1. Module N° 10 – Phased approach to SMS Implementation Safety Management Systems (SMS) Course

2. Module N° 10 ICAO Safety Management Systems (SMS) Course 2 Building an SMS Module6 SMS regulation Module7 Introduction to SMS Module8 SMS planning Module9 SMS operation Module 1 SMS course introduction Module 2 Basic safety concepts Module 3 Introduction to safety management Module 4 Hazards Module 5 Risks Module6 SMS regulation Module7 Introduction to SMS Module8 SMS planning Module9 SMS operation Module10 Phased approach to SMS implementation Module10 Phased approach to SMS implementationSafetyManagementSystem

3. Module N° 10 ICAO Safety Management Systems (SMS) Course 3 Objective à At the end of this module participants will be able to develop a proposal for an SMS standard, based upon a phased implementation.

4. Module N° 10 ICAO Safety Management Systems (SMS) Course 4 Outline àWhy a phased approach to SMS? àThe four phases àCAAs – Four steps for SMS implementation àPoints to remember àExercise 10/01 – Model of SMS regulation – Outline of a SMS Standard àExercise 10/02 – Collision between two aircraft at Milano-Linate International Airport (See Handout N° 6) àWhy a phased approach to SMS? àThe four phases àCAAs – Four steps for SMS implementation àPoints to remember àExercise 10/01 – Model of SMS regulation – Outline of a SMS Standard àExercise 10/02 – Collision between two aircraft at Milano-Linate International Airport (See Handout N° 6)

5. Module N° 10 ICAO Safety Management Systems (SMS) Course 5 Why a phased approach to SMS? àTo provide a manageable series of steps to follow in implementing an SMS. àTo effectively manage the workload associated with SMS implementation. àTo pre-empt a “ticking boxes” exercise. à Four implementation phases are proposed. àEach phase is based upon the introduction of specific SMS elements. àTo provide a manageable series of steps to follow in implementing an SMS. àTo effectively manage the workload associated with SMS implementation. àTo pre-empt a “ticking boxes” exercise. à Four implementation phases are proposed. àEach phase is based upon the introduction of specific SMS elements.

6. Module N° 10 ICAO Safety Management Systems (SMS) Course 6 Phase 1 àProvides a blueprint on how the SMS requirements will be met and integrated to the organization’s work activities. àProvides an accountability framework for the implementation of the SMS. àProvides a blueprint on how the SMS requirements will be met and integrated to the organization’s work activities. àProvides an accountability framework for the implementation of the SMS.

7. Module N° 10 ICAO Safety Management Systems (SMS) Course 7 Phase 1 1.Identify the accountable executive and the safety accountabilities of managers. Elements 1.1 and 1.2 2.Identify the person (or planning group) within the organization responsible for implementing the SMS. Element 1.3 3.Describe the system (Air operator, ATC services provider, approved maintenance organization, certified aerodrome operator) Element 1.4 1.Identify the accountable executive and the safety accountabilities of managers. Elements 1.1 and 1.2 2.Identify the person (or planning group) within the organization responsible for implementing the SMS. Element 1.3 3.Describe the system (Air operator, ATC services provider, approved maintenance organization, certified aerodrome operator) Element 1.4

8. Module N° 10 ICAO Safety Management Systems (SMS) Course 8 Phase 1 4.Conduct a gap analysis of the organization’s existing resources compared with the national and international requirements for establishing a SMS. Element 1.4 SARPs gap analysis. 5.Develop a SMS implementation plan that explains how the organization will implement the SMS on the basis of national requirements and international SARPs, the system description and the results of the gap analysis. Element 1.4 6.Develop documentation relevant to safety policy and objectives Element 1.5 7.Develop and establish means for safety communication Element 4.2 4.Conduct a gap analysis of the organization’s existing resources compared with the national and international requirements for establishing a SMS. Element 1.4 SARPs gap analysis. 5.Develop a SMS implementation plan that explains how the organization will implement the SMS on the basis of national requirements and international SARPs, the system description and the results of the gap analysis. Element 1.4 6.Develop documentation relevant to safety policy and objectives Element 1.5 7.Develop and establish means for safety communication Element 4.2

