NOTICE OF PROPOSED RULE MAKING DGTA-ADF 2015-01

TAREG 4.4.4 SAFETY MANAGEMENT SYSTEMS IN MAINTENANCE

Reference: A. AAP 6734.001 Defence Aviation Safety Manual

INTRODUCTION

Applicability

1. This proposal is applicable to all Defence and commercial maintenance organisations subject to the Technical Airworthiness Regulations (TAREG).

Purpose Statement

2. Process regulation provides a minimum level of protection against hazards that threaten safety, with overall effectiveness limited by organisational, environmental and human factors. A safety management system provides a higher level of safety by supporting and extending the protection afforded through process regulation alone.

3. Safety management systems are commonly used in the aviation domain to systematically manage risks to aviation safety and, in part, discharge obligations under WH&S legislation. The requirement for Defence and commercial authorised maintenance organisations to operate a safety management system (new regulation TAREG 4.4.4) is therefore consistent with expected industry practice and extant WH&S obligations, and is expected to have minimal impact on current arrangements within regulated entities.

4. The new Defence Aviation Safety Regulations (DASRs) shall be released over the next few years. The DASR will require all organisations involved in the design, production, maintenance and continuing airworthiness management of aircraft to operate a safety management system. Accordingly, the requirements of new regulation TAREG 4.4.4 are enduring and shall not be affected with the imminent rollout of the new DASR.

Benefit Statement

5. The benefits of the new regulation are:

a. clarification of Defence expectations in the consideration, mitigation, retention and communication of potential technical airworthiness risks in maintenance;

b. alignment of ASMS requirements in operations and maintenance, providing opportunities for efficiencies in system and process integration, and communication;

c. exploitation of proactive and predictive safety risk management principles in maintenance, allowing for greater awareness of potential technical airworthiness risks while implementing Defence reforms;

d. alignment of Defence aviation maintenance safety management to local and international standards; and

e. alignment with the early adoptors of ASMS intent by commercial CASR Part 145 AMOs.

Consultation

6. TAREG 1.1.2 requires that interested persons are provided the opportunity to participate in the regulation drafting process. This NPRM therefore promulgates details of the proposed change and provides advice on how responses to the proposal can be returned to the Technical Airworthiness Regulator (TAR).

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PROPOSAL

Background

7. DGTA-ADF’s Aviation Maintenance Safety (AMSAFE) project was established in 2013, to investigate, assess and implement measures to strengthen safety management systems in the maintenance domain.. In doing so, the AMSAFE project was to primarily exploit existing systems of management, thus minimising the impact to Defence aviation.

8. The AMSAFE project confirmed that the most practical, enduring architecture for SMS regulation was alignment with the ICAO Annex 19 framework including consideration of the Commonwealth WHS Act 2011. The ICAO framework is considered by most industry regulators as best practice and therefore has extensive supporting guidance material available for regulated entities. Further, as reference A is based on ICAO principles, this approach retains the substantial extant policy and guidance available.

9. The AMSAFE project is also delivering other outcomes intended to provide ASMS awareness and phased training enablers for the enduring requirements of the proposed TAREG 4.4.4. Additional information on these other outcomes can be found on the intranet at http://caas/Areas/RAAF/exec/DGTA/INNO/WikiLandingPages/AMSAFE.aspx or by emailing the point of contact identified below.

Anticipated impact of TAREG 4.4.4

10. ICAO-based SMS principles allow for:

a. SMSs to be tailored to the scope of equipment/aircraft, operations and maintenance to be conducted by the unit;

b. a phased SMS introduction based on complementary organisational culture change management programs and timelines; and

c. agreement of individual SMS plans’ scope by the aviation regulator.

11. The anticipated impact of TAREG 4.4.4 will therefore vary between AMOs, as follows:

a. For Service AMOs. All Service AMOs are already expected to have been complying with reference A. Further, reference A also provides the corporate systems applicable, thus the impact is constrained to reviewing compliance to reference A, and locally introducing solutions to cover gaps identified.

b. For Commercial AMOs. DGTA-ADF is aware that for business reasons many commercial maintenance units have already implemented the safety management requirements of CASR Part 145 (or equivalent). These safety management systems provide an alternate means of compliance to the TAREG 4.4.4 proposed in this NPRM. Hence the only additional effort foreseen is related to assure the systems feature an incident information-sharing mechanism with Defence. Conversely, where commercial maintenance units have not yet introduced a CASR Part 145 (or equivalent) safety management system, impacts and tailoring will be dependent on the scope of equipment/aircraft maintenance conducted by the unit, type of TAR-approved maintenance construct applicable under TAREG 4.1.1, and on the agreed tailoring of ASMS requirements with the TAR.

c. For AMOs maintaining ground-based aviation materiel and Aviation Support Systems (AvSS). Impacts will be dependent on the scope of equipment maintenance to be conducted by the unit, the type of TAR-approved maintenance construct applicable under TAREG 4.1.1, and on the agreed tailoring of ASMS requirements with the TAR. This approach is supported in the guidance. These AMOs are expected to develop tailored documentation describing their ASMS commensurate with the size, nature and complexity of their business.

d. For Other TAR Approval (OTA) maintenance organisations and their sponsors. By the phase-in date below, sponsors are expected to have assessed the applicability of the intent of TAREG 4.4.4 to the OTA maintenance organisation, and to have implemented their assessment recommendations. The assessment is to be made under the same considerations that were

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applicable to the initial award of OTA. That is, TAREG 1.1.7 guidance advises that OTAs are an alternate form of TAR approval, where the cost of certification is difficult to justify when compared to the level of safety risk of the unit’s activities. It may be applicable where:

(1) the safety risk of a unit’s activities is sufficiently low that full certification as an AEO/AMO and full compliance with applicable TAREGs is not warranted; and

(2) there are alternative methods available to both initially assess a unit’s competence and provide ongoing oversight of their activities, commensurate with the level of safety risk.

12. The Service sponsor is not expected to notify DGTA-ADF of the completion of their formal TAREG 4.4.4 applicability assessment, but is to retain evidence of the assessment, in accordance with their organisation’s records management requirements.

13. Defence Aviation Safety Regulations (DASRs). DGTA-ADF has also recently commenced planning for an overall transition of TAREGs to DASRs, which for technical aspects will be based on European Military Airworthiness Requirements (EMARs). EMARs are in turn based upon European Aviation Safety Authority (EASA) regulations, which use the ICAO State Safety Programme as their basis. Since TAREG 4.4.4 is also ICAO-based, organisations compliant to TAREG 4.4.4 are expected to also be compliant with future maintenance DASR requirements for SMS. Further details pertaining to the transition to DASRs, including any additional SMS requirements for design organisations, will be released by December 2015.

Phase-in of TAREG 4.4.4

14. Compliance will be required to either TAREG 4.4.4 or a TAR-approved civil or military Safety Management System alternative. Where the unit does not currently comply with a TAR-approved alternative, compliance to the TAREG is expected by 31 December 2016. This approach provides a transition strategy consistent with anticipated Defence Materiel Organisation (DMO) scheduled contract change methodologies; and allows AMOs to identify gaps, and develop and implement solutions prior to the commencement of TAR oversight.

