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Advisory Circular
Subject:Safety Management Systems Development Guide for SmallOperators/Organizations
Issuing Office: Civil AviationActivity Area: Oversight AC No.: 107-002
File No.: Z 5015-11-2 Issue No.: 01
RDIMS No.: 2382587 Effective Date: 2008-06-15
TABLE OF CONTENTS
1.0 INTRODUCTION.............................................................................................................................. 21.1 Purpose...........................................................................................................................................2 1.2 Applicability....................................................................................................................................2 1.3 Description of Changes................................................................................................................. 22.0 REFERENCES AND REQUIREMENTS .........................................................................................22.1 Reference Documents...................................................................................................................22.2 Cancelled Documents.................................................................................................................... 22.3 Definitions and Abbreviations ......................................................................................................23.0 BACKGROUND............................................................................................................................... 33.1 What is this guide for and who should use it? ...........................................................................33.2 What is a SMS? ..............................................................................................................................33.3 Key Generic Features of the SMS Approach ..............................................................................44.0 SMALL OPERATORS/ORGANIZATIONS GUIDE......................................................................... 54.1 Determining Complexity................................................................................................................ 54.2 Appendix A: Safety Management Plan ........................................................................................54.3 Appendices B to E .........................................................................................................................75.0 CONTACT OFFICE ......................................................................................................................... 7APPENDIX ASAFETY MANAGEMENT PLAN .................................................................................................8 APPENDIX BOCCURRENCE REPORT AND HAZARD IDENTIFICATION FORM .................................................49APPENDIX CINCIDENT/ACCIDENT ANALYSIS ............................................................................................50 APPENDIX DCORRECTIVE/PREVENTATIVE ACTION PLAN.......................................................................... 51APPENDIX ERISK MANAGEMENT WORKSHEET.........................................................................................52 APPENDIX FRISK MATRIX .......................................................................................................................54
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2008-06-15 2 of54 AC 107-002 Issue 01
1.0 INTRODUCTION
This Advisory Circular (AC) is provided for information and guidance purposes only. It may
describe an example of an acceptable means, but not the only means, of demonstrating
compliance with regulations and standards. On its own, this AC does not change, create, amend
or permit deviations from regulatory requirements, nor does it establish minimum standards.
1.1 PurposeThe purpose of this document is to provide additional guidance on the practical application of the
regulations pertaining to Safety Management Systems (SMS). This guide provides examples of
SMS processes suitable for small operators/organizations operating under the Canadian AviationRegulations(CARs) Parts IV, V and VII.
1.2 Applicability
This document is applicable to the aviation industry, delegates, individuals and organizations and
all Transport Canada Civil Aviation (TCCA) employees when they are exercising privileges
granted to them under an External Ministerial Delegation of Authority.
1.3 Description of Changes
Not applicable.2.0 REFERENCES AND REQUIREMENTS
2.1 Reference Documents
It is intended that the following reference materials be used in conjunction with this document:
(a) Part I, Subpart 7 of the Canadian Aviation Regulations(CARs)Safety ManagementSystem Requirements;
(b) Part V, Subpart 73 of the CARApproved Maintenance Organizations;
(c) Part VII, Subpart 5 of the CARAirline Operations;
(d) Staff Instruction (SI) SUR-001, Issue 01, dated 2008-03-07Safety Management System
Assessment and Program Validation Procedures;(e) Transport Publication (TP) 14135, dated 2004-09-01Safety Management Systems for
Small Aviation OperationsA Practical Guide to Implementation; and
(f) TP 14343, Revision 1, dated 2005-06-01Safety Management System ImplementationProcedures Guide for Air Operators and Approved Maintenance Organizations.
2.2 Cancelled Documents
Not applicable.
2.3 Definitions and Abbreviations
The following definitions and abbreviations are used in this document:
(a) AC means Advisory Circular.(b) AMO means Approved Maintenance Organization.
(c) COM means Company Operations Manual.
(d) MCM means Maintenance Control Manual.
(e) MPM means Maintenance Policy Manual.
(f) Policy means a guiding principle used to set direction in an organization. It is a high-leveloverall plan that outlines goals and objectives.
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(g) Procedure means a group of interrelated activities (procedures) that convert inputs tooutputs.
(h) Process means a specified way to carry out an activity (e.g. a series of steps).
(i) SMS means Safety Management System.
(j) System means a group of inter-dependent processes and people that work together toachieve a defined result. Together, the policies, procedures and processes form the
system.
