You may not have the time or resources to investigate everything that is reported, so it
is best to define when you will investigate an issue. For example, it does not make
sense to investigate a problem that is of negligible consequence, but you would
certainly want to investigate a problem that is both likely and potentially serious.
A simple approach is to review the safety reports and any operational occurrences and
then use the risk matrix to assess the need to investigate. Document the investigation
and add the outcomes to the Hazard Log. The following is a generic investigation
approach.
Gather information.
o What happened, when, and where?
o What is the impact on the organization?
o What were the conditions and actions that led to the safety issue?
o Who was involved?
Interview those involved.
Analyze the information.
o Examine all the facts and determine what happened and why (the root
causes).
o Assess whether this event or something similar has happened before
o Identify contributory factors, such as:
Job factors (e.g., Did the work require too much or too little attention?
Were there distractions or conflicting demands? Were the procedures
adequate and properly understood?);
Human factors (e.g., physical ability (size and strength), competence
(knowledge, skill and experience), fatigue, stress, morale, alcohol or
drugs);
Organizational factors (e.g., work pressure, long hours, availability of
sufficient resources, quality of supervision, safety culture);
Plant and equipment factors (e.g.. clarity of the controls and
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3 Safety Assurance
If you do not know how well you are doing, you will not know how to do better; and we
can all do better.
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mitigations are working as planned. Then take action if things are not improving. In
addition to using SPIs, you can use your internal audit or review to check your
performance.
The SM ICG document Measuring Safety Performance: Guidelines for Service
Providers provides additional guidance on establishing SPIs.
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It may be more useful to monitor some SPIs against the number of movements (e.g.,
flights, flying hours, maintenance cycles), as this will allow for changes in your
operation. So, for example, if your target was less than 2 mandatory reports per year
and you bought a second aircraft, you would need to change your target, probably to 4
reports per year. But if your target was 2 reports per 1000 flights, doubling the number
of aircraft would have no effect on the target.
Be careful when reviewing SPIs, unless you have a reasonably large number of events.
A change from one to two incidents per year is a 100% rate increase, but is not nearly
as useful an indicator as a 10% change from 50 to 55.
The following are examples of organization-type SPIs.
Operator: Number of flights flown with operational Minimum Equipment List
(MEL) restrictions
Aerodrome: Number of runway incursions, number of bird incidents
Maintenance: Number of maintenance errors
Air Traffic Service (ATS): Number of airspace infringements, number of losses
of separation
You will need to think carefully about these. Good indicators will help you improve
safety, while poorly thought out indicators may just waste everybody’s time.
Only you can decide if, and what, indicators are applicable and valuable to your
organization.
Finally, once you have set these targets, be sure to regularly measure your actual
performance against them. That will tell you how well you are doing.
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Tools: There are many examples of audit tools available, including the SM ICG
SMS Evaluation Tool that can be found on SKYbrary. But if you use one of these,
you should tailor it to your organization to gain the most benefit.
Frequency: Audits and reviews should be carried out at least annually, but
covering the scope in several smaller audits or reviews may be more productive
and effective.
Addressing Findings: Audit and review findings should be addressed with
preventive and corrective actions. A template for managing this can be found in
Appendix 12. Corrective and Preventive Action Report Template.
Risk assessment is a key part of the process, so when you decide to make a change,
start by assessing the overall risk of the change itself. It may be that the change is
simply not worth the risk or that the risk of not making the change is just too high. You
have probably done this intuitively, but make sure you involve the right people as they
may bring up risks you had not taken into account. This may mean involving people
from outside your organization (key stakeholders).
Once you decide to go ahead, identify all the factors that must be considered. For
instance, if you plan to introduce a new aircraft type, you will probably need to consider
aircraft certification and registration issues, training requirements and schedules and
maintenance arrangements among other things. Do not forget to ask the question, "Is it
suitable for our operations?". You will need to determine when things will need to
happen, who will be involved, what needs to be done beforehand, what will happen
next, and so on.