15. Post TAREG 4.4.4 phase-in compliance assessments. Compliance to TAREG 4.4.4 in the future will be determined through maturity assessments, tailored to match ICAO methodologies. Maturity indicators have therefore been provided, to assist both AMOs and DAVCOMP-DGTA staff in assessing the degree of ASMS maturity present. Further details will be provided in eTAMM S1C6 – Compliance Assurance.

Proposed New TAREG 4.4.4

16. Annex A provides the new TAREG 4.4.4 and its associated guidance material.

HOW TO SUBMIT COMMENTS ON THIS NPRM

Format

17. Responses to this NPRM are to be recorded on the NPRM Response Comment proforma found at annex B, or downloaded from the DGTA-ADF intranet or internet websites (http://intranet.defence.gov.au/dgta/WebPages/DAVREG/NPRM.htm and http://www.defence.gov.au/dgta/WebPages/DAVREG/nprm.htm respectively).

18. All responses are to be submitted by email to DGTA-ADF.NPRM@defence.gov.au. Hardcopies of the NPRM Response Comment proforma are not required.

Timing

19. Comments to this NPRM are to be received by close of business Friday 24 July 2015.

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Additional Information

20. The point of contact for additional information on the content of this NPRM is the AMSAFE Project Manager, Mr Ross Liley on 03 9256 1965, or ross.liley1@defence.gov.au.

DISPOSITION OF COMMENTS RECEIVED

21. A Summary of Responses will be prepared and published on the above websites. DGTA-ADF will not individually acknowledge or respond to comments or submissions.

A. HOWELL Wing Commander Acting Director Aviation Regulation Directorate General Technical Airworthiness – ADF Tel: (03) 9256 3049 26 Jun 15 Annexes: A. NPRM DGTA 2015-01 – Proposed New TAREG 4.4.4 and Guidance Material B. NPRM DGTA 2015-01 – NPRM Response Comment Proforma

ANNEX A TO NPRM DGTA 2015-01

NPRM DGTA 2015-01

PROPOSED NEW TECHNICAL AIRWORTHINESS REGULATION AND GUIDANCE

Background: These regulations are derived from ICAO Annex 19, based on the implementation approach of the CASA Part 145 Manual of Standards 145.A.65, and formatted in accordance with DGTA(I) REG 1–6.

NEW TAREG 4.4.4 – Safety Management System

a. The AMO must have an effective Safety Management System (SMS) that includes:

1. the AMO’s safety policy and objectives, including details of:

a. a nominated Senior Executive, who will be accountable to the TAR for the AMO’s SMS;

b. the Senior Executive’s commitment to the SMS;

c. the appointment and responsibilities of key safety personnel;

d. relevant third party relationships and interactions;

e. the coordination of emergency responses; and

f. SMS documentation.

2. a safety risk management system, including details of:

a. hazard identification, investigation and reporting processes, including the requirement to report accidents and serious incidents to the TAR; and

b. risk assessment and mitigation processes, including procedures for the remedial corrective and preventative actions required for the mitigation of risk or identified hazards.

3. a safety assurance system, including details for:

a. safety performance monitoring and measurement, including the requirement to report safety findings to the Senior Executive;

b. the management of change;

c. continuous improvement of the performance of the SMS.

4. a safety promotion system, including details of:

a. education and training; and

b. safety communication internal and external to the AMO.

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REGULATION 4.4.4 – SAFETY MANAGEMENT SYSTEM

BACKGROUND

1. Regulators impose regulations with the aim of providing a minimum level of protection against hazards within their domain scope. However, the effectiveness of the regulatory intent is dependent on organisational, environmental and human factor influences present in the regulated organisations. Safety Management System (SMS) regulations assist by enhancing the traditional regulation set, by providing mechanisms by which these influences can be effectively assessed for safety implications and treated. SMS regulations also implicitly acknowledge that safety improvements are not possible beyond a rudimentary minimal level without a corresponding strengthening of the organisational safety culture.

PURPOSE

2. The purpose of a Safety Management System is to provide organisations with a systematic, explicit, staged and comprehensive approach to managing risks to aviation safety, including the necessary organisational structures, accountabilities, policies and procedures. An SMS in Defence aviation AMOs provides opportunities to further enhance protection mechanisms against the release of aircraft or aeronautical product in an unserviceable state, thus helping to preserve aviation safety. An effective Safety Management System improves the likelihood of predicting, preventing and treating maintenance hazards, errors and violations by ensuring that SMS elements are present, suitable, operating and effective. In doing so, the SMS should be seen as a capability sustainment investment, not as an overhead.

3. While the guidance provided in the following sections is self-contained, it is not intended as comprehensive SMS training material, nor does it discuss in detail the range of possible implementation options. A reference section has therefore been included at the end for readers that may wish to further consider implementation examples, tips, lessons learned, or expanded guidance.

INTRODUCTION

Safety Management System Framework

4. This TAREG is derived from the international standards and recommended practices published by ICAO in Annex 19 to the Convention on International Civil Aviation. This advocates an SMS as a dynamic risk management system based on quality management system principles, in a structure scaled appropriately to the organisational risk, and applied in a safety culture environment. It also defines the SMS framework as comprising four core components, as follows:

a. safety policy and objectives,

b. safety risk management,

c. safety assurance, and

d. safety promotion.

5. The combination of safety risk management, safety assurance and safety promotion, as enacted by safety policy and objectives, provide the means for an organisation to maintain a balance between capability and safety. ICAO acknowledges that for the aviation domain to effectively continue to progressively improve safety, many interfacing functions need to be considered as part of the broader SMS, including: operations, maintenance, engineering services, airspace management, aerodrome services, and training development and delivery service providers. Defence aviation acknowledges that a phased approach to SMS introduction is required, starting with operations and maintenance, and expanding to the latter functions discussed above as SMS implementation matures, lessons learned are adapted, and Defence makes a conscious choice to broaden SMS applicability.

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6. Within Defence, AMOs are typically integrated into operational squadrons, to provide more effective turn-key solutions to capability. This means that an AMO’s implementation of their maintenance-focused SMS will only be totally effective, and strive for continual safety improvement, when a level of coordination and/or integration to their organisation’s operationally-focused SMS also exists. This is ICAO’s Annex 19 intent, and ensures that:

a. a richer picture of aviation safety is provided against the organisational mission;

b. efficiencies in process intent and application can be exploited across all areas of the organisation; and

c. the likelihood of identifying real, but typically ill-defined safety concerns at the interfaces between each function and area, is increased.

Safety Culture

7. The safety culture of an organisation is one of the most challenging elements of the SMS. Simply put, the safety culture is the way safety is perceived, valued and prioritised. It reflects the real commitment to safety at all levels and can be described as ‘how’ the organisation conducts its activities to ensure safety is considered in all cases. Practices that support the creation and nurturing of a positive safety culture evolve as the organisation continuously promotes safety as a core value.

