Par 2-1 Page 3 CHAPTER 2. SAFETY MANAGEMENT SYSTEM (SMS) FOUNDATIONS
2-1. SAFETY CULTURE AND SAFETY MANAGEMENT. One key aspect that is essential to safety performance is the culture of the organization. “Safety culture” is the term that we apply to those aspects of the organization’s culture that relate to safety performance. The concept of safety culture underlies safety management and is the basis for the SMS requirements of Title 14 of the Code of Federal Regulations (14 CFR) part 5.2
a. Interdependence. Because the culture of an organization includes the deeply ingrained and automatic psychological and behavioral aspect of human performance, there is a strong correlation between safety culture and accident prevention. Therefore, safety culture and SMS are interdependent. Management’s constant attention, commitment, and visible leadership are essential to guiding an organization toward a positive safety performance.
b. Safety Culture. Cultures are the product of the values and actions of the organization’s leadership as well as the results of organizational learning. Cultures are not really “created” or “implemented;” they emerge over time and as a result of experience. Organizations cannot simply purchase a software program, produce a set of posters filled with buzzwords, require their people to attend an hour of slide presentations, and instantly install an effective SMS. As with the development of any skill, it takes time, practice and repetition, the appropriate attitude, a cohesive approach, and constant coaching from involved mentors.
c. Management Framework. It is for this reason that a management framework that facilitates decisionmaking and shapes the environment in which employees work is crucial to organizational performance in all aspects of the organization’s business, including safety.
A safety culture matures as safety management skills are learned and practiced and become second nature across the entire organization. The following have been found to be characteristics of organizations that consistently achieve safe results.
(1) Open Reporting. Policies and processes that foster open reporting while, at the same time, stressing the need for continuous diligence and professionalism. The organization should encourage disclosure of error without fear of reprisal, yet it should also demand accountability on the part of employees and management alike.
(2) Just Culture. The organization should engage in identification of systemic errors, implement preventative corrective action, and exhibit intolerance of undesirable behaviors such as recklessness or willful disregard for established procedures. This is often referred to as a “just culture.”
(3) Personnel Involvement. Involvement of line personnel and all levels of management in functions dealing with aviation safety, including the accountable executive, is critical to effective safety management throughout an organization.
2 While the concepts discussed in this section underlie the requirements of part 5, they are included solely for background purposes. The actual regulatory requirements of part 5 are discussed in Chapter 3.
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(4) Use of Information. Effective use of all safety information assures informed management decisionmaking.
(5) Commitment to Risk Reduction. The organization expects direct management involvement in identifying hazards and managing risk.
(6) Vigilance. Processes that provide vigilance of ongoing operations and the environment to ensure effectiveness of risk controls and awareness of emerging hazards.
(7) Flexibility. Using information effectively to adjust and change to reduce risk, and a willingness to commit resources to making changes necessary to reduce risk.
(8) Learning. The organization learns from its own failures and from those of allied and similar businesses. The organization actually uses acquired data to feed analysis processes, the results of which yield information that can be acted upon to improve safety.
d. Management Involvement. Management leadership should demonstrate their visible commitment to and involvement in safe operation performing their daily work. SMS processes do not have to be expensive or sophisticated; however, active personal involvement of operational leaders is essential. Safety management must be accomplished by those managers who “own” the processes in which risk resides. Safety cultures also cannot be “created” or “implemented” by management decree, no matter how sincere their intentions. Every organization has a safety culture. It is embodied in the way the organization and its members approach safety in their jobs. If positive aspects of culture are to emerge, the organization’s management must set up the policies and processes that create a working environment that fosters safe behavior. That is the purpose of the SMS processes.
2-2. SMS FUNDAMENTALS.
a. What Is an SMS? SMSs can be a complex topic with many aspects to consider, but the defining characteristic of an SMS is that it is a decisionmaking system. An SMS does not have to be an extensive, expensive, or sophisticated array of techniques to do what it is supposed to do.
Rather, an SMS is built by structuring your safety management around four components: safety policy, safety risk management (SRM), safety assurance (SA), and safety promotion. A brief description of these components is provided below.
b. Safety Policy. Safety policy is where you set objectives, assign responsibilities, and set standards. It is also where management conveys its commitment to the safety performance of the organization to its employees. As SRM and SA processes are developed, you will come back to the safety policy to ensure that the commitments in the policy are being realized and the standards are being upheld.
c. Safety Risk Management (SRM). The SRM component provides a decisionmaking process for identifying hazards and mitigating risk based on a thorough understanding of the organization’s systems and their operating environment. SRM includes decisionmaking regarding management acceptance of risk to operations. The SRM component is the organization’s way of fulfilling its commitment to consider risk in their operations and to reduce it to an acceptable level. In that sense, SRM is a design process, a way to incorporate risk
Par 2-2 Page 5 controls into processes, products, and services or to redesign controls where existing ones are not meeting the organization’s needs.
d. Safety Assurance (SA). SA provides you with the necessary processes to give you confidence that your system is meeting your organization’s safety objectives and that your mitigations, or risk controls, developed under SRM are working. In SA, your goal is to watch what is going on and review what has happened to ensure that your objectives are being met.