Once you have your basic plan in place, you can start to identify and manage the risks.
And remember, introducing any new procedure, operation, or equipment type is likely to
bring new safety risks.
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You should include a risk assessment of each issue, so that you can take any
necessary steps to minimize the risks and their potential effects. For example: What is
the likelihood that the training will not be completed as scheduled? If the training is late,
what will be the effect on your operations and your business? And how will you
minimize the risk?
Be prepared to manage the effects of changes in other organizations on your operation.
For example: How would it affect your organization if your third party maintenance
provider had a significant leadership change or a move to another location? How would
it affect your organization if your ANSP was to reduce operations at your aerodrome?
Document what you plan to do and what you actually do at each stage. This will help
you and others to see what went well and what did not. This will also help provide a
historic record of why certain actions were taken as the organization continues to
improve and expand its operations.
Appendix 13, Management of Change Template, provides material to help you
document the change in a structured approach.
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Management review can be conducted via a safety review meeting, and actions
documented in a form, such as the template in Appendix 14, Management Review
Template.
The expected result of management review is to answer the question: How effective is
your SMS?
4 Safety Promotion
Keep the safety message alive and well; tell your people, tell your customers, tell
everyone!
Refresher Training: Your safety training program should include periodic refresher
training; this could involve regular briefings rather than formal training sessions, or a
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workshop format where the staff can discuss hazards or safety issues and risk
mitigations. It is useful to include lessons arising from incidents and investigations, both
internal and external.
Training Plan and Record: You should have a training plan, which includes as a
minimum a list of staff requiring SMS training and a record of when the specific safety
training (including refresher training) took place.
Training Materials: Some regulators have online training packages (some can be
tailored) that could fulfil the training needs on general concepts, though you may still
need to develop specific training for your organization. Your training material should be
reviewed from time to time to ensure that the training continues to meet the needs of
your staff and the organization.
Safety education is an ongoing process; try to make safety-related information
(magazines, books, pamphlets, posters, videos, DVDs, online resources) readily
available.
Your training program should be reviewed for effectiveness during the Management
Review process. See the Training and Safety Promotion Review section in Appendix
14, Management Review Template.
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case, you might carry out an inspection or audit. If there is no SMS, there may be less
to audit and it exposes your organization to more unknowns.
It is useful to work out a scheme for sharing safety data with your third party contractors:
their hazard and occurrence reports may alert you to a potential problem, and vice
versa. This could be done through meetings with your key contracting organizations.
For example, if the contracted maintenance organization discovers a problem with
something it has done for another customer operating the same aircraft type as you, the
company should alert you too. And if you have a problem that might have arisen from
its maintenance activity, the company needs to know.
It is important to include your SMS requirements in any contract or service agreement;
your contractors need to understand your expectations from the outset, which should
include how safety issues are reported.
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The following is a summary of the main considerations when implementing an SMS within a
small aviation organization.
IMPLEMENTATION GUIDE
Step 1 GAP ANALYSIS 1.1 Review the requirement of an SMS
1.2 Identify what you have
1.3 Identify what you need
Step 2 DESIGN AND DEVELOPMENT 2.1 Implementation Plan
2.2 Document your SMS
Step 3 INTRODUCTION AND 3.1 Get your people involved
ROLLOUT 3.2 Communicate the changes
3.3 Set a realistic timeframe
Step 4 IMPROVEMENT AND 4.1 Gather feedback
MEASUREMENT 4.2 Measure performance
4.3 Continuously improve your SMS
STEP 1: GAP ANALYSIS
1.1 REVIEW THE REQUIREMENTS OF AN SMS
The first step is to know what an ideal SMS looks like, and then consider this in the light of your organization. Look
at your regulatory requirements and any guidance from your regulator or other sources such as the SM ICG Small
organization material. Your regulator may provide you with a gap analysis tool for you to use. The SM ICG SMS
Evaluation Tool found on SKYbrary may be used as gap analysis tool. The following resources and actions should
help.
a) Research existing guidance material from your regulator
Put aside three to four hours to research and read any guidance material thoroughly. If this seems too much, ask
yourself whether three to four hours is too long to invest in a new management system for your organization.
