SMS

Continuation
Training
 FOREWORD

• This training of “SMS Continuation” describe about

the importance of Safety Management System,
Safety & Quality Policy, Safety Management System
process, all procedures related safety and any
specific safety issues relevant to organization.
• GMF as Approved Maintenance Organization (AMO)
must comply with required authority regulation,
manufactures and customer requirement when
perform inspection during maintenance.
• Beneficial comments and any pertinent data that
may be use in improving this document should be
addressed to GMF Training Department.
 OBJECTIVES

This training satisfies for:

ICAO Doc. 9859 Safety Management Manual,

Fourth Edition 2018

Upon completion the training, the students will be able to:

1. Understanding the importance of Safety Management
System
2. Describe company Safety & Quality Policy
3. Describe Safety Management System flow process
4. Describe all procedures related safety
5. Informed any specific safety issues relevant to organization
 COURSE OUTLINE

Understanding Safety Management System

Safety & Quality Policy
SMS Process & Procedure
Safety Risk Management
Safety Reporting
Safety Communication
Safety Highlight Issues
UNDERSTANDING
SAFETY MANAGEMENT SYSTEM
 BASICS SAFETY MANAGEMENT

Is it ….
➢ Zero accidents (or serious incidents) ?
➢ Freedom from danger, risks or injury ?
➢ Error avoidance ?
➢ Regulatory compliance ?
➢ ………. ?

• But….
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
 SAFETY & SAFETY MANAGEMENT (ICAO)

Safety is the state in which risks associated with aviation

activities, related to, or in direct support of the operation of
aircraft, are reduced and controlled to an acceptable level.

Safety management is a systematic approach to hazard

identification and risk management — in the interests of
minimizing the loss of human life, property damage, and
financial, environmental and societal losses

Safety management system is a systematic approach to managing

safety, including the necessary organizational structures,
accountability, responsibilities, policies and procedures.
 WHAT KIND OF INDUSTRY WE ARE IN ?

河豚
FUGU
✓ Fugu (puffer fish) contains lethal amounts of the poison
tetrodotoxin the internal organs, especially the liver and “Fugu wa kuitashii,
ovaries, and the skin. inochi wa oshishii”
✓ Therefore, only specially licensed chefs are allowed to
prepare and sell fugu to the public. “I want to eat Fugu,
but I don’t want to die”
✓ However, a number of people die every year from
consuming improperly prepared fugu
 THE MANAGEMENT DILEMMA

Management levels

Resources Resources

Protection Production
 THE MANAGEMENT DILEMMA

Resources Resources

Production Protection

Protection Production

Bankruptcy

Catastrophe
 THE SAFETY SPACE

Financial
Management

Bankruptcy
Protection

Safety
Catastrophe Management

Production
 WHY SM? AN IMPERFECT SYSTEM

System Baseline performance

design

Operational “Practical
deployment drift”
 CULTURE

➢A system developed by a group including:

✓ beliefs → what is true,
✓ values → what is important,
✓ expectations of behavior → what is implied by engaging in
a given action.
➢It is what one expects of oneself and what one expects of
others in the groups in which one lives and works.
➢It is the man-made part of the environment (i.e. machines,
buildings, technology).
➢It is the way we do things around here and how we talk about
the way we do things around here.

ICAO Circular 302-AN/175

 THE COMPONENTS OF SAFETY CULTURE

Reporting Just Informed Flexible Learning

An There is an Who manage and An An Organisational

atmosphere of trust. operate the system Organisational must posses the
Organisational
People are have current can adapt in the willingness and the
climate in which encouraged (even knowledge about face of high- competence to
people are rewarded) for the human, tempo draw the right
prepared to providing essential technical, operations or conclusions from
safety –related organisational and certain kinds of its safety
report their information, but they enviromental information system
are also clear about danger.
errors and near- factor that and be willing to
where the line must
misses. be drawn between determine the implement major
acceptable and safety of the reform.
unacceptable system as whole.
behavior.
Source: CASA
 ACCIDENTS / INCIDENTS CAUSATION

Accidents require the coming together of a number of contributing factors

— each one necessary to breach system defenses and may involve active
failures at the operational level, and latent conditions.
➢Active failures are generally the result errors committed by
operational personnel.