8. Safety culture has been defined as the set of values, beliefs, norms, attitudes and practices shared by a group, concerned with minimising hazardous exposures to staff and the public. Safety culture promotes a shared attitude of concern and responsibility, and is regarded as a fusion of the following desirable sub-cultures within an organisation:

a. Informed culture—staff are knowledgeable about the system (human, technical, organisational and environmental factors) and what factors determine the level of safety.

b. Flexible culture—organisationally characterised by shifts from conventional ‘hard-coded’ hierarchies to flatter professional outcome-based structures, better pre-empting the need to adapt processes and intents to suit changing organisational contexts.

c. Reporting culture—staff are willing to report hazards, errors and experiences, even when such reports may reflect poorly on their involvement, as the motivation to maintain a safe environment and the safety of their colleagues is considered the highest priority.

d. Learning culture—staff have the will and competence to draw safety conclusions from information, and the will to implement corrective/preventive actions.

e. Just culture—staff are encouraged to reactively and proactively self-assess and generate safety-related information, but a clear line exists between acceptable and unacceptable behaviour (ie. individuals are both held accountable for their actions and treated fairly by the organisation).

9. In combination, the above sub-cultures set the boundaries for acceptable behaviour and provide a framework for decision making, thus providing an environment for improving safety culture maturity. Further, as cultures are generated from the top down, safety culture can be positive, negative or neutral. A positive safety culture is pervasive across all SMS core components and self-sustaining in the main, and places safety at the forefront of every task conducted. Organisations benefit from a positive safety culture through:

a. minimising the opportunity for human error, resulting in fewer accidents and incidents, and thus reduces costs and increases capability;

b. increasing safety knowledge, and the consistency of that knowledge across all levels of the organisation;

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c. increasing motivation, trust and staff participation;

d. helping to promote communication and positive attitudes towards safety throughout the organisation; and

e. greater integration of safety within all work practices over time.

10. Safety culture maturity exists along a continuum that reflects the standard of safety performance possible in the organisation. Higher levels of safety performance can only exist with corresponding advancements in an organisation’s safety culture.

Acceptable Means of Compliance to TAREG 4.4.4

11. Where corporate Acceptable Means of Compliance (AMC) exists for components of TAREG 4.4.4, they are described within AAP 6734.001 Defence Aviation Safety Manual (DASM). Nonetheless, given the regulation is as applicable to civilian AMOs as it is to Service AMOs, the intent of some DASM guidance has been reproduced within this document.

12. Regulation Incorporation Maturity Indicators. SMS incorporation maturity indicators have been included within grey boxes within the guidance provided. The indicators are based upon ICAO’s SMS framework and ICAO’s Safety Management International Collaboration Group (SMIGC) SMS Evaluation Tool. The tool represents current best practice in helping regulators and organisations assess SMS compliance, conformance and effectiveness, as objectively as possible. While the indicators have been provided here for transparency purposes, they may not be included in the published TAMM regulation. However, if not, the indicators will still be made easily available to all Defence and civilian AMOs operating under the TAMM, and suggestions as to an optimum storage location are welcome.

SAFETY POLICY AND OBJECTIVES

Explanation and amplification

13. Management commitment to, and responsibility for, aviation safety needs to be formally expressed in the AMO’s safety policy and safety objectives. The safety policy is a reflection of the AMO’s influence on the aviation safety outcomes sought and its safety management strategy to achieve them. The policy provides the basis upon which the AMO’s SMS is built.

14. The safety policy should describe (or include a reference to) how an appropriate balance of continuous safety improvement and continuous capability support will be provided, and explicitly state, or out-refer to: safety responsibilities, authorities, accountabilities and expectations, at all levels of the organisation. The safety policy also encourages employees to report maintenance-related hazards, incidents and errors, and requires all employees to comply with defined safety standards, procedures and expectations.

15. In preparing the safety policy, senior management should consult widely with AMO staff responsible for safety-critical functions. Consultation ensures that the policy is relevant to staff and provides them a sense of ownership. Once generated, the safety policy should be communicated to all employees and necessary third parties, and be periodically reviewed to ensure its ongoing relevance.

16. AMOs need not develop a separate, unique, safety policy if the AMO is already subject to a suitable corporate policy flowed-down through the chain-of-command, provided that it:

a. remains applicable to all personnel employed within the AMO, and

b. meets the requirements of TAREG 4.4.4.a(1).

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Clause a.1(a) – Senior Executive

17. The AMO should nominate an individual who will be accountable to the TAR for the implementation and on-going management of the SMS, and the safety performance of the AMO. While the Senior Executive remains accountable, SMS functions may be delegated, provided the safety responsibilities of each individual in the AMO are clearly defined through the AMO’s safety policy.

18. The safety accountabilities of the Senior Executive include ensuring:

a. commitment of AMO personnel to their individual and collective safety responsibilities;

b. provision of the resources necessary for effective safety management;

c. awareness of the AMO’s SMS at all levels of the organisation;

d. promotion and demonstration of commitment to the safety policy through his or her active and visible participation in SMS processes;

e. defined standards for acceptable safety behaviour;

f. active encouragement of safety reporting, with explicit support of a ‘just culture’ as part of the overall safety culture of the AMO;

g. an appropriate process by which safety culture can be measured and improvements planned;

h. periodic review of the safety policy to ensure it remains relevant and appropriate to the AMO; and

i. commitment to continuous improvement of SMS performance.

19. Large or geographically dispersed AMOs wishing to implement a corporate-based SMS may choose a Senior Executive at the Wing, Group or FEG level, whereas smaller AMOs may choose a local executive. Regardless of the choice, SMS responsibilities should not be delegated below the level of SMM in the organisational structure. The Senior Executive should have the ability within the organisation to provide and adjust the resources necessary to operate an effective SMS, and be the signatory of the AMO’s safety policy and safety objectives statement.

Maturity indicators for clause a.1(a)

a. A Senior Executive has been appointed with full responsibility and ultimate accountability for the SMS to ensure it is properly implemented and performing effectively.

b. The Senior Executive has control of the financial and human resources required for the proper implementation of an effective SMS.

c. The Senior Executive is fully aware of their SMS roles and responsibilities in respect of the safety policy, safety standards and safety culture of the organisation.

d. Safety accountabilities, authorities and responsibilities are defined and documented throughout the organisation.

e. Personnel at all levels are aware of and understand their safety accountabilities, authorities and responsibilities regarding all safety management processes, decisions and actions.

f. Safety management is shared across the organisation (and is not just the responsibility of the Safety Manager and their team).

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g. There are documented management organisational diagrams and job descriptions for all personnel.

Clause a.1(b) – Management commitment

20. The AMO’s safety policy should indicate genuine management commitment to, and responsibility for, the SMS. Senior management should develop and resource an organisational structure that is capable of supporting the agreed SMS functions. It should clearly depict safety accountabilities and lines of communication for safety issues, and recognise the commitment to the safety contributions required by all staff. The creation of a positive safety culture begins with the issuance of clear, unequivocal direction, an indication of the types of behaviours that are unacceptable, and the conditions under which disciplinary action would not apply.