Read through the gap analysis tool (if available) as this will help you understand what you need to address in your
SMS.
b) Work together: industry and regulator
Work with similar or partner organizations and industry groups to compare and contrast your understanding of
what is required. Do not aim for a cut‐and‐paste solution though; it might not work well and may actually waste
time and effort. Some regulators provide manual builders and templates for forms that you can customize to fit
your organization. Your regulator may also be able to provide advice on how to build a suitable SMS.
1.2 IDENTIFY WHAT YOU HAVE
While you are reading through any guidance material, consider and document what you have in place already. Jot
down some notes as you go about what you already do, and what you do well. Use the language your organization
understands in your SMS.
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1.3 IDENTIFY WHAT YOU NEED
This is where you need to consider carrying out a gap analysis. Here is the part where a lot of organizations feel
initially overwhelmed by all the things they may not have in place (and then promptly fail to start the gap
analysis!). If you follow these steps, you will end up with an easy, manageable list of actions to focus on.
A gap analysis does not have to take too long or be overly complex. Your regulator may have provided one for
you. Here’s an example of a simple table to capture results:
No. Element What we have What we don’t have Actions
1 Safety policy and Quality Policy Safety commitment CEO to develop and
objectives (with safety statement sign commitment
mentioned) Safety objectives for statement
2014 Workshop
STEP 2: DESIGN AND DEVELOPMENT
In this step, the person responsible for the SMS needs to design and develop a plan to implement the SMS. If it is
just you, consider seeking help or support from a partnering company or industry association.
2.1 IMPLEMENTATION PLAN
Using the action item list from the gap analysis, go through and introduce all under‐developed or absent elements
in an implementation plan.
Just a few things to consider while you do this:
Think about each action. Does it require the development of a philosophy (e.g., safety objectives), a
process (e.g., safety reporting system) or a practice (e.g., risk assessment tool)? It can help to differentiate
these to make sure you have the philosophies sorted out first.
Read through the actions identified, and prioritize them. It is useful to do a quick sensibility check, to ask
yourself, "Do I really need everything I’ve identified to achieve a successful system?" This is a good time to
see if your actions sufficiently address the gaps identified and are suitable for your organization.
You do not need to have each action up and running straight away. Develop an implementation plan
that will allow you to phase different elements over a period of time. Building an SMS overnight will be far
too challenging and your goal at this stage is just setting up the foundations.
Go with what works. Do not try to force a process or activity that clearly has no place in your business.
For example, if you are attempting to develop a risk assessment methodology, think about how complex
you want to make this process; make it practical and keep a focus on what you’re trying to achieve (e.g.,
identifying the safety and business risks of a new venture).
2.2 DOCUMENT YOUR SMS
You need to document the processes and activities you currently carry out, and the ones you plan to introduce. A
sensible approach is to add your SMS processes and activities to the documentation you already have such as your
Operations Manual.
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STEP 3: INTRODUCTION AND ROLLOUT
3.1 GET YOUR PEOPLE INVOLVED
No matter how small your organization, failing to get your people involved will be a missed opportunity and a
showstopper. So, be sure your people are on board and understand what you are trying to achieve. A clear safety
policy and a commitment from the accountable executive is the best place to start. A good safety culture begins
with the accountable executive 'walking the talk.' A few one‐on‐one discussions go a long way.
3.2 COMMUNICATE THE CHANGES
Let your staff know about the changes, why they are being implemented, the benefits they are designed to bring,
and, of course, their own roles within the SMS.