➢Latent conditions, may be the result of undetected design flaws and

related to unrecognized consequences of officially approved
procedures. Latent condition in the system at the management level
 ACCIDENTS CAUSATION – REASON’S MODEL
“Swiss Cheese” Model

Organizational Latent Condition

Factors
Unsafe Latent Condition
Supervision

Unsafe Act Latent Condition

Preconditions
Unsafe
Active Failure
Failed or Acts
Absent Defenses

Accident
COMPANY
SAFETY & QUALITY POLICY
 GMF SAFETY & QUALITY POLICY

1. Recognizing SAFETY as prime consideration by:

❑ Implementing Aviation Regulation & Safety Management System effectively.
❑ Making everyone responsible for safer operations.

2. Focusing on CUSTOMER REQUIREMENTS by:

❑ Providing our customer with services that meet or exceed their stated and implied
requirements in a timely and cost effective manner.
❑ Maintaining a continual focus on fast and systematic response to our internal and external
customer needs.

3. Applying HUMAN FACTORS principles by:

❑ Encouraging free and frank reporting of safety related occurrence and establishment of
just culture (personnel are not inappropriately punished for reporting or co-operating with
occurrence investigations).
❑ Making everyone responsible for Human factor issues

4. Implementing QUALITY SYSTEM by:

❑ The effective use of the quality system and resolving problems by taking timely corrective
and preventive actions.
❑ Being committed to making good cooperation and communication with auditing personnel.

SMM 1.1 and MOE / AMO 1.2

 SAFETY OBJECTIVE

The GMF AeroAsia safety objectives are listed below :

1. To minimized accidents/incidents attributed to
organization factors
2. To prevent property damage and personnel injury
that resulting from our operations
3. To promulgate a continuous systematic hazard
identification
4. To provide a safe and healthy work environment for
all personnel
COMPANY PROCEDURES
RELATED TO SAFETY
 GMF QUALITY SYSTEM STRUCTURE

SMM describes the Safety Management

System implementation of GMF as
Approved Maintenance Organization are
AMOM, SMM in accordance with:
RSQM, (OHS - ICAO SMM (Doc 9859)
MOE included)
- ICAO Annex 19
QUALITY PROCEDURES (QP)
EMERGENCY RESPONSE PLAN (ERP)

WORK INSTRUCTIONS (WI)

Departmental Procedures & NDT Procedures
MAINTENANCE INSTRUCTIONS
Job Cards, PD Sheets, MDR, Records, Engineering Instruction ,
Engineering Order

Other organizations which are subcontractors of GMF shall be responsible to

follow GMF’s Safety Management Manual when they perform the service or
deliver the product in GMF area.
 PROCEDURES RELATED TO SMM

Procedure
No. Title
Number
1 QP 107-03 Aircraft Maintenance Safety
2 QP 107-04 Safety Work and Facilities
3 QP 207-02 Foreign Object Damage Prevention
4 QP 218-01 Internal Occurrence Reporting
5 QP 218-02 Line Operation Safety Audit
6 QP 218-03 Mandatory Reporting
7 QP 225-02 Hazard Identification , Risk Assessment & Mitigation
8 QP 225-01 Disciplinary Policy for Maintenance Event
9 QP 301-01 Internal Safety and Quality Audit
10 QP 303-01 Investigation of Deficiency, Incident or Accident
11 DS 002 Emergency Response Plan
12 DQ 008 Approved Maintenance Organization Manual