9. Module N° 10 ICAO Safety Management Systems (SMS) Course 9 Phase 2 àPuts into practice those elements of the SMS implementation plan that refer to: 1.Safety hazard identification and risk management component. äReactive processes äInvestigation and analysis äHazard identification and risk management Elements 2.1, 2.2 and 2.3 àPuts into practice those elements of the SMS implementation plan that refer to: 1.Safety hazard identification and risk management component. äReactive processes äInvestigation and analysis äHazard identification and risk management Elements 2.1, 2.2 and 2.3

10. Module N° 10 ICAO Safety Management Systems (SMS) Course 10 Phase 2 2.Training relevant to: äThe SMS implementation plan components. äThe safety hazard identification and risk management component (Reactive processes). Element 4.1 3.Documentation relevant to: äThe SMS implementation plan components. äThe safety hazard identification and risk management component (Reactive processes). Elements 1.4 and 1.5 2.Training relevant to: äThe SMS implementation plan components. äThe safety hazard identification and risk management component (Reactive processes). Element 4.1 3.Documentation relevant to: äThe SMS implementation plan components. äThe safety hazard identification and risk management component (Reactive processes). Elements 1.4 and 1.5

11. Module N° 10 ICAO Safety Management Systems (SMS) Course 11 Phase 3 àPuts into practice those elements of the SMS implementation plan that refer to: 1.Safety hazard identification and risk management component. äProactive processes äProactive and predictive processes äInvestigation and analysis äHazard identification and risk management Elements 2.1 and 2.2 2.Training relevant to proactive and predictive processes. Element 4.1 3.Documentation relevant to proactive and predictive processes. Element 1.4 and 1.5 àPuts into practice those elements of the SMS implementation plan that refer to: 1.Safety hazard identification and risk management component. äProactive processes äProactive and predictive processes äInvestigation and analysis äHazard identification and risk management Elements 2.1 and 2.2 2.Training relevant to proactive and predictive processes. Element 4.1 3.Documentation relevant to proactive and predictive processes. Element 1.4 and 1.5

12. Module N° 10 ICAO Safety Management Systems (SMS) Course 12 Phase 4 1.Operational safety assurance äDevelopment of acceptable level (s) of safety. äDevelopment of safety indicators and targets. äSMS continuous improvement. Elements 3.1, 3.2, 3.3 and 3.4 2.Emergency response planning Element 5.1 1.Operational safety assurance äDevelopment of acceptable level (s) of safety. äDevelopment of safety indicators and targets. äSMS continuous improvement. Elements 3.1, 3.2, 3.3 and 3.4 2.Emergency response planning Element 5.1

13. Module N° 10 ICAO Safety Management Systems (SMS) Course 13 Phase 4 3.Training relevant to operational safety assurance and emergency response planning. Element 4.1 4.Documentation relevant to operational safety assurance and emergency response planning. Element 1.4 and 1.5 3.Training relevant to operational safety assurance and emergency response planning. Element 4.1 4.Documentation relevant to operational safety assurance and emergency response planning. Element 1.4 and 1.5

14. Module N° 10 ICAO Safety Management Systems (SMS) Course 14 CAAs – Four steps for SMS implementation STEP 1 à State’s safety programme äConduct a gap analysis vis-à-vis the current status in the State of the following: æSafety regulation æSafety oversight (capabilities and planning) æAccident/incident investigation æMandatory/voluntary/confidential reporting systems æSafety data analysis æSafety promotion STEP 1 à State’s safety programme äConduct a gap analysis vis-à-vis the current status in the State of the following: æSafety regulation æSafety oversight (capabilities and planning) æAccident/incident investigation æMandatory/voluntary/confidential reporting systems æSafety data analysis æSafety promotion

15. Module N° 10 ICAO Safety Management Systems (SMS) Course 15 CAAs – Four steps for SMS implementation STEP 2 à Implementation SMS SARPs: äDevelop SMS regulations for operators/service providers. æRefer to the SMS components and elements as per the ICAO SMS training course. äPrepare guidance material for the implementation of SMS. æRefer to ICAO Doc 9859 and the ICAO SMS training course. äOperators/service providers may need to use third party assistance to implement their SMS. STEP 2 à Implementation SMS SARPs: äDevelop SMS regulations for operators/service providers. æRefer to the SMS components and elements as per the ICAO SMS training course. äPrepare guidance material for the implementation of SMS. æRefer to ICAO Doc 9859 and the ICAO SMS training course. äOperators/service providers may need to use third party assistance to implement their SMS.