Who else may benefit from knowing that you have an SMS in place? For example, your customers and your
contractors and if you are a small operator based on an aerodrome, it might be valuable to let the aerodrome
operator know ‐ your reporting system may have safety information that’s worthwhile passing on to them.
It is worth letting your regulator know; this will help build the regulator’s confidence in your organization.
3.3 SET A REALISTIC TIMEFRAME
Be sure to space out the implementation activities over a reasonable timeframe. Even for small organizations, it
will take time to implement your SMS and longer for it to become effective. Do one or two things at a time. Make
sure these are in place and working before moving to the next step in your plan.
Keep checking your progress. For example, if you have implemented a new safety reporting process but have not
received (or submitted) any reports, find out why.
STEP 4: IMPROVEMENT AND MEASUREMENT
An important part of implementation is seeing whether your actions have worked. This step focuses on what you
can do to determine this. Consider doing a review six months after your initial development has started; you can
increase the interval as your SMS matures.
4.1 GATHER FEEDBACK
To understand what is working, and what is not, consider getting both an internal and external perspective.
Internally:
Review any regulatory guidance material and compare your thoughts now with what they were when you
first read it.
Use your initial gap analysis to identify what may need updating. Have things changed?
Talk to your people and see what they think.
Externally:
Check in with your partner organization or industry association.
Consider having an independent evaluation done.
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Ask for feedback from your regulatory inspector.
4.2 MEASURE PERFORMANCE
Establish some performance measures that will help you measure your safety performance. This can be simply
measuring the amount of significant safety events you have, the amount of voluntary safety reports you receive or
the amount of safety meetings you have. Use them to see how far you have come and tell your staff about the
progress made.
4.3 CONTINUE TO IMPROVE YOUR SMS
The previous steps should give you an indication of what can be improved. Refining and enhancing your SMS does
not stop. If you think you have done all you can, just remember that continual improvement is fundamental to
your SMS. Your implementation is successful when it is embedded in your day‐to‐day activity (and has been for a
while), it works consistently, and it is actually effective. This won’t happen overnight, but with time you’ll see the
system maturing and your confidence growing.
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1. Safety Policy
Our safety objective is simply for no aircraft accidents to occur as a result of our operations.
Therefore it is important that we meet all applicable regulations and where appropriate exceed them
when a safety risk is identified.
I believe in a reporting system that allows people to report safety issues without fear of unfair reprisals.
Everybody makes mistakes, and honest mistakes will be treated fairly. A healthy reporting system
gives us the information to address safety issues as they arise, not when it is too late. We expect
everyone who works or is connected to our operations to report any safety related events or issues
they identify to me or one of our staff. In this respect we will apply just culture principles to any event
that is reported to us directly in a timely manner.
This will help our organization to continuously improve our safety performance which is a shared
responsibility.
Signed
(insert name)
(insert date)
The Accountable Manager will fulfill the role of the Safety Manager and contract in expertise as
required.
Copies of the separate Emergency Response Plan (Insert document reference) are held by (insert
name) and in the (insert location i.e., Operations Office).
All safety events, issues, or hazards should be reported to (insert name) by e-mail (insert e-mail
address), telephone (insert telephone number) or verbally; they will all be documented and assessed
as below.
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All events and reported issues will be assessed by (insert name) to determine what the issue is, what
could happen as a result, and what actions need to be taken (if any) and by whom to manage the risk.
The Hazard Log (see below) will be updated and reviewed on a monthly basis and the updated
version will be posted on the (state location i.e., workshop safety notice board). All staff should read
the Hazard Log and provide feedback if they have any issues with the content or feel something is
missing.
4. Management of Change
Any significant organizational changes will be assessed for safety issues related to the change and
documented in the hazard log. If appropriate, an ad-hoc meeting will be arranged with all available
staff to discuss significant changes where their expertise will be beneficial to identify possible safety
issues. Any actions or decisions from this meeting will be documented.