13 DQ 046 Approved Maintenance Organization Manual Training Programe

SMS PROCESS
 SMS FLOW PROCESS

Directions Safety Action Group

Safety Performance
Safety Committee : and
Decisions
Report QSMR & SMR Quarterly Meeting
Semesterly review by Top Quarterly review by each department
Management
SMAR (SAG Monthly Activity Review)
Safety Targets Monthly review by all SAG department
& Planning
1. Base Maintenance
2. Component Services
3. Engineering Services
Quality Assurance & 4. Line Maintenance
Safety 5. Material Services
Facilitator & Monitor by Audit , 6. Cabin Maintenance Services
Surveillance, & Promotion Coordination 7.
8.
Engine Maintenance
Corporate Affairs
9. Kalimantan Line Maint
10. Bali & Nusa Tenggara Line Maint
11. Sulawesi & Eastern Line Maint
12. Sumatera Line Maint
13. Surabaya Line Maint
Operation & 14. Learning Services
15. Outstation Line Maintenance
Action 16. Furnishing & Upholstery Services
Implementing Safety 17. GMF A/C Support & Power Serv.
Management System 18. Logistic & Bonded Services
Safety Risk Management Safety 19. Information & Comm.Technology
20. Human Capital Management
& Safety Assurance Risk Mitigation
& Corrective Action
SAG Chairman chaired by VP in each dept.
SAG Secretary is selected person
that appointed by SAG Chairman
 SAFETY ACTION GROUP (SAG)
ROLES AND FUNCTION

Safety Action Group ref. SMM 1.2.8:

Overseeing operational safety Implemeting mitigation or

corrective actions relevant to
within the functional area
the area.

Managing the area’s hazard Maintaining and reviewing

identification relevant performance indicators

Assessing the impact of

safety on operational Managing safety training and
changes and activating promotion activities within the
hazard and risk analysis area
process as appropriate
SMS TOOLS:
- MEDA
- AUDIT & SURVEILLANCE
- MLOSA
- HIRAM
 MEDA
Maintenance Error Decision Aid (MEDA) is a
process that used to investigate the events Organization
Immediate environment Supervision
caused by Mechanic / Inspector / Engineering / Faciliti -Philosophy
- Planning
Planner performance and the related Weather -Other M & E
- Organizing
personnel Mechanic Aircrsft - Prioritizing Organization
MEDA Goal : To IMPROVE SAFETY and Reduce - Knowledge Design/configuration - Deligating
- Skill Component Design
-Policies
Economic Impact due to Maintenance Error - Instructing
- Abilities Equipment /tools/parts -Procedure
- Feedbact
MEDA Objective : Maintenance Manual -Processes
- Other - Performance
➢ Investigate maintenance errors caracteristic
Tasks Management -Selection
➢ Make system changes to eliminate / Time pressure -Team -Training
reduce error Team Work Building -Continous
On-the –job training
➢ Dispatch airplanes with no maintenance Communication
quality
error induced discrepancies improvement
Anything that affects how a mechanic does
his/her job can be contributing factor to an
error or a violation.

The MEDA Event Model

Probability Probability Probability

Contributing Factors Violation Error Event

✓ The torque wrench The mechanic does not The bolt is under A/C RTB
not available; or use a torque wrench to torque
✓ The work group torque a bolt
norm
 HUMAN ERRORS: ERROR VS VIOLATION

The difference lies in the intent,

a violation is a deliberate act (sengaja), while an
error is unintentional (tidak disengaja).
➢ Error must be accepted as a normal component of any system
where humans and technology interact. “TO ERR IS HUMAN.”
➢ Understanding how normal people commit errors is fundamental
to minimize the effects of human errors on safety.
➢ Human errors are manageable through the application of
improved technology, relevant training, and appropriate
regulations and procedures.
 AUDIT & SURVEILLANCE

What’s Audit?
• A systematic, independent and documented process for
obtaining audit evidence and evaluating it objectively to
determine the extent to which the audit criteria are fulfilled.
(Lead Auditor Course, GMF AeroAsia)

What’s Surveillance?
• The activities through proactively verifies through inspections
and audits that continue to meet the established requirements
and function at the level of competency and safety required by
the company procedure.
 MLOSA AND ITS CHARACTERISTICS