Thus, SA requires monitoring and measuring safety performance of operational processes and continuously improving the level of safety performance. Strong SA processes will yield information used to maintain the integrity of risk controls. SA processes are thus a means of assuring the safety performance of the organization, keeping it on track, correcting it where necessary, and identifying needs for rethinking existing processes.
e. Safety Promotion. The last component, safety promotion, is designed to ensure that your employees have a solid foundation regarding their safety responsibilities, the organization’s safety policies and expectations, reporting procedures, and a familiarity with risk controls. Thus, training and communication are the two key areas of safety promotion.
f. Summary. An SMS does not have to be large, complex, or expensive in order to add value. If you have active involvement of the operational leaders, maintain open lines of communication up and down the organization and among peers, stay vigilant in looking for new operations, and ensure that your employees know that safety is an essential part of their job performance, you will have an effective SMS that helps you make better safety management decisions.
2-3. CONCEPTUAL OVERVIEW OF SRM AND SA.
a. Graphical Overview of SRM and SA Processes. Figure 2-1, Safety Management Decisionmaking Processes, provides an expanded view of the principal two sets of processes of the SMS: SRM and SA. In the discussion that follows, we’ll introduce some key terms and concepts related to SMS processes. A more detailed discussion of the SRM and SA processes is set out in Chapter 3, Safety Management System (SMS) Components Explained. Because safety management is a decisionmaking process, the SRM and SA processes follow a set of processes outlined in Figure 2-1. These processes work as follows. The Description and Context step requires the user of the process to gain an overall understanding and context of the operation that either is being or will be performed. The Specific Information step requires the user of the process to obtain information about aspects of the systems and environments involved that may present risk. Under the Analysis step, the user analyzes or makes sense of that information. The Assessment step requires the user to make decisions regarding the acceptability or risk of system performance. Finally, under the Resolution step, the user takes necessary action.
Par 2-3 Page 6 FIGURE 2-1. SAFETY MANAGEMENT DECISIONMAKING PROCESSES.
b. SRM.
(1) In SRM, the first step, System Description (Analysis), is used to understand the aspects of the operation that might cause harm. In most cases, Hazard Identification flows from this system analysis. Hazard identification requires you to ask: What hazards exist in the operational environment? What are the human factors issues of the operation (e.g., workload, distraction, fatigue, or system complexity)? What are the limitations of the hardware, software, procedures, etc.?
(2) While the diagram above depicts that processes as distinctly defined components, in practice they flow from one to the other. For example, in a careful discussion of how a system currently works (System Description (Analysis)), hazards will often become evident. Thus, the hazard identification step has also been at least partially accomplished.
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(3) The process then progresses into an analysis of the potential consequences of operation in the presence of the identified hazards (Risk Analysis). This culminates in an assessment of the acceptability of operating with these hazards, Risk Assessment, or whether or not the risk of such operations can be mitigated to an acceptable level, Risk Control. For this reason, operational managers must be the ones who are accountable for these decisions.
(4) After a system has been designed or revised using the SRM process, special attention should be given to the new or revised system using the SA process. It should not be surprising to find at this time that there are still things that might not have been considered or that there are changes over time in the operational environment, requiring a return to SRM. Thus, the SRM and SA processes operate in a continuous exchange.
c. SA and Interactions with SRM.
(1) In SA, the process continues with measuring and monitoring the performance of the system operation, System Monitoring, with the designed risk controls in place. This involves a variety of data sources (Data Acquisition) that will be further explained in Chapter 3. As in SRM, the data will need to be analyzed in order for it to be used in decisionmaking, Analysis of Data. In the case of SA, the decisionmaking can result in several paths, System Assessment. If the data and analysis say that the system and its risk controls are functioning as intended, the result is confirmatory: the management now can have confidence in system safety performance.
(2) If this is not the case, the analysis needs to continue to determine if the shortfall is due to the fact that the controls are not being used as intended (e.g., required training not accomplished, procedures not followed, org improper tools or equipment provided), or if, even though the system is being used as intended, it is not producing the expected results. In the former case, action should be taken to correct the problem, Corrective Action. In the latter case, the system design should be reconsidered using the path back to the SRM process.