5. Safety Assurance
Safety Assurance is carried out by (insert name) using the SM ICG SMS Evaluation Tool and this will
include a review of the effectiveness of all risk mitigations in the Hazard Log. The Hazard Log will be
reviewed as part of the annual Management Review with the assistance of an independent SMS
auditor from (insert name).
Our safety performance indicators (SPIs) are detailed in Appendix 1 and will be used to monitor our
safety performance and help us strive for continuous improvements. These SPIs and our targets will
be reviewed as part of our annual Management Review that will use the template in Appendix 2.
The Management Review will culminate in a meeting to allow all our staff to contribute.
Any new employee, contractor, or contracted organization will be required to read this manual
(including updates) and sign for having read and understood it.
Any safety critical information that needs distributing will be sent by e-mail to all our stakeholders and
posted on the safety notice board. A distribution list is available held on the secure (company name)
website and will be reviewed annually. All staff are expected to review the safety notice board and
read any new safety articles.
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Table of Contents
List of Effective Pages
Distribution List
Safety Policy and Objectives
o Safety Policy signed by the Accountable Executive to indicate
“Management commitment and responsibility”
Safety Organization
o Safety accountabilities and responsibilities
o The Accountable Executive and key safety personnel
SMS Documentation
o What, when, who, where and how to document and record the SMS
activities
Safety Risk Management
o Safety reporting and hazard identification process
o How to assess hazards and risks and how to take corrective actions
Safety Assurance
o Safety performance monitoring and measurement
o Safety audits and surveys
o How to manage changes using SMS
o How to improve the SMS continuously using the monitoring result
o Management Review
Safety Promotion
o How to provide safety training and education to all staff
o How to achieve safety communication
Emergency Response Plan
o How to deal with emergency situations
o Quick reference guide for key staff members
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Issue What is the How bad is How likely is it What action Follow-up (if
(hazard) result the result to occur are we taking applicable)
(consequence) (Who and
when)
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Location:
Section /
Name of Reporter
Organization
In your opinion, what is the likelihood of such an event or similar happening or happening
again?
What do you consider could be the worst possible consequence if this event did happen or
happened again?
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Report Reference
Signature Date:
Name
If further investigation is needed, perform that now and document on the investigation form. This
information will support the Safety Committees activities.
What action or actions have been or are being taken to prevent the issue or hazard from
occurring in the future and/or to mitigate its consequences?
Resources required
Responsibility for
Action
Signed:
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Location:
Section /
Name of Reporter
Organization
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What action or actions have been or are being taken to prevent the issue from occurring in the
future and/or to mitigate its consequences?
Resources required
Responsibility for
Action
Signed: Date
Who
When
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Situation - An apprentice engineer installed the landing gear pins in the main landing gear so the aircraft
could be jacked up to allow a retraction test of the nose gear. When the gear switch was selected up, the
main and nose gear retracted. The main jacks (which had been lowered but not removed) punched
through the bottom of the wings as the aircraft came to rest on its belly on the hangar floor. The incident
took place at 3:00 AM and the aircraft was to be on line at 6:00 AM.
Problem Statement – At 3:00 AM on March 1 this year, both aircraft wings were punctured on C-FOX
during a retraction test of the nose gear at Prairie Base, even though landing gear safety pins had been
installed.
1. Why did the main gear retract with the pins installed?
A: The apprentice engineer installed the landing gear pins in the wrong hole.
2. Why did the apprentice install the pins in the wrong hole?
A: These holes had not A: The apprentice had A: The lighting in the A: The apprentice was
been filled, as never been shown the hangar was not working under pressure.
recommended by the correct location for the adequate for night
aircraft manufacturer’s pins and was working conditions.
service bulletin (SB). completing the work
without supervision.
3. Why was the SB not 3. Why was the 3. Why was the lighting 3. Why was the
complied with? apprentice completing in the hangar apprentice working
unsupervised work inadequate? under pressure?
without adequate
direction?