21. Effectiveness is achieved when the organisation has defined a safety policy that clearly states its intentions, safety objectives and methods of achieving it, and there is visible evidence of active safety leadership and management in the SMS.

Maturity indicators for clause a.1(b)

a. There is a safety policy that includes a commitment towards achieving the highest safety standards signed by the Senior Executive.

b. The Senior Executive and the senior management team promote and demonstrate their commitment to the Safety Policy through active and visible participation in the safety management system.

c. The safety policy is communicated to all personnel with the intent that they are made aware of their individual contributions and obligations with regard to Safety.

d. The safety policy includes a commitment to observe all applicable legal requirements, standards and best practice providing appropriate resources and defining safety as a primary responsibility of all Managers.

e. The safety policy actively encourages safety reporting.

f. The safety policy states the organisation’s intentions, management principles and commitment to continuous improvement in the safety level.

g. The safety policy is reviewed periodically to ensure it remains current.

h. There is commitment of the organisation’s senior management to the development and ongoing improvement of the safety management system.

i. A disciplinary policy has been defined that clearly identifies the conditions under which punitive action would be considered (e.g. illegal activity, negligence or wilful misconduct).

j. There is evidence of decision making, actions and behaviours that reflect a positive safety culture.

k. The organisation has based its safety management system on the safety policy.

Clause a.1(c) – Appointment and responsibilities of key safety personnel

22. The appointment of key safety personnel is vital to the effective functioning of an SMS. The number, type, skills, composition and appointment approach of these members will differ greatly depending on the size, scope, context and complexity of the AMO. Despite the Senior Executive being accountable to the TAR for the safety performance of the AMO, safety management functions need to be tailored to the business scope of the AMO, for example:

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a. Large AMOs. Large AMOs are typically characterised as providing operational or deeper maintenance services to more than one aircraft type or across multiple sites. Large AMOs would be expected to have a dedicated safety department, led by dedicated Safety Manager whose duties may encompass SMS management. There would be scope within the department to appoint deputies and additional staff as required.

b. Medium-sized AMOs. Medium-sized AMOs are typically characterised as providing operational or deeper maintenance services in one location for an entire fleet of one aircraft or engine type. A medium-sized AMO could be expected to have a dedicated Safety Manager who might also hold responsibilities within other contributing management systems, and possibly some dedicated safety employees. There would be scope for deputies to be appointed when required.

c. Small AMOs. Small AMOs typically maintain only aircraft components, or sub-assemblies other than whole-of-aircraft or engines. Small AMOs could be expected to allocate Safety Manager responsibilities to one or more of its employees as the primary secondary duty, given the AMO’s limited SMS complexity.

23. Other safety-related personnel may include:

a. members of safety committees,

b. safety investigators,

c. safety training facilitators, and

d. emergency response coordinators.

Maturity indicators for clause a.1(c)

a. A competent person with the appropriate knowledge, skills and experience has been nominated to manage the operation of the SMS.

b. The person managing the operation of the SMS fulfils the required job functions and responsibilities.

c. There is a direct reporting line between the Safety Manager and the Senior Executive.

d. The organisation has allocated sufficient resources to manage the SMS including manpower for safety investigation, analysis, auditing and promotion.

e. Personnel in key safety roles are kept current through additional training and attendance at conferences and seminars.

Clause a.1(d) – Relevant third party relationships and interactions

24. This section of the SMS explains the manner in which the AMO manages interactions with all organisations and personnel external to the AMO. The provision of maintenance support activities often involves third parties (HQs, service providers, contractors and suppliers) in areas as such ground handling, ground support, component repair, training, planning, asset movement, painting, non-destructive testing (NDT), etc. An SMS assures that the level of safety provided by the AMO is not eroded by the inputs, services and supplies provided by external organisations.

25. The AMO holds overall responsibility for the safety of services provided by any third parties. The ‘work scope’ instrument should specify the safety standards to be met. The instrument management authority then has the responsibility for ensuring that the third party understands and complies with the safety standards prescribed.

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Maturity indicators for clause a.1(d)

a. A register of all third party contractors and suppliers is kept and maintained.

b. Contractors and third parties are integrated into the SMS including safety reporting and SMS training.

c. Contractors and third parties are incorporated into safety assurance including the safety audit program.

d. Potential safety risks associated with third party suppliers are assessed and mitigated.

e. Contracts/service level agreements specifying safety standards are in place.

f. Documented procedures are in place to establish and manage third party interfaces, based on risk.

Clause a.1(e) – Emergency response coordination

26. The purpose of emergency response coordination is to ensure that there is an orderly and efficient transition from normal to emergency AMO operations, including the assignment of emergency responsibilities and delegations of authority. An Emergency Response Plan (ERP) would provide the means to coordinate emergency efforts. The overall objectives are to minimise harm to personnel, continue the safe delivery of capability, and then return to normal operations as soon as possible.

27. An ERP is an integral part of the SMS, and is activated in the event of defined occurrences. The ERP is designed to ensure the following is in place prior to the occurrence:

a. the orderly and efficient transition from normal to emergency operations,

b. the delegation of emergency authority,

c. the assignment of emergency responsibilities,

d. the authorisation of key personnel for actions contained in the plan,

e. the definition and management of appropriate initial and recurrency training for personnel assigned to emergency roles,

f. the required coordination of efforts to cope with the emergency,

g. the safe continuation of operations or return to normal operations as soon as possible, and

h. the plans and coordinated actions to ensure the risks attributable to a major safety event can be managed and minimised.

28. AMOs need not develop a new ERP if their defined emergency operations are already covered by a suitable existing plan. They may leverage off a corporate ERP, or a site ERP, provided they identify the interfaces to that plan, their responsibilities within it, and what circumstances would cause it to be activated. Like all facets of an SMS, the ERP will depend on the size, scope, context and complexity of the AMO, and the emergency scenarios that are relevant to the organisation. The ERP will need to be periodically exercised to test its effectiveness.

Maturity indicators for clause a.1(e)

a. An ERP that reflects the size, nature and complexity of the operation has been developed and defines the procedures, roles, responsibilities and actions of the various organisations and key personnel.

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b. Key personnel in an emergency have easy access to the ERP at all times.

c. The organisation has a process to distribute the ERP procedures and to communicate the content to all personnel.

d. The ERP is periodically tested for the adequacy of the plan and the results reviewed to improve its effectiveness.

Clause a.1.(f) - SMS Documentation

29. Simply, the purpose of formal SMS documentation is to describe the organisation’s SMS, as defined by the elements of this regulation, and communicate it internally to staff, and externally to interfacing organisations. Documentation provides the authoritative basis for the establishment, and improvement of, the organisation’s level of safety. Tailored to AMO size, scope, complexity and risk context, SMS documentation captures SMS components, management, procedures and activities, including relevant integration for effectiveness and efficiency; and provides traceability. It also clarifies how the AMO’s safety management activities link to the organisation’s safety policy.