(3) The path back to SRM is a particularly important part of the SA process, especially for carriers who are transitioning into SMS. Their operational systems have likely not been built using an SRM process, so they may lack formal or well understood risk controls. The SA process covers the day-to-day life of system operations, so, in many cases, the determination to review existing processes for hazard and risk may be the first time that these aspects of operation have been considered.
(4) As in SRM, managers who are responsible for operational processes are the ones who are also responsible for assuring that they are performing as intended from a safety, as well as operational, standpoint. Moreover, correct design, performance, and risk control need to be a concern of top management, including the accountable executive.
2-4. DEFINITIONS.
a. Hazard. A condition that could foreseeably cause or contribute to an aircraft accident as defined in Title 49 of the Code of Federal Regulations (49 CFR) part 830, § 830.2.
b. Risk. The composite of predicted severity and likelihood of the potential effect of a hazard.
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c. Risk Control. A means to reduce or eliminate the effects of hazards.
d. Safety Assurance (SA). Processes within the SMS that function systematically to ensure the performance and effectiveness of safety risk controls and that the organization meets or exceeds its safety objectives through the collection, analysis, and assessment of information.
e. Safety Management System (SMS). The formal, top-down, organization-wide approach to managing safety risk and assuring the effectiveness of safety risk controls. It includes systematic procedures, practices, and policies for the management of safety risk.
f. Safety Objective. A measurable goal or desirable outcome related to safety.
g. Safety Performance. Realized or actual safety accomplishment relative to the organization’s safety objectives.
h. Safety Policy. The certificate holder’s documented commitment to safety, which defines its safety objectives and the accountabilities and responsibilities of its employees in regard to safety.
i. Safety Promotion. A combination of training and communication of safety information to support the implementation and operation of an SMS in an organization.
j. Safety Risk Management (SRM). A process within the SMS composed of describing the system, identifying the hazards, and analyzing, assessing, and controlling risk.
Par 3-1 Page 9 CHAPTER 3. SAFETY MANAGEMENT SYSTEM (SMS) COMPONENTS EXPLAINED
3-1. OVERVIEW OF THE STRUCTURE OF CHAPTER 3. SMS requirements are organized around building blocks of safety management. These processes are essential for an SMS. This chapter contains short descriptions of each SMS component and the processes contained therein. After the title of each process are the following.
a. Specific Regulatory Requirement (SRR). The SRR for the process (where it may be found in Title 14 of the Code of Federal Regulations (14 CFR) part 5).
b. Related Regulatory Requirements. Where applicable, to help put part 5 in context of existing regulations and provide reference for interrelated requirements within part 5, e.g., requirements for management accountability related to a process.
c. Tracking Tags.3 A reference to International Civil Aviation Organization (ICAO)/former Safety Management System Pilot Project (SMSPP) - Component/Element tags.
These do not denote legal requirements; they are provided solely as reference to facilitate cross-referencing and gap analysis on the part of SMSPP participants to assist them in revising their plans and systems to comply with part 5. The Federal Aviation Administration (FAA) emphasizes that fully complying with part 5 satisfies almost all4 of the pertinent ICAO SMS requirements.
d. A Summary. A brief plain language overview of the process.
e. An Objective. A brief explanation of the goal of the process.
f. A Regulatory Text Box. A copy of part 5 regulatory text, for reference, which should facilitate readers’ ability to relate regulatory requirements with explanations without the need to cross-reference additional documents.
g. A Discussion. A more detailed plain language explanation of the process as it relates to the SMS. It includes some examples, when appropriate, and offers optional Recommended Design Characteristics.
h. Scalability. A short discussion, where applicable, of scalability, providing examples of how different-sized carriers can meet the pertinent SMS requirements. Information on scalability is broken down into small, medium, and large carriers. Small carriers are generally defined as those carriers operating fewer than 10 airplanes; medium carriers are those with fewer than 48 airplanes; and large carriers are those with more than 48 airplanes.
3 These tags are included to assist carriers who originally developed their documentation in accordance with AC 120-92A, Appendix 2, and for alignment with international standards. The items referenced as “components” or “elements” are also consistent with ICAO Annex 19, Appendix 2, SMS Framework.
4 ICAO Safety Management standards require operators of airplanes over 27,000 kg to have include a Flight Data Analysis (FDA) program as part of their SMS. Part 5 will not require these programs.
Par 3-1 Page 10 NOTE: The scalability discussions are for illustration only and impose neither requirements nor resource allocation by a service provider.
3-2. SUBPART A: GENERAL.
a. Applicability: Requirements for Implementation.
