Implementing Safety Management Systems The Canadian Perspective

1. Implementing Safety Management Systems The Canadian Perspective

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

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

4. 1. Safety Management Plan • Safety Policy • Non-punitive Safety Reporting Policy • Roles, Responsibilities & Employee Involvement • Communication • Safety Planning, Objectives & Goals • Performance Measurement • Management Review Transport Canada’sSMS: Components & Elements • 2. Document Management • Identification & Maintenance of Applicable Regulations • SMS Documentation • Records Management • 3. Safety Oversight • Reactive Processes • Proactive Processes • Investigation and Analysis • Risk Management 4. Training 5. Quality Assurance 6. Emergency Preparedness

5. SMS COMPONENTS • Safety Management Plan • Documentation • Safety Oversight • Training • Quality Assurance • Emergency Response Plan

6. COMPONENT1– SMS Plan The Safety Management Plan should include: • Company safety policy • Roles and responsibilities • Description of safety management system processes • Safety performance targets • Management review

7. COMPONENT 2 - Documentation Processes for: • Identifying applicable aviation safety regulations, including standards and exemptions, and where required, procedures for demonstrating compliance with them; • Implementing changes to company documentation as required due to amendments to aviation safety regulations, standards and exemptions.

8. COMPONENT 2 - Documentation • Consolidated documentation describing the systems for each component of the safety management system; • Maintenance of current applicable; and • Maintenance of effective documentation. Note: Documentation includes all types of printed material including manuals, bulletins and safety reports.

9. COMPONENT3 – Safety Oversight Subcomponents of Safety Oversight are: • Reactive processes of occurrence/ hazard reporting and event investigation and analysis; • Proactive safety assessments; and • Common elements to both reactive and proactive processes.

10. COMPONENT3 – Safety Oversight Reactive Processes • Occurrence/hazard reporting; and • Event investigation and analysis Proactive Processes • Hazard Identification • Hazard Register • Safety Risk Profile • Safety Case

11. COMPONENT4 – Training • Training for SMS should be commensurate with the individual’s function in the System and might include: • Investigation and analysis techniques • Human and organizational factors • Business processes • Reporting techniques • Auditing Techniques • LOSA/FOQA

12. COMPONENT5 – Quality Assurance An effective QA system should encompass: • Well designed and documented procedures for product and process control; • Inspection and testing methods; • Internal and external audits, as applicable; • Corrective and preventive action; and, • The use of appropriate statistical analysis, when required.

13. COMPONENT6 – Emergency Response Preparedness • Emergency planning should aim where possible to prepare an organization in the event that an emergency situation occurs. • This preparation should through good planning, reduce, control or mitigate the effects of the emergency. • The ERP should • be monitored and changed as the operation changes • be subject to regular exercises • address all interested parties

14. Safety Management System Process Flow Initial Risk Assessment • (REACTIVE) • REPORTS • Hazards • Incidents • Accidents • Data base • Risk Analyses • (PRO-ACTIVE) • SAFETY ASSESSMENT • Audits • Policy and Procedures Assessment • Hazard Identification Database • Information • Dissemi- • nation • Trend analysis • Safety bulletins • Report distribution No Action Further Investigation Second Risk Assessment No Action Determine Contributing Factors Determine and Implement Corrective Action Monitor Corrective Action Correct Confirmation of Corrective Action – Quality Assurance System Evaluation

15. The CARs vs ICAO Requirements 1. Safety Management Plan Safety Policy Non-punitive Safety Reporting Policy Roles, Responsibilities & Employee Involvement Communication Safety Planning, Objectives & Goals Performance Measurement Management Review 2. Document Management Identification & Maintenance of Applicable Regulations SMS Documentation Records Management 3. Safety Oversight Reactive Processes Proactive Processes Investigation and Analysis Risk Management 4. Training 5. Quality Assurance 6. Emergency Preparedness PLAN: Safety Policy and objectives Management commitment and responsibility Safety accountability of managers Appointment of key personnel SMS implementation plan PLAN: Safety Assurance - Safety performance and measurement Management of change PLAN: Safety Promotion - safety communication DOCUMENTATION -Documentation SAFETY OVERSIGHT: Safety Hazard Identification & Risk Management Hazard identification process Risk assessment and mitigation Internal safety investigation TRAINING: Safety Promotion - Training and Education QUALITY ASSURANCE: Safety Assurance - Audits and surveys Safety performance measurement Audits and surveys Safety Hazard Identification & Risk Management – Continuous improvement EMERGENCY RESPONSE PREPAREDNESS - Development of ERP 15

16. What Have we’ve learned (as a regulator) about SMS Implementation?

17. 1. - Implementing SMS Draft the (a) regulations and appropriate (b) standards Consult with the industry on (a) and (b) Get the industry involved from the outset

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

19. Why a phased in approach to SMS? Issuance of regulatory exemption to the CARs Provides a manageable series of steps for organizations to follow. Four implementation phases were identified; each phase involves the introduction of specific SMS components and elements. Provides for continuous improvement through “lessons learned”

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

21. Regulations should define the Accountability Framework The Accountable Executive The Person Responsible for Maintenance The Director of Flight Operations The Person Responsible for the SMS

22. Company-wide understanding of human performance & error Human Factors Training Transport Canada’s Philosophy A three layered approach Accountability- responsibility upper management Accountable Executive Safety Management System Systemic Approach to Safety

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

24. Safety responsibilities – An example Safety Review Board (SRB) Accountable executive Director of operations Director of maintenance Other directorates Safety services office Flight safety officer Maintenance safety officer Safety Action Group (s) (SAG) Source: ICAO

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

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

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

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

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

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

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

32. Small Operators Working Group What did we learn? We learned one size does not fit all… A component of TCCA’s continuous improvement approach to SMS. Invitation sent to CARAC Technical Committee members in January 2005 to identify volunteers for the project.

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

35. SMS Guidance Material For Small Operators • Guidance for CAR 107.04 - “A safety management system shall correspond to the size, nature and complexity of the operations, activities, hazards and risks associated with the operations…” • Describes examples of acceptable means, but not the only means, of demonstrating compliance with regulations and standards. • Does not change, create, amend or permit deviations from regulatory requirements nor does it establish minimum standards.

36. Examples

37. Examples

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

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

40. SMS Enforcement Policy General Statement The Civil Aviation Enforcement policy remains the same in that intentional contraventions of the Aeronautics Act and the Canadian Aviation Regulations will still be investigated.

41. SMS Enforcement Policy Pith & Substance The contravention appears to have been unintentional; and The certificate holder is proposing corrective measures that are likely to address the event and prevent recurrence. • No punitive action will be taken against a certificate holder governed by an SMS, if:

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

43. Audits versus Assessment Past (Audit) Auditing to the procedures Focus is on records review Oriented mainly towards conformity to standard Documentation reflects front line employees and middle management Future (Assessment) Assessment of the processes Balances manual review, on-site interviews, observations and records review More oriented towards outputs and outcomes Documentation reflects more involvement with senior management

44. Example TC Protocol • Typical protocolexpectations include: • CARS & TC standards • Industry guidelines & standards • Permits & approvals • SMS expectations as defined in TP13881 E • Generally accepted “safety management practices” The CARS plus more!!!

45. Example of Assessment Criteria • Assessmentlevel 3 defines the minimum requirements for the SMS to meet the CARS and TC standards

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

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

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