16. Module N° 10 ICAO Safety Management Systems (SMS) Course 16 CAAs – Four steps for SMS implementation STEP 3 à CAA training programme: äDevelop a training programme for CAA officers to: æprovide knowledge of safety management concepts and ICAO SARPs on safety management in Annexes 6, 11 and 14, and related guidance material; and ædevelop knowledge to certify and oversee the implementation of key components of an SMS, in compliance with the national regulations and relevant ICAO SARPs. STEP 3 à CAA training programme: äDevelop a training programme for CAA officers to: æprovide knowledge of safety management concepts and ICAO SARPs on safety management in Annexes 6, 11 and 14, and related guidance material; and ædevelop knowledge to certify and oversee the implementation of key components of an SMS, in compliance with the national regulations and relevant ICAO SARPs.

17. Module N° 10 ICAO Safety Management Systems (SMS) Course 17 CAAs – Four steps for SMS implementation STEP 4 à CAA enforcement policy: äRevision of enforcement policy. æOperators/service providers allowed to deal with deviations/minor violations internally, within the context of the SMS, to the satisfaction of the authority. æGross negligence, willful deviation and so forth to be dealt through established enforcement procedures. STEP 4 à CAA enforcement policy: äRevision of enforcement policy. æOperators/service providers allowed to deal with deviations/minor violations internally, within the context of the SMS, to the satisfaction of the authority. æGross negligence, willful deviation and so forth to be dealt through established enforcement procedures.

18. Module N° 10 ICAO Safety Management Systems (SMS) Course 18 Points to remember 1.Reduce a complex task to series of manageable steps. 2.Avoid a bureaucratic exercise (“Ticking boxes”). 3.Element allocation under a particular phase may slightly vary depending upon the specific Annex. 4.The CAAs four steps for SMS implementation 1.Reduce a complex task to series of manageable steps. 2.Avoid a bureaucratic exercise (“Ticking boxes”). 3.Element allocation under a particular phase may slightly vary depending upon the specific Annex. 4.The CAAs four steps for SMS implementation

20. Module N° 10 ICAO Safety Management Systems (SMS) Course 20 Exercise 10/01 – Model of SMS regulation – Outline of a SMS Standard à Group activity: äA facilitator will be appointed, who will coordinate the discussion. äA summary of the discussion will be written on flip charts, and a member of the group will brief on their findings in a plenary session. à Group activity: äA facilitator will be appointed, who will coordinate the discussion. äA summary of the discussion will be written on flip charts, and a member of the group will brief on their findings in a plenary session.

21. Module N° 10 ICAO Safety Management Systems (SMS) Course 21 Group assignment à Task äOn the basis of what was presented and discussed in modules 6 to 9, develop a model of SMS regulation, that addresses the following three general areas: 1.Scope and application 2.Main definitions (Do not develop) 3.General contents (Only headlines) of the SMS regulation à Task äOn the basis of what was presented and discussed in modules 6 to 9, develop a model of SMS regulation, that addresses the following three general areas: 1.Scope and application 2.Main definitions (Do not develop) 3.General contents (Only headlines) of the SMS regulation

23. Module N° 10 ICAO Safety Management Systems (SMS) Course 23 Exercise 10/02 – Collision between two aircraft at Milano-Linate International Airport à Group activity: äA facilitator will be appointed, who will coordinate the discussion. äA summary of the discussion will be written on flip charts, and a member of the group will brief on their findings in a plenary session. à Group activity: äA facilitator will be appointed, who will coordinate the discussion. äA summary of the discussion will be written on flip charts, and a member of the group will brief on their findings in a plenary session.

24. Module N° 10 ICAO Safety Management Systems (SMS) Course 24 Milano-Linate International Airport accident à Scenario äAn MD-87 taxied to the holding point for runway 36R. Heavy fog had delayed the flight by more than one hour. While the visibility was improving, RVR was still only 225 metres. äA Cessna Citation parked at the West Apron was cleared to taxi via taxiway Romeo 5 and to report reaching the first holding point. The crew read the clearance back correctly, but entered taxiway Romeo 6. à Scenario äAn MD-87 taxied to the holding point for runway 36R. Heavy fog had delayed the flight by more than one hour. While the visibility was improving, RVR was still only 225 metres. äA Cessna Citation parked at the West Apron was cleared to taxi via taxiway Romeo 5 and to report reaching the first holding point. The crew read the clearance back correctly, but entered taxiway Romeo 6.