Gap Analysis

30. Prior to developing an SMS implementation plan, a gap analysis should be conducted to compare the AMO’s extant safety management processes with the requirements of the ICAO-based SMS framework. Most established AMOs are expected to already have implemented many SMS requirements due to their organisation’s need to comply to either the Defence Aviation Safety Manual, civil or military airworthiness regulations, or industry best-practice. The gap analysis facilitates AMO-specific definition of a tailored SMS implementation, reflective of the AMO’s business context.

SMS Plan

31. The most important document in an SMS is its SMS plan. The SMS plan—ensures that safety policy is implemented and maintained at all levels of the organisation, and to develop goals to match safety objectives. As part of an AMO’s initial or on-going TAR certification, the AMO needs to have developed, and demonstrated adherence to, an SMS plan that covers all elements of the regulation. This can be a stand-alone document, or included within another relevant AMO management plan.

32. Initially the document may need to be structured as a SMS implementation plan, with intended SMS scope, tasks required to be implemented, and phasings, to capture how the AMO will develop an effective SMS. Over time, as SMS processes are embedded and become functional within the AMO, the implementation plan will transitional naturally to become the SMS ‘management’ plan. Whether a progressive SMS implementation plan, or fully functioning SMS Plan, the document will form an agreement between the TAR and the AMO for the AMO’s growth path from current state, to a fully effective SMS.

Phased Approach to SMS Implementation

33. Every AMO should ensure that its SMS is tailored for its organisational mission, irrespective of AMO size, scope, complexity and risk context. There is no ‘one size fits all’ SMS approach, however all elements required by the regulations need to be evident.

34. Where one or more AMOs exist within a larger business group, each AMO may leverage off a single, corporate level SMS. A dedicated department of the group may provide any or all of the safety management functions for all AMOs under its umbrella.

35. Larger or more diverse AMOs may need several safety management levels and/or safety committee structures to effectively focus on strategic as well as tactical safety issues. Conversely, small AMOs may not need dedicated safety staff, instead relying on a number of employees to perform the multiple functions required—SMS management may therefore be more simplified. In very small organisations, maintaining independence in safety assurance functions may not be possible, in

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which case it would be acceptable for safety assurance and investigation functions to be conducted by other parties with the requisite competencies.

36. Following the gap analysis, a time-phased approach to SMS implementation is favoured. The bigger the AMO and scope of activities, the longer the period required. The phased approach recognises that the implementation and sustainment of a fully mature SMS can only be achieved over successive years, permitting the SMS to gradually mature with each phase. A time-phased approach also recognises that continuous SMS improvement is not possible without corresponding advancement towards a ‘generative safety culture’. Other benefits of a phased approach to SMS implementation include:

a. the provision of a manageable series of steps to follow in implementing the SMS, including allocation of resources;

b. effectively balancing workloads associated with SMS implementation against capability generation;

c. the ability to more easily report SMS implementation progress;

d. the need to allow implementation of the SMS framework in various sequences, depending upon the AMO’s current level of SMS maturity;

e. the initial availability of data and processes to support reactive, proactive and predictive safety risk management practices;

f. the need for a methodical process to ensure an effective and sustainable SMS implementation; and

g. to avoid ‘cosmetic compliance’, whereby a realistic implementation of an effective SMS is sought.

37. An example of a phased approach to SMS implementation is provided at annex A, to be tailored by each AMO dependent on its gap analysis results.

Maturity indicators for clause a.1(f)

a. A gap analysis comparing the AMO’s existing safety processes with the requirements of the SMS framework has been conducted.

b. There is documentation that describes the safety management system and the interrelationships between all of its elements.

c. SMS documentation is regularly reviewed and updated with appropriate version control in place.

d. SMS documentation is readily available to all personnel.

e. The SMS documentation details and references the means for the storage of other SMS related records.

SAFETY RISK MANAGEMENT

Explanation and amplification

38. AMOs needs to ensure that the risks to aviation safety posed by their maintenance activities, and the interface of those maintenance activities to other AMO functions, are controlled to meet agreed safety performance targets. This process is known as safety risk management and includes hazard identification, safety risk assessment and the implementation and monitoring of appropriate safety risk controls.

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39. Safety risk management is the core component of an SMS and systematically identifies risks that exist within the context of the delivery of an AMO’s products or services. Safety risks could be identified reactively, proactively or predictively, and a mature SMS caters equally for all three.

40. At the micro level, hazards may result from product, process or behaviours that are deficient in design, training, function, or human interfaces with other processes or systems. At the macro level, hazards may also result from latent failures of product, process, or organisational systems to account for human performance nuances, or failures to adequately adapt to changes in the AMO’s operating context. Generally it will always be easier to adapt the system to human performance nuances, rather than the other way around.

41. The AMO needs to identify, analyse, evaluate and treat all risks to aviation safety using a documented process derived from a suitable risk management standard, such as AS/NZS ISO 31000:2009—Risk Management–Principles and Guidelines. Maintenance-based risks will also be discovered during the in-Service life of equipment, through mandatory and voluntary employee reporting, and incident investigations.

Clause a.2(a) – Hazard identification, investigation and reporting

42. Hazard identification forms the basis of safety risk management. Hazards in an AMO can be classified into two groups—airworthiness hazards and personal safety hazards. They give rise to different risks with different consequences, and the good management of one type does not automatically indicate good management of the other. Airworthiness hazards in an AMO arise from the process of performing maintenance (including the behavioural aspects of the output), or internal and external interfaces to that maintenance and, and may ultimately compromise flight safety by potentially allowing the release of unserviceable aircraft or aeronautical product. Personal safety hazards on the other hand, affect individuals but may have little impact on flight safety. They typically give rise to consequences such as falls, hearing damage, electric shocks and the effects of chemical exposure. An effective SMS ensures that both types of hazards are addressed, either directly or indirectly through the integration of multiple management systems. Both types of hazards can be identified by considering:

a. the initial design of AMO management systems and their interfaces;

b. organisational structures and services;

c. latent equipment hazards;

d. development and review of existing and new procedures;

e. safety assurance function findings (audits, in-process task observations of tasks performed, self-reporting systems, data analysis, etc.);

f. planned changes to the systems and procedures;

g. communications required, including means, terminology and language;

h. human factors;

i. work environment factors; and

j. required defences.

43. Hazards can be identified reactively, proactively and predictively from a range of sources. Obviously the more proactive and predictive hazard identification and control is present, the less we will be bound to continue learning from incidents and accidents. Other possible sources include, but are not limited to:

a. Reactive hazard identification.

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(i) Mandatory incident, serious incident, and accident reporting and the investigations that have arisen for these occurrences.

b. Proactive hazard identification.

(i) voluntary and confidential hazard reporting,

(ii) hazard and incident database analysis,

(iii) brain-storming using experienced maintenance personnel,

(iv) development of risk scenarios and controls for all activities,

(v) surveys and audits,

(vi) in-process task observations,

(vii) feedback from training, and

(viii) maintenance program completion reviews.

c. Predictive hazard identification.

(i) Objective performance improvement health indicators,

(ii) trend analyses, and

(iii) data mining, information sharing and exchange systems (to similar/related organisations, regulators, etc).