(1) SRR. Part 5, § 5.1.
(2) Related Regulatory Requirements. None.
(3) ICAO/SMSPP. N/A.
(4) Part 5 Requirements.
(5) Discussion. The SMS required by this regulation is intended to cover only the aviation operational processes of the carrier. For example, the aviation operational processes in a typical carrier may include:
• Flight operations,
• Operational control (dispatch/flight following),
• Maintenance and inspection,
• Cabin safety,
• Ground handling and servicing,
• Cargo handling, and
• Training.
NOTE: Information concerning implementation planning for 14 CFR part 121 certificate holders and applicants for part 121 certificates is outlined in greater detail in Chapter 4, Implementation: Building a Safety Management System (SMS).
b. General Requirements: Components of an SMS.
(1) SRR. Section 5.3(a).
(2) Related Regulatory Requirements. None.
§ 5.1 Applicability.
(a) A certificate holder under part 119 of this chapter authorized to conduct operations in accordance with the requirements of part 121 of this chapter must have a Safety Management System that meets the requirements of this part and is acceptable to the Administrator by March 9, 2018.
(b) A certificate holder must submit an implementation plan to the FAA Administrator for review no later than September 9, 2015. The implementation plan must be approved no later than March 9, 2016.
(c) The implementation plan may include any of the certificate holder ’s existing programs, policies, or procedures that it intends to use to meet the requirements of this part, including components of an existing SMS.
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(3) ICAO/SMSPP. N/A.
(4) Part 5 Requirements.
(5) Discussion. For a discussion on size, scope and complexity with regard to SMS scalability, see paragraph 1-3 and the scalability examples in this chapter.
c. Recordkeeping Requirements.
(1) SRR. Section 5.3(b).
(2) Related Regulatory Requirements. Section 5.95.
(3) ICAO/SMSPP. N/A.
(4) Part 5 Requirements.
(5) Discussion. Documentation and recordkeeping requirements are in part 5, subpart F.
d. Compliance with Code of Federal Regulations (CFR).
(1) SRR. Section 5.3(c).
(2) Related Regulatory Requirements. None.
(3) ICAO/SMSPP. N/A.
(4) Part 5 Requirements.
§ 5.3 General requirements.
(a) Any certificate holder required to have an SMS under this part must submit the Safety Management System to the Administrator for acceptance. The SMS must be appropriate to the size, scope, and complexity of the certificate holder’s operation and include at least the following components:
(1) Safety policy in accordance with the requirements of subpart B of this part;
(2) Safety risk management in accordance with the requirements of subpart C of this part;
(3) Safety assurance in accordance with the requirements of subpart D of this part; and
(4) Safety promotion in accordance with the requirements of subpart E of this part.
§ 5.3 General requirements.
(b) The Safety Management System must be maintained in accordance with the recordkeeping requirements in subpart F of this part.
§ 5.3 General requirements.
(c) The Safety Management System must ensure compliance with the relevant regulatory standards in chapter I of Title 14 of the Code of Federal Regulations.
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3-3. SUBPART B: SAFETY POLICY.
a. Introduction.
(1) SRR. Part 5, subpart B.
(2) Related Regulatory Requirements. None.
(3) ICAO/SMSPP. N/A.
(4) Summary. This section of the advisory circular (AC) provides guidance about how the accountable executive, in coordination with other senior managers, might define safety performance objectives, assign accountability, and allocate resources. The safety policy should be appropriate to the size, scope, and complexity of the operation. Additionally, the safety policy component is where your management defines their commitment to managing safety throughout the organization.
b. Safety Policy.
(1) SRR. Section 5.21.
(2) Related Regulatory Requirements. None.
(3) ICAO/SMSPP. Element 1.1.
(4) Part 5 Requirements.
(5) Discussion. The safety policy statement is a concise document from the accountable executive that conveys the organization’s basic commitments to safety management. It provides a basis for more detailed setting of objectives for planning and performance measurement, assignment of responsibility, and reporting, including clear statements regarding behavioral and performance expectations. The safety policy may be supported by additional documents that expand in specific areas, and, where applicable, it may also set out procedures. An example of a § 5.21 Safety policy.
(a) The certificate holder must have a safety policy that includes at least the following:
(1) The safety objectives of the certificate holder.
(2) A commitment of the certificate holder to fulfill the organization's safety objectives.
(3) A clear statement about the provision of the necessary resources for the implementation of the SMS.
(4) A safety reporting policy that defines requirements for employee reporting of safety hazards or issues.
(5) A policy that defines unacceptable behavior and conditions for disciplinary action.