A: It was in a pile of A: The supervising A: The lights were more A: The aircraft had to
SB's that had not been engineer was on than 20 years old and fly at 6:00 AM, the
assessed. vacation that week. some of the fixtures aircraft maintenance
were broken. manual required the
The apprentice had
retraction test to be
completed similar tasks
done, and the
to this before and felt
apprentice was fatigued.
qualified to complete
this task.
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4. Why had the SB’s not 4. Why were there no 4. Why were the fixtures 4. Why was the
been assessed? arrangements to ensure not repaired or apprentice fatigued?
alternate supervision? replaced?
A: The company did not A: Management did not A: Management did not A: The apprentice was
have a documented foresee the schedule upgrade the lighting finishing a 12-hour
procedure for assessing conflict in time to correct when the hangar was graveyard shift, and did
SB's. the omission. purchased 15 years not recognize the
ago, and did not act on cumulative effect of
complaints made about fatigue and pressure on
poor lighting. work performance.
5. Why was there no 5. Why did 5. Why was the lighting 5. Why did the
procedure for assessing management not not upgraded when apprentice not
SB's? foresee the schedule complaints were recognize the effect of
conflict in time to received? these factors on work
compensate? performance?
A: The Director of A: Although staff must A: Senior management A: Human factors
Maintenance was over- get approval for did not feel there was a training had not been
tasked due to a staff vacation time, no one in need to upgrade the provided.
shortage. Scheduling followed up lighting, citing expense
to see if there was a reasons.
conflict.
Appendix 7 30 | P a g e
SMS for Small Organizations
Location:
Section /
Name of Investigator
Organization
Describe why the issue happened and any factors associated with it:
“Root Cause”
Appendix 8 31 | P a g e
SMS for Small Organizations
Document the recommended action plan and any follow-up (by whom and when):
Appendix 8 32 | P a g e
SMS for Small Organizations
All events and reported issues will be assessed for severity and likelihood using the following
definitions and then assessed using the following risk acceptability matrix. The person
responsible for the SMS (insert title) will carry out the initial risk assessment and an independent
validation is carried out by one of the following personnel:
• Accountable Executive
• Quality Manager (or identify alternative post)
• Identify another post if appropriate
Likelihood of Occurrence
Qualitative Meaning Value
Definition
Likely Likely to reoccur or to occur several times in a 3
year
Possible Possibly reoccur or to occur at least once a 2
year
Unlikely Very unlikely to reoccur or occur 1
Appendix 9 33 | P a g e
SMS for Small Organizations
Likelihood
Unlikely (1) Possible (2) Likely (3)
Severity
Management of Change
Any issues identified as part of a change such as organizational, operational, and
physical changes, will be assessed using this same process.
Appendix 9 34 | P a g e
SMS for Small Organizations
All events and reported issues will be assessed by (insert name or role) to determine
what the issue is, what could happen as a result and what actions need to be taken (if
any) and by whom to manage the risk. The Hazard Log (see below) will be updated
and reviewed on a monthly basis and the updated version will be posted in the (insert
where it will be posted).
What is the What could happen as a What action are we Action by whom
issue? result? taking? and when
(consequence)
Management of Change
Any significant changes, such as organizational, operational, and physical changes, will
be assessed for safety issues related to the change and documented in the Hazard Log.
Appendix 10 35 | P a g e
SMS for Small Organizations
Target Performance
Performance Indicator
Qtr1 Qtr2 Qtr3 Qtr4
Major Risk Incidents* per 100 flights 0
Mandatory Reports per 100 flights 3 or less
Voluntary Reports per employee
More than 10
per year
Overdue safety report closures per
2 or less
year
Safety meetings per year 4
Safety briefings per year 2
Safety audits per year 2
Organization-specific SPIs
Operator: Flights flown with
operational MEL restrictions per Less than 5%
100 flights
Aerodrome: Runway incursions per
Less than 5
year
Maintenance: Maintenance errors
Less than 5
per year
ATS: Airspace infringements per
Less than 2
100 movements
*as defined in Safety Management Manual para XX
These are only suggested to give small organizations some ideas for safety
performance indicators (SPIs) and the targets will need to be customized to the size and
nature of the operation and the values given are just examples.