44. Where risks are identified, safety controls are generated and tracked to completion to minimise recurrence.

45. Human factors and maintenance error management. Hazards arising from human factors and the subsequent risk of maintenance error are inherent to any AMO. These hazards should be captured using both proactive hazard identification tools (such as bow-tie analysis), and through the analysis of incident investigation reports. Identification of these hazards does not diminish the requirement for continued compliance with TAREG 4.5.4.

Definitions of accident and serious incident have been provided in the glossary. For commercial AMOs, reporting such occurrences to an appropriate member of the TAR’s staff is considered satisfactory to meet the requirement of this clause.

Maturity indicators for clause a.2(a)

a. The organisation has a reporting system to capture errors, hazards, incidents, serious incidents and accidents that is simple to use and accessible to all personnel.

b. The organisation has proactively identified all hazards and assessed risks related to its current activities.

c. The safety reporting system provides feedback to the reporter of any actions taken (or not taken) and, where appropriate, to the rest of the organisation.

d. Safety investigations are carried out to identify underlying causes and potential hazards for existing and future operations.

e. Safety-related reports are acted on in a timely manner.

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f. Hazard identification is an ongoing process and involves all key personnel and appropriate stakeholders.

g. Personnel responsible for investigating reports are trained in investigation techniques.

h. Investigations establish causal/contributing factors (why it happened, not just what happened).

i. Personnel express confidence and trust in the organisation’s reporting policy and process.

j. The hazards identified are documented and kept available for future reference and review.

k. The organisation uses the results of investigation of incidents and accidents as a source for hazard identification in the system.

Clause a.2(b) – Risk assessment and treatment

46. Risk assessment and treatment involves the systematic, rational and thoughtful manner in which to assess and prioritise identified risks. The risk lists which this process generates then provide the corporate lessons learned for future staff to better understand.

47. Bow-tie hazard analyses may be useful for AMOs to gain a systematic and rich understanding of the full spectrum of preventive and recovery controls applicable (or absent), and their adequacy. However, all risk management outcomes, residual risk and risk acceptance, as adapted from AS/NZS ISO 31000:2009—Risk Management–Principles and Guidelines needs to be documented and be made available to the TAR upon request. Note that risk treatments also need to be assessed, to ensure that the treatment does not inadvertently introduce unknown risks. Defence aviation needs to eliminate or otherwise minimise risk to safety so far as is reasonably practicable as required by the Workplace Health and Safety Act 2011.

48. Risks need to also be reviewed at regular intervals, at least yearly, to ensure extant safety risk treatments remain effective.

Maturity indicators for clause a.2(b)

a. There is a structured process for the management of risk that includes the assessment of risk associated with identified hazards, expressed in terms of severity and probability.

b. There are criteria for evaluating the level of risk the organisation is willing to accept.

c. The organisation has risk control strategies that include hazard elimination, risk control, risk avoidance, risk acceptance, risk mitigation, and where applicable an action plan.

d. Mitigating actions resulting from the risk assessment, including timelines and allocation of responsibilities are documented.

e. Risk management is routinely applied in decision making processes.

f. Risk assessments and risk ratings are appropriately justified.

g. Senior management has visibility of medium and high risk hazards and their mitigation and controls.

SAFETY ASSURANCE

Explanation and amplification

49. The safety assurance component is composed of three elements:

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a. safety performance monitoring, measurement and communication;

b. the management of change; and

c. continuous improvement of the SMS.

50. Safety assurance processes systematically provide confidence that organisational products/services meet or exceed safety requirements. It determines whether the SMS is operating, and continuously improving, according to agreed requirements. AMOs need to continually monitor their internal processes as well as their environment to detect changes or deviations that may introduce emerging safety risks, or degrade the effectiveness and efficiency of existing safety risk treatments. In addition to internal monitoring, AMOs need to incorporate findings from external audits/assessments. These external assurance and evaluation functions provide an element of independence to complement the internal program, and collectively provide the basis for continuous improvement. Changes or deviations identified can then be addressed through the AMO’s safety risk management process and corrective actions raised against findings. In addition, safety assurance provides stakeholders an indication of the level of safety performance of the system.

SMS-QMS Integration Considerations

51. The SMS and QMS share many common principles, with safety assurance emphasis being on the assurance and reporting that safety risk controls are in place, practised, and remain effective. This affords AMOs the opportunity to consider integrating some requirements or execution methodologies without compromising the outcomes of either system. Integration has subtle benefits, such as more robust and consistent management processes and resource maximisation.

52. The safety assurance process complements that of quality assurance, with each requiring specific performance criteria to be met. While quality assurance typically focuses on the organisation’s performance against business processes, safety assurance specifically monitors the performance of the agreed SMS. The complementary relationship between the two allows opportunities for the integration of any number of supporting processes. Such integration can provide synergies and increase efficiencies.

53. Quality management focuses on continual improvement through the assurance of product/service quality, and the repeatable means to achieve it. Safety management instead focuses on the mechanisms required for the identification and mitigation of safety risks. To be effective, an SMS integrates quality management principles, risk management principles and human factors’ principles into AMO processes.

54. The integration of the quality assurance functions with safety management is a marker of a more mature SMS, and along with the integration of other safety related governance regimes is expected to be a requirement of future regulatory development. Pre-positioning of organisational structures to gain early access to these benefits is encouraged.

Clause a.3(a) – Safety performance monitoring and measurement

55. Safety performance monitoring and measurement requires AMOs to develop a balanced series of lead and lag Safety Performance Indicators (SPIs) to quantitatively measure the effectiveness of each of their SMS elements and their intended outcomes. The number of SPIs is not as important as their coverage of SMS elements. Used effectively, SPIs can both provide an early warning of failures to maintain agreed performance or requirements, and confirmation that agreed improvements have been achieved.

56. Information sources for safety performance monitoring and measurement include:

a. proactive and predictive hazard reporting;

b. safety studies;

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c. safety reviews and surveys;

d. audits; and

e. safety investigations.

57. Frequency of monitoring. Many organisations may rely solely on audits to highlight system deterioration. However, audit intervals can be too infrequent, or may not provide an ability to collect data on all SPIs. Instead, the use of SPIs should be seen as complementing audit programs. Deficiencies uncovered by either an audit or SPI may highlight the need for a new SPI or vice versa. Inevitably, just like audit frequencies, some SPIs may have long lead or lag times. It is therefore important to establish balanced sets of SPIs that can be regularly reviewed in short, medium and long timeframes. Most importantly, each SPI needs to be defined so as to be clear as to what is being displayed, and what safety actions need to be taken as a result.

58. Communication of safety findings. Safety findings uncovered as part of the safety assurance process or SPI reviews are only useful if acted upon to the extent necessary to optimise SMS performance. This iterative feedback and refinement facilitates continuous improvement of the SMS. Those who can act of the safety findings, or need to be informed, can be quite varied. Hence given the volume and frequency of possible findings with time, a graduated approach should be used, based on criteria which may include the safety risk of the finding, possible audience, and resources required to correct.