25. Module N° 10 ICAO Safety Management Systems (SMS) Course 25 Milano-Linate International Airport accident à Scenario äThe Cessna Citation’s crew called for clearance to proceed from the Romeo 5 holding point though it was in fact at the Romeo 6 holding point. äThe MD-87 was cleared for take-off. äThe Cessna Citation crossed the holding point for runway 36R-18L. äThe two aircraft collided. äThe MD-87 skidded off the runway into a baggage hangar adjacent to the passenger terminal. à Scenario äThe Cessna Citation’s crew called for clearance to proceed from the Romeo 5 holding point though it was in fact at the Romeo 6 holding point. äThe MD-87 was cleared for take-off. äThe Cessna Citation crossed the holding point for runway 36R-18L. äThe two aircraft collided. äThe MD-87 skidded off the runway into a baggage hangar adjacent to the passenger terminal.

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30. Module N° 10 ICAO Safety Management Systems (SMS) Course 30 Excerpts from the accident report àAfter analysis of evidence available and information gathered, it can be assumed that the immediate cause for the accident has been the runway incursion in the active runway by the Cessna. àThe obvious consideration is that the human performance issues related to the Cessna crew – during low visibility conditions – must be weighted against the scenario that allowed the course of events that led to the fatal collision. àAfter analysis of evidence available and information gathered, it can be assumed that the immediate cause for the accident has been the runway incursion in the active runway by the Cessna. àThe obvious consideration is that the human performance issues related to the Cessna crew – during low visibility conditions – must be weighted against the scenario that allowed the course of events that led to the fatal collision.

31. Module N° 10 ICAO Safety Management Systems (SMS) Course 31 Excerpts from the accident report àEqually it can be stated that the system in place at Milano-Linate aerodrome was not geared to trap misunderstandings, inadequate procedures, human errors and faulty airport layout. àThe aerodrome standard did not comply with ICAO Annex 14. àNo functional Safety Management System (SMS) was in operation. àEqually it can be stated that the system in place at Milano-Linate aerodrome was not geared to trap misunderstandings, inadequate procedures, human errors and faulty airport layout. àThe aerodrome standard did not comply with ICAO Annex 14. àNo functional Safety Management System (SMS) was in operation.

32. Module N° 10 ICAO Safety Management Systems (SMS) Course 32 Group assignment à Task Nº 1 äList the generic risk(s) and current risk(s) index (Probability/severity). äDescribe the risk(s). äDefine current measures to reduce risk(s). äDefine further actions to reduce the risk and resulting risk(s) index (Probability/severity). äEstablish individual responsibility to implement the risk mitigation. äComplete the log below (Table 10/01) à Task Nº 1 äList the generic risk(s) and current risk(s) index (Probability/severity). äDescribe the risk(s). äDefine current measures to reduce risk(s). äDefine further actions to reduce the risk and resulting risk(s) index (Probability/severity). äEstablish individual responsibility to implement the risk mitigation. äComplete the log below (Table 10/01)

33. Module N° 10 ICAO Safety Management Systems (SMS) Course 33 Risk reference Generic risk and current risk index Risk description Current measures to reduce risk Further actions to reduce risk and resulting risk index Responsibility Probability: ____ Severity:_______ Risk index:_____ Probability: ____ Severity:_______ Risk index:_____ Table 10/01 – Risk control/mitigation log

34. Module N° 10 ICAO Safety Management Systems (SMS) Course 34 Group assignment à Task Nº 2 äThe accident investigation has identified that no functional Safety Management System (SMS) was in operation at Milano-Linate International Airport. Therefore you should: æDevelop a SMS implementation plan for Milano- Linate International Airport æComplete the Gantt chart below (Table 10/02). à Task Nº 2 äThe accident investigation has identified that no functional Safety Management System (SMS) was in operation at Milano-Linate International Airport. Therefore you should: æDevelop a SMS implementation plan for Milano- Linate International Airport æComplete the Gantt chart below (Table 10/02).

35. Module N° 10 ICAO Safety Management Systems (SMS) Course 35 Table 10/02 – Gantt chart for the SMS implementation plan Nº ComponentDate:

36. Module N° 10 – Phased approach to SMS Implementation Safety Management Systems (SMS) Course