• Peer observations of tasks being carried out

conducted by trained observers.
• Goal: Stop errors from occurring that lead to
injuries, equipment/aircraft damage, airline
process failures, and other events.
• Voluntary, non-threatening, and non-punitive.
 MANAGEMENT OF CHANGE

➢ As part of aviation organizations, GMF experiences constant change due to

expansion and introduction of new equipment or procedures.
➢ Change can introduce new hazards; impact the appropriateness of existing
safety risk mitigation strategies, and/or impact the effectiveness of existing
safety risk mitigation strategies.
➢ External changes will include change of regulatory requirements, change
of security level, etc.
➢ Internal changes can involve management/organizational changes, major
new equipment introduction or new procedures, etc.
➢ GMF shall establish a formal management of change process which
identify changes within or from outside the organization which may affect
established processes and services from a safety viewpoint as per QP-225-
02 (Hazard Identification, Risk Assessment and Mitigation).
➢ Prior to implementing such changes, the new arrangements shall be
assessed using the SMS hazard and risk analysis protocol or in relation
to previously completed risk mitigation as applicable.
 HIRAM FORM GMF/Q-286 R2

30 Agustus 2018
Joint Venture Engine Maintenance Shop with other Company
10% of the engine repair process will be carried out and managed by other under company certification
Alignment of Quality System and Process and also approved by Authority
Engine Maintenance Shop

Man power not qualified Personnel can’t 1. Undersupervise

with CASR and company personnel of other XX 20
Perform maintenance
Quality System company XX Des
process comply with 5B 2. Develop Qualified 2D XX
18
regulation Manpower to meet
regulation
requirement

Caroline
Budi
SAFETY RISK MANAGEMENT
 HAZARD, CONSEQUENCE & RISK

➢ Hazard – Condition, object or activity with the potential

of causing injuries to personnel, damage to equipment or
structures, loss of material, or reduction of ability to
perform a prescribed function.
➢ Consequence – Potential outcome (s) of the hazard.
➢ Risk – The assessment, expressed in terms of predicted
probability and severity, of the consequence (s) of a
hazard taking as reference the worst foreseeable situation.
 EXAMPLE OF HAZARD, CONSEQUENCE

➢ Unsecured stair in the apron close to a parked aircraft is

a hazard.

➢ The potential that unsecured stair hit and causing

damage to the aircraft is one of the consequences of
the hazard.
➢ The assessment of the consequences of the potential
of the aircraft damaged by the stair expressed in terms
of probability and severity is the risk.
 SAFETY RISK MANAGEMENT (SIMPLE PROCESS)

Hazard Identification
Identify the hazards to equipment, Step 1: Hazard
property, personnel or the organization Identification

Severity / Criticality
Evaluate the seriousness of the
consequences of the hazard occurring

Probability of Occurrence
What are the chances of it happening? Step 2: Risk
Assessment
Acceptability
Is the consequent risk acceptable and
within the organization safety
performance criteria?

Yes No
Take action to reduce the risk Step 3: Risk
Accept the risk to An Acceptable level Mitigation
 HAZARD IDENTIFICATION METHOD

Step 1: Hazard identification is the critical first step in managing safety

Hazard Identification

Reactive method Proactive method Predictive method

The reactive method The proactive method The predictive
responds to the looks actively for the method captures
events that already identification of system
happened, such as safety risks performance as
incidents and through the analysis it happens in
accidents of the organization’s real-time
activities. normal operations

REACTIVE METHOD: PROACTIVE METHOD: PREDICTIVE METHOD:

• By analyzing IOR and
• MEDA • Hazard Report (using
MEDA data
IOR system) • HIRAM for management
Investigation • Safety Audit & of changes or Specific
Surveillance Condition.
• M-LOSA
 HAZARD EXAMPLES IN THE HANGAR

Access / Stairs Lighting

Temperature

Tools &
Equipments

Electrical

F.O(D)

Fuel spill
Documentation
Materials Maintenance Data Personnel Safety
38
 HAZARD EXAMPLES IN THE RAMP

Wildlife Tool & Equipment

Obstacles

Personnel Safety Security issues

Non Standard
Vehicles Procedure

Fuel Spill
Stand

FOD
Signing / Marking
 HAZARD IDENTIFICATION METHOD

Step 2: Typically, the assessment of hazard involves two considerations:

Risk Assessment

1. The PROBABILITY of the hazard precipitating an unsafe event

(i.e. the probability of adverse consequences should the
underlying unsafe conditions be allowed to persist).