(6) An emergency response plan that provides for the safe transition from normal to emergency operations in accordance with the requirements of § 5.27.
(b) The safety policy must be signed by the accountable executive described in § 5.25.
(c) The safety policy must be documented and communicated throughout the certificate holder organization.
(d) The safety policy must be regularly reviewed by the accountable executive to ensure it remains relevant and appropriate to the certificate holder.
Par 3-3 Page 13 safety policy statement can be found in Appendix 3, Sample Safety Policy Statement.
Section 5.21(a)(1) requires carriers to develop safety objectives as part of their safety policy. The assessment process required by § 5.73 is where decisions are made regarding attainment of these objectives. In setting these objectives, this is a case where “starting with the end in sight” is sound advice. Objectives can fall into a number of categories, including:
• Compliance with regulations. Compliance with all regulations is an expectation for all carriers and assurance of such compliance is an explicit requirement of the SMS (refer to § 5.3(b)).
• Milestones for implementation of safety-related programs or initiatives.
• Reduction of error or incident rates.
• Tracking of safety events. Certain events such as ground damage, pilot deviations, weight and balance errors, or maintenance errors may be targets for safety objectives and associated tracking and action. One caution with these types of measures is not to lose focus on risk factors that may be associated with potentially more serious events.
(6) Scalability. Safety policies would not be expected to vary between small, medium, and large organizations; however, the levels of management involved in preparation and implementation of the policy may vary.
(a) Small. The owner or most senior manager (the accountable executive) may personally perform this process. The policy can be a simple, often single-page, written document, signed by the accountable executive. Small organizations typically operate in smaller networks of employees, so the policy may be posted in company work areas or included in company briefings or in training.
(b) Medium. The accountable executive, with the involvement of other senior managers, is likely to develop, publish, and communicate the safety policy. The policy may be disseminated via company newsletters, company Web sites, employee briefings, or existing indoctrination and recurrent training.
(c) Large. A large organization may require the accountable executive or other senior managers and technical staff to perform this process. While the regulations only require the accountable executive to sign the safety policy, members of senior management may also sign the safety policy. Large carriers may disseminate their policy using a variety of resources such as company Web sites, intranets, email, or existing indoctrination and recurrent training.
c. Safety, Accountability, and Authority.
(1) SRR. Section 5.23.
(2) Related Regulatory Requirements. Section 5.25 and 14 CFR part 119, § 119.65.
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(3) ICAO/SMSPP. Element 1.2.
(4) Part 5 Requirements.
(5) Discussion. This SMS process requires defined accountability for achieving safety performance objectives within the organization’s safety policy for the following individuals:
NOTE: “Accountability” as used here, refers to active management and line employee involvement and action in managing and maintaining safety performance. A certificate holder defines accountability by ensuring that each of its management and line employees is aware of his or her specific role within SMS and actively participates in carrying out his or her SMS-related duties. Once the accountabilities for these employees have been defined, Subpart D (Safety Promotion) requires that these accountabilities be communicated throughout the organization.
(a) Accountable Executive. The accountable executive has the ultimate responsibility for safety management within the organization. The specific duties of the accountable executive are discussed in more detail in the discussion of § 5.25 below.
(b) All Members of Management. Managers are the individuals who are responsible for identifying hazards, conducting risk assessments, and developing risk controls for their areas of responsibility. They have the technical expertise and are the ones responsible for implementation and operation of risk controls (often in the form of operational procedures, specified tools, training, communication, etc.). A key element in your SRM process is to identify the levels of management with the authority to make risk decisions related to aviation safety.
Thus, managers that have the authority to implement changes in systems and procedures must use the SMS processes in managing their area of operational responsibility. They are also responsible for assuring the continuing operational safety of risk controls. Through data collection methods and analytical processes in the SA component, managers are able to determine that risk controls are effective and that their safety performance is acceptable. For example, the Director of Maintenance (DOM) is one of the managers accountable for SMS within his or her area of responsibility.
§ 5.23 Safety accountability and authority.
(a) The certificate holder must define accountability for safety within the organization’s safety policy for the following individuals:
(1) Accountable executive, as described in § 5.25.
(2) All members of management in regard to developing, implementing, and maintaining SMS processes within their area of responsibility, including, but not limited to:
(i) Hazard identification and safety risk assessment.
(ii) Assuring the effectiveness of safety risk controls.
(iii) Promoting safety as required in subpart E of this part.
(iv) Advising the accountable executive on the performance of the SMS and on any need for improvement.
(3) Employees relative to the certificate holder’s safety performance.
(b) The certificate holder must identify the levels of management with the authority to make decisions regarding safety risk acceptance.