Maturity indicators for clause a.3(a)

a. Safety objectives have been established.

b. Safety performance indicators have been defined, promulgated and are being monitored and analysed for trends.

c. Risk mitigations and controls are being verified/audited to confirm they are working and effective.

d. Safety audits are carried out that focus on the safety performance of the organisation and its services and assess normal operations.

e. Safety objectives and performance indicators are reviewed and updated periodically.

f. Safety objectives and targets are specific, measurable, agreed to, relevant and time-based.

g. Information obtained from safety assurance and compliance monitoring activities feeds back into the safety risk management process.

h. Information obtained from safety assurance and compliance monitoring activities feeds back into the safety risk management process.

Clause a.3(b) – Management of Change

59. Either self-generated or imposed, most changes at the AMO have the ability to affect the appropriateness or effectiveness of existing safety risk controls. Additionally, whenever change occurs, the opportunity exists for new aviation safety hazards to be inadvertently introduced. Hazards resulting from any change to what is considered to be the status quo should therefore be identified and addressed through the safety risk management process. Changes from the status quo can take many forms, including, for example, internal and external safety reviews and audits, nominal staff turn-over, more frequent need for shift-work, increased operational tempo, new or changes to deployments, introduction of new technologies or processes, etc.

60. The AMO’s documented organisational change management procedure should consider:

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a. Criticality. Processes, equipment, roles and activities that have higher aviation safety criticality should be ideally reviewed prior to organisational changes, to ensure that corrective actions can be proactively taken to control potentially emerging safety risks.

b. Existence of Effective Indicators. Safety Performance Indicators should be used to anticipate and monitor SMS effectiveness as a result of the introduced organisational change. Treatments can then be evaluated and adjusted where needed.

61. As AMOs mature, incremental changes can go unnoticed and accumulate. Effective change management therefore includes periodic reviews of the AMO system description, associated processes, and baseline hazard analyses to determine their continued validity.

Maturity indicators for clause a.3(b)

a. The organisation has established a process and conducts formal hazard analyses and risk assessments for major operational changes, major organisational changes and changes in key personnel.

b. Safety Case/Risk assessments are aviation safety focused.

c. Key stakeholders are involved in the change management process.

d. During the change management process previous risk assessments and existing hazards are reviewed for possible effect.

Clause a.3(c) – Continuous improvement of the SMS

62. Continuous improvement is measured through verification and monitoring of an AMO’s Safety Performance Indicators, and is related to the maturity and effectiveness of an SMS against the agreed implementation plan. Sources of information that can feed the continuous improvement include, for example, safety investigations, internal and external audit results, documentation reviews, SPI reviews, safety surveys, DDAAFS ASOR trending, etc.

Maturity indicators for clause a.3(c)

a. The Safety Committee has the necessary authority to make decisions related to the improvement and effectiveness of the SMS.

b. The SMS is periodically reviewed for improvements in safety performance.

SAFETY PROMOTION

Explanation and amplification

63. Safety promotion, both internal and external to the AMO, includes education, training and communication. The safety promotion intent is to encourage and celebrate a positive safety culture and to create an environment that is conducive to achieving the AMO’s safety objectives, as agreed in the SMS Implementation Plan. Safety promotion provides a sense of purpose to AMO safety efforts and enables the continuous improvement process.

64. Through safety promotion an organisation adopts a culture that goes beyond merely avoiding accidents or reducing the number of incidents and hazards, to focussing on creating an attitude to do the right thing at the right time in response to normal and emergency situations. Safety Promotion supports safety culture communication, dissemination of lessons learnt. A positive safety culture is one in which every person, from Senior Executive to the newest and most junior staff member, understands his or her role in maintaining safe operations, and actively participate in controlling and minimising safety risk. A positive culture is characterised by attitudes, behaviours, beliefs, values and evidence that the AMO is committed to agreed improvements in safety, at all levels. This is achieved through a combination of technical competence that is continually enhanced

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through education and training, effective safety communication, and targeted information sharing. Every leadership position in the AMO is a catalyst for the promotion and improvement of safety culture.

65. An AMO’s level of safety cannot be improved solely by being directed to do so, or by strict adherence to published policies. Safety promotion affects both individual and organisational culture, and supplements the AMO’s policies, procedures and processes by providing and supporting tangible and intangible evidence, and values, to support safety efforts. Safety culture is dynamic, and needs to be constantly reinforced as the AMO is affected by either nominal or imposed changes (eg. postings and/or staff movements, reforms, etc).

66. The AMO needs to establish and implement processes that facilitate effective communication and feedback throughout all levels of the organisation—from the abstract safety vision and goals to discrete actions and results. Nothing can provide positive reinforcement like the communication of successes, no matter how small or large.

67. AMOs need to also encourage bottom-up communication, providing an environment that allows senior management to receive open and constructive feedback from maintenance personnel at all levels. As the members closest to the coal-face, maintenance staff are likely to be able to proactively identify most of the undiscovered hazards, and be able to provide practical treatment options.

Clause a.4(a) – Education and training

68. The AMO needs to facilitate safety training relevant to specific issues encountered in their AMO’s context. The provision of education and training to appropriate staff, regardless of their level in the organisation, is an indication of management’s commitment to an effective SMS. Safety education and training at the local level should complement core promotion and specialisation courses, and be adapted to organisational context. Generally, local education and training should ensure coverage of the following topics and the benefits expected from each, from the macro to the micro, adapted for rank and responsibilities at the AMO:

a. organisational safety policies, goals, objectives and safety performance indicators,

b. safety roles and responsibilities of all staff levels,

c. safety risk management principles,

d. reactive, proactive and predictive safety reporting systems,

e. management’s visible support of safety,

f. communication of safety-related information,

g. maintenance resource management,

h. training effectiveness validation systems,

i. training recording and re-currency requirements, and

j. continuous safety improvement methodologies

69. As each individual within an AMO has safety responsibilities, safety education and training needs to ensure that personnel are competent to perform the safety-related duties expected. The closer to the coal-face staff are, the more safety education and training should be focused on practical implementation of safety concepts, and the outcomes expected. Conversely, the more removed from the coal-face, the more safety education and training should focus on national, corporate and organisational safety objectives and requirements, interfaces to other AMO business systems, allocation of resources, active safety promotion and assurance, and the creation of simple, practical

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means for working level staff to meet AMO SMS objectives. Given the different training coverage dependent on rank and seniority, there is no one-size fits all approach to safety education and training.

Maturity indicators for clause a.4(a)

a. There is a documented process to identify Safety Management training requirements so that personnel are competent to perform their duties.

b. There is a process in place to measure the effectiveness of training and to take appropriate action to improve subsequent training.

c. There is a process that evaluates the individual’s competence and takes appropriate remedial action when necessary.

d. Training includes initial and recurrent training.

e. A training record is maintained for all personnel trained.

Clause a.4(b) – Safety communication

70. The purpose of safety communication is to ensure that aviation safety issues are openly, effectively and regularly discussed and disseminated within, and external to, the AMO, to the right audience, at all levels. This includes coverage of SMS objectives, safety performance indicators and trends, procedures and remedial actions as a result of feedback or safety performance.