2. The SEVERITY of the potential adverse consequences, or the

outcome of an unsafe event.
GMF RISK INDEX
 HAZARD IDENTIFICATION METHOD

Step 3: Three basic strategies in risk mitigation are as follows:

Risk Mitigation

➢ Avoidance – The operation or activity is cancelled because risks exceed

the benefits of continuing the operation or activity.

➢ Reduction – The frequency of the operation or activity is reduced, or

action is taken to reduce the magnitude of the consequences of the
accepted risks.

➢ Segregation of exposure – Action is taken to isolate the effects of risks

or ensure there is build-in redundancy to protect against it i.e. reducing
the severity of risk.
 HAZARD IDENTIFICATION SUBJECTS SEMESTER 1 2019

The total subjects in Semester 1 2019 is 1186

Subjects that consist of:
Proactive
(721 sub)
Predictive Methode
This Predictive method is consist of
HIRAM (195) and MLOSA (68)
Predictive
(263 sub)
Proactive Methode
This method is consist of IOR (517), Safety Audit
(37), Procedure Audit (17), Quality Audit (94),
Random Audit (2) and Surveillance (54 subjects)
.

Reactive Methode
This method is consist of MEDA and
Common investigation (149 subjects).

Internal Risk Assessment (IRA)

Internal Risk This IRA consist of HIRA (26) and Review
Reactive J/C prior to Distribution (27).
Assessment (IRA) (149 sub)
(53 sub)
 CORPORATE RISK VALUE

Risk Value Distribution Extreme Risk (750-1000)

Stop or cancel operation or process immadiately,
unacceptable under the existing circumtances. Do not permit
any operation until sufficient control measures have been
795 implemented to reduce the risk.
772 High Risk (550-749)
Ensure that corrective action has been satisfactorily
completed and declared preventive control are in place
HIRAM Medium Risk (350-549)
item Perform Risk Mitigation and review the operational safety.
that
Low Risk (175-349)
384 propose
d in end Acceptable after review, mitigation are optional.
of June Neglegible Risk (1-174)
230
Acceptable as is, no mitigation required. .
162

29 21 13
0 2
418.8 Proposed Current Risk

Neglegible Low Medium High Extreme

Corporate Current Risk
313.2
Current Risk Value Proposed Risk Value
 TOP 5 RISK DIMENSION

Facilities (288 Subjects)

Perform Facility PMI and
5S/5R consistently. Information (205 Subjects)
Analyze the finding regarding of Jobcard, manual,
etc and revise the master jobcard.

Organizational Factor (150 Subjects)

Make safety bulletin, perform cascading socialization, Individual Factor (126 Subjects)
and perform HIRAM if any Management of change Perform briefing, surveillance, safety
campaign, and indoctrination.

Equipment (Aircraft & Personel) (86 Subjects)

Perform Equipment PMI, briefing to maintenance personnel regarding the
used of equipment and provide the necessary equipment as per
manual/procedure.
SAFETY REPORTING
 THE FOCUS OF SMS

Accidents
1–5

Serious incidents
30 – 100

Incidents
100 – 1000

Latent conditions
(Hazards)
SMS 1000 – 4000
 WHY SHOULD WE REPORT INTERN OCCURRENCE ?

1 FATAL ACCIDENT

10 ACCIDENTS

30 INCIDENTS

600 REPORTABLE OCCURENCES

The Heinrich – 1 : 600 ratio

 WHAT TO REPORT?