The objectives and SPIs should be reviewed as part of the Management Review to
decide whether they need to be amended or updated.
Appendix 11 36 | P a g e
SMS for Small Organizations
ORGANIZATION/
BUSINESS AREA/
DEPARTMENT
DESCRIPTION OF
THE ISSUE OR
NON-
CONFORMANCE
ROOT CAUSE(S)
STEP 2 : ANALYSIS OF CAUSES AND
PREVENTIVE
ACTION TO BE
TAKEN INCLUDING
RESPONSIBLE
PERSON AND
DEADLINE
ACTUAL DATE OF
ACTION (S) TAKEN:
STEP 3 : VERIFICATION AND
Comments:
EVALUATION
Appendix 12 37 | P a g e
SMS for Small Organizations
2. Who?
Describe who is responsible to implement the change
Appendix 13 38 | P a g e
SMS for Small Organizations
What is the issue? What could happen as a result? How Bad How likely Risk What action(s) are we Action by
(hazard) (consequences) will it be? is it to rating taking? whom and
(severity) occur? (mitigations) when
(likelihood)
1
There may be more that one
mitigation for each issue
2
3
Appendix 13 39 | P a g e
SMS for Small Organizations
What is the issue? What could happen as a result? How Bad How likely Risk What action(s) are we Action by
(hazard) (consequences) will it be? is it to rating taking? whom and
(severity) occur? (mitigations) when
(likelihood)
4
5
Date:
Appendix 13 40 | P a g e
SMS for Small Organizations
Date Time
Present
Absent
AGENDA
# of Mandatory Reports
# of Voluntary Reports
Appendix 14 41 | P a g e
SMS for Small Organizations
Performance
Performance Indicator Target
Qtr1 Qtr2 Qtr3 Qtr4
# of Safety Meetings
# of Safety Briefings
# of Safety Audits
Organization-specific SPIs
Appendix 14 42 | P a g e
SMS for Small Organizations
Management
…..
SPIs
Documentation
……
8. Other Business
Person
Completion
Issue Follow up Action fulfilling
Date
Action
Appendix 14 43 | P a g e
SMS for Small Organizations
Appendix 15 44 | P a g e
SMS for Small Organizations
This paper was prepared by the Safety Management International Collaboration Group (SM
ICG). The purpose of the SM ICG is to promote a common understanding of Safety
Management System (SMS)/State Safety Program (SSP) principles and requirements,
facilitating their application across the international aviation community.
The current core membership of the SM ICG includes the Aviation Safety and Security Agency
(AESA) of Spain, the National Civil Aviation Agency (ANAC) of Brazil, the Civil Aviation
Authority of the Netherlands (CAA NL), the Civil Aviation Authority of New Zealand (CAANZ),
the Civil Aviation Safety Authority (CASA) of Australia, the Direction Générale de l'Aviation
Civile (DGAC) of France, the Ente Nazionale per l'Aviazione Civile (ENAC) in Italy, the
European Aviation Safety Agency (EASA), the Federal Office of Civil Aviation (FOCA) of
Switzerland, the Finnish Transport Safety Agency (Trafi), Japan Civil Aviation Bureau (JCAB),
the United States Federal Aviation Administration (FAA) Aviation Safety Organization, Transport
Canada Civil Aviation (TCCA) and the Civil Aviation Authority of United Kingdom (UK CAA).
Additionally, the Civil Aviation Department of Hong Kong (CAD HK), the International Civil
Aviation Organization (ICAO), and the United Arab Emirates General Civil Aviation Authority
(UAE GCAA) are observers to this group.
To get copies of the templates in the appendices so you can edit them please contact Simon
Roberts
simon.roberts@caa.co.uk