71. Safety communication therefore aims to:

a. ensure that staff are fully aware of the scope of their SMS and their part in it;

b. convey safety-critical information and resultant actions in language the audience can relate to;

c. encourage timely, relevant and clear two-way discussions;

d. raise awareness of hazards and treatment effectiveness;

e. provide transparent information regarding changes at the AMO and their assessed safety impacts;

f. provide feedback on AMO safety performance indicators and resultant preventive/corrective actions; and

g. share successes and lessons learned.

72. Communication can take any form that most effectively imparts the outcomes sought to the audience required. Successful safety communication strategies employ multiple means of communication, each adapted for a different type of safety information and audience. Safety information has no value unless the audience learns from it, which in its simplest form reinforces safety awareness and at its most complex, stimulates action to mitigate future risks. Visual, verbal, written or interactive communication means can be used effectively. Bulletins, briefings, safety groups, scrolling banners on web pages and hazard and incident workshops, among others, have been used successfully in the past as part of an overall coordinated safety communication strategy. Safety lessons learned can also be gained from sharing information with, and from, other AMOs.

73. Safety communication has to be two-way, internal and external to the AMO. Both from the leadership to staff, and vice-versa. This will ensure that the right people are communicating and receiving feedback on the different types of safety issues at the right time, either as an action status or as new hazards.

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Maturity indicators for clause a.4(b)

a. Safety plans and strategies are communicated throughout the organisation to all personnel.

b. Significant events and investigation outcomes associated with the organisation are communicated to all personnel, including contracted organisations where appropriate.

c. Safety-related information is proactively shared with other parties.

FURTHER INFORMATION

74. For readers that wish to consider additional implementation examples, tips, lessons learned, or expanded guidance, the following documents are provided as an initial reference source. Most of the information provided in this document has been extracted from these references:

a. AAP 6734.001—Defence Aviation Safety Manual [DASM]. Retrieved from: http://www.defence.gov.au/dgta/Documents/Publications/6734001/AAP6734_001.pdf.

b. Civil Aviation Safety Authority [CASA]. (2002). Safety management and the CEO. Retrieved from: http://www.casa.gov.au/sms/toolkit/sms-ceo.pdf.

c. Civil Aviation Safety Authority [CASA]. (2009). Safety management systems for RPT operations. Civil Aviation Advisory Publication [CAAP] SMS-1(0). Canberra, Australia: Retrieved from http://www.casa.gov.au/wcmswr/_assets/main/download/caaps/ops/sms-1.pdf.

d. Civil Aviation Safety Authority [CASA]. (2009). Integration of human factors into safety management systems. Civil Aviation Advisory Publication [CAAP] SMS-2(0). Canberra, Australia: Retrieved from http://www.casa.gov.au/wcmswr/_assets/main/download/caaps/ops/sms-2.pdf.

e. Civil Aviation Safety Authority [CASA]. (2011). Non-technical skills training and assessment for regular public transport operations. Civil Aviation Advisory Publication [CAAP] SMS-3(1). Canberra, Australia: Retrieved from http://www.casa.gov.au/wcmswr/_assets/main/download/caaps/ops/sms-3-1.pdf.

f. Federal Aviation Administration [FAA]. (2010). SMS for aviation service providers. AC120-92A. Washington, DC: Retrieved from http://www.faa.gov/documentLibrary/media/Advisory_Circular/AC_120-92B.pdf.

g. Hudson, P. (2000). Safety management and safety culture: The long and winding road. The Netherlands: Centre for Safety Research, Leiden University. Retrieved from: http://skybrary.aero/bookshelf/books/2417.pdf.

h. International Civil Aviation Organisation [ICAO], (2012). Safety Management International Collaboration Group [SMIGC]. Safety Management System Evaluation Tool. Retrieved from http://www.icao.int/safety/SafetyManagement/Documents/Forms/AllItems.aspx.

i. International Civil Aviation Organisation [ICAO], (2013). Safety Management Manual (3rd ed.). Document No. 9859. Montreal, Canada: ICAO. Retrieved from http://www.icao.int/safety/SafetyManagement/Documents/Forms/AllItems.aspx

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j. Reason, J. (1997). Managing the risks of organisational accidents. Surrey: UK, Ashgate.

k. Transport Canada Technical Program [TP] 14343. (2012). Implementation procedures for air operators and approved maintenance organisations. Retrieved from https://www.tc.gc.ca/eng/civilaviation/publications/tp14343-guide-3084.htm.

l. Transport Canada http://www.tc.gc.ca/eng/civilaviation/standards/sms-menu-618.htm provides an outstanding source of SMS information and templates for how to assess safety culture.

ANNEX A TO

TAREG 4.4.4 GUIDANCE

Example of Phased SMS implementation

Phase 1 Phase 2 Phase 3 Phase 4

1. Implementation planning:

a) identify the SMS Senior Executive;

b) establish an SMS implementation team;

c) define the scope of the SMS;

d) perform an SMS gap analysis.

e) develop an SMS implementation plan.

2. Safety appointments:

a) establish a key person/office responsible for the administration and maintenance of the SMS.

3. Training and education:

a) establish an SMS training programme for personnel, with priority for the SMS implementation team.

4. Safety communication:

a) initiate SMS/safety communication channels.

1. Management commitment:

a) establish the safety policy and objectives.

2. Safety accountabilities:

a) define safety management responsibilities and accountabilities across relevant departments of the organisation;

b) establish an SMS/safety coordination mechanism/ committees;

c) establish departmental/ divisional Safety Action Groups where applicable.

3. Emergency response planning:

a) develop an emergency response plan.

4. SMS documentation:

a) initiate progressive development of SMS documentation and other supporting documentation.

1. Hazard identification:

a) establish a voluntary hazard reporting procedure.

2. Safety risk management:

a) establish safety risk management procedures.

3. Safety performance monitoring:

a) establish occurrence reporting and investigation procedures;

b) establish a safety data collection and processing system for occurrence outcomes;

c) develop higher-consequence SPIs and associated targets and alert settings, and that provide predictive hazard management.

4. Change management:

a) establish a ‘management of change’ procedure that includes proactive safety risk assessment.

5. Continuous improvement:

a) establish an internal quality audit programme;

b) establish an external quality audit programme.

1. Management commitment:

a) enhance the existing disciplinary procedure/ policy with due consideration of unintentional errors or mistakes from deliberate or gross violations.

2. Hazard identification:

a) integrate hazards identified from occurrence investigation reports with the voluntary hazard reporting system;

b) integrate hazard identification and risk management procedures with the subcontractor’s or customer’s SMS where applicable.

3. Safety performance monitoring:

a) enhance the safety data collection and processing system to include lower-consequence events;

b) develop lower-consequence SPIs and associated targets/alert settings, and that provide predictive hazard management.

4. Continuous improvement:

a) establish SMS audit programmes or integrate them into existing internal and external audit programmes;

b) establish other SMS review/survey programmes where appropriate.

5. Training and education:

a) ensure that the tailored SMS training programme for all unit personnel has been completed.

6. Safety communication:

a) promote safety information sharing and exchange internally and externally.