Any Hazard : Condition, object or activity with The potential

of causing
1. Injuries to personnel,
2. Damage to equipment or structures, loss of material
or reduction of ability to perform a prescribed function
3. Threatens (mengancam) the organization’s viability
(“kelangsungan hidup”)
 WHAT TO REPORT? SCOPE OF HAZARD
The scope for hazards may be related but not limited to:
Design Factor equipment and task design

Procedures and documentation and checklists

Operating Practices
Communications language proficiency and terminology

Organizational company policies for recruitment, training, remuneration and allocation of

Factors resources
Work Environment ambient noise and vibration, temperature, lighting, protective equipment
Factors and clothing
Defenses detection and warning systems, and the extent to which the equipment is
resilient against errors and failures
Human Factors medical conditions, circadian rhythms and physical limitations

Regulatory the applicability of regulations and the certification of equipment, personnel

Factors and procedures
Changes changes to personnel, location of facility, organization, capability list, working shift and
handover procedure and other procedures, equipment and tools
SMM 2.2
 MANDATORY REPORTING

This procedure is related with:

a) Reporting important operating defects and malfunctions found by GMF AeroAsia to TC
Holder, Operator, and Authority.
b) Reporting deficiencies caused by GMF AeroAsia to Operator or Authority.

Authority Database for Mandatory Reporting & Required Time

Authority Reporting Required time
EASA The Report will be done through 2 ways: on-line reporting via a web-
interface www.aviationreporting.eu or off-line reporting using a pdf 72 Hours
form downloadable from the EASA portal.
CASA On a form using the following web site http://drs.casa.gov.au Two business
days
FAA On a form using the following web site http://av-info.faa.gov/sdrx 72 Hours
DGCA For DGCA Indonesia: Service Difficult Report Form No. DGCA 43-01
pdf downloadble through http://dkppu.id 72 Hours
Other For any other Authority: As instructed by the NAA.
authority As instruction
Customer As instructed by customer manual As instruction
IOR/ VOLUNTARY REPORT
FLOW PROCESS
 IOR/ VOLUNTARY REPORT
FLOW PROCESS
Hazard Identification

Address :
http://apps.gmf-aeroasia.co.id/app_ior/
OR you can report via WhatsApp on +62 856 9467 4404.
 IOR 2007 – 2019 (Smtr 1)

2000
IOR Trend 2007 - 2019
1549
IOR Quantity

1500 1257
966 901 984
1000 741
609 578 554 556 512 522
500 148
0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Sem I
2019
SAFETY COMMUNICATION
SAFETY PROMOTION
PENITY
SAFETY HIGHLIGHT ISSUES
 HIGHLIGHT ISSUE:
HIRAM AIRCRAFT PARKING
Found aircraft
B737 NG parked
too close with
other aircraft. It is
too risky during
towing or moving
the aircraft. It can
cause collision
during move the
aircraft.
And also found aircraft has no marking. It can cause
ambiguity for the GSE operator and collision during
move the aircraft.

Current Risk After follow-up Risk

5B 5B
 HIGHLIGHT ISSUE:
IOR - PAINTING IN OPEN HANGAR
Event :
Wide Body Aircraft Painting process in open maintenance
hangar cause excesive paint fume impact.
There was office personnel get health impact (ISPA)

Follow Up :
- Perform painting process on out of office hour or on
day off (Saturday/Sunday).
- Perform plastic covering on aircraft during painting
process.
- HIRAM has been initiated however excesive paint fume
was not eliminate or reduce

Current Risk After follow-up Risk

4B 4B
 HIGHLIGHT ISSUE:
MLOSA DEMOGRAPHIC Sem 1 2019
Most of Risk happened on
REMOVAL PHASE.

The most contributing factor

comes from
ORGANIZATIONAL FACTOR.

The most Threat is Work

Process / Procedure not
Followed.
Thank You.

PT GMF AeroAsia Tbk.

Soekarno-Hatta International Airport
Tangerang, Indonesia 15125