(k) TCCA means Transport Canada Civil Aviation.
3.0 BACKGROUND
3.1 What is this guide for and who should use it?
(1) In anticipation of the regulatory SMS requirements for small operators, this document has been
developed to address organizations of minimum to moderate complexity.
(2) This guidance material provides an interpretation of the intent and application of the SMS
regulatory requirements in small operators. It contains practical examples of how the components
that make up a SMS might be implemented; however, it is not meant to be a list of prescriptive
requirements or a template to be used verbatim. Each organization is required to develop policiesand procedures in accordance with their unique operating requirements.
(3) Depending on the size and complexity of the organization, the tools that make up a SMS will vary.
As such, the material contained herein is not intended as a formula for meeting the regulatory
requirements, but rather is offered as an information source for interpreting the regulatory
requirements, and is intended to pave the way forward for the successful implementation of a
SMS in an organization.
(4) Whether an organization has chosen to develop an overarching SMS manual or has incorporated
their SMS program into their existing manuals, such as the Maintenance Control Manual (MCM),
Maintenance Policy Manual (MPM) or Company Operations Manual (COM), Transport Canada
requires adequate document control in order to avoid any potential discrepancies on policy or
procedures, omissions or conflicts that could result from having multiple manuals. The format
used to document the SMS program must allow end users to promptly locate required informationto enable them to execute their functions.
(5) Amendments to the SMS manual will be treated as an amendment to the actual MCM, MPM or
COM and hence need to follow the established approval process.
(6) Users of this AC should consult the CARs and SI SUR-001, Safety Management SystemAssessment and Program Validation Proceduresto ensure that their SMS meets all regulations,applicable expectations and measurement criteria. Although the expectations outlined in SI SUR-
001 vary, all SMS regulations must be met regardless of the organizations complexity.
(7) The information and examples provided in this document were developed by applying the
applicable CARs, relevant SI SUR-001 expectations and level 3 measurement criteria to models
representing small aviation operations.
3.2 What is a SMS?
(1) In technical terms, a SMS is an explicit, comprehensive and proactive process for managing risks
that integrates operations and technical systems with financial and human resource
management, for all activities related to a Canadian aviation document.
(2) Practically speaking, a SMS is a business-like approach to safety. In keeping with all
management systems, a SMS provides for goal setting, planning, and measuring performance. It
deals with organizational safety rather than the conventional health and safety concerns in the
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workplace. An organizations SMS defines how it intends to manage air safety as an integral part
of its business management activities. A SMS becomes part of the way people do their jobs.
(3) An organizations structure, or set-up, and the activities that make up a SMS are found
throughout the organization. Every employee contributes to the safety health of the organization.
In some areas or sections, safety management activities will be more visible than in others, but
the system must be integrated into the way things are done throughout the organization. This
will be achieved by the implementation and continuing support of a safety program based on a
coherent policy that leads to well-designed procedures.
3.3 Key Generic Features of the SMS Approach
(1) There is no definitive meaning attached to the term SMS. Every organization, and industry, for
that matter, has its own interpretation of what it is. From the Civil Aviation perspective, five
generic features characterize a SMS. These are:
(a) A comprehensive systematic approach to the management of aviation safety within an
organization, including the interfaces between the organization and its suppliers,
subcontractors and business partners;
(b) A principal focus on the hazards of the business and their effects upon those activities
critical to flight safety;
(c) The full integration of safety considerations into the business, through the application ofmanagement controls to all aspects of the business processes critical to safety;
(d) The use of active monitoring and audit processes to validate that the necessary controls
identified through the hazard management process are in place and to ensure continuing
active commitment to safety; and
(e) The use of quality assurance principles, including improvement and feedback
mechanisms.
(2) When considering how to meet CARs requirements with respect to SMS, some organizations
may choose to utilize a commercial off-the-shelf system. Whilst this might be appropriate for
some organizations, the program should be tailored to meet the requirements of the individual
organization rather than assuming that one size fits all. Attention should also be given to the need
to ensure that linkages between the individual components are in place so that the systemfunctions in a cohesive manner.
(3) A SMS includes the following key components:
(a) Safety management plan;
(b) Documentation;
(c) Safety oversight;
(d) Training;
(e) Quality assurance; and
(f) Emergency preparedness.
(4) A SMS can be divided into three principle parts, all interlinked and interdependent. The key point
to remember is that if any one of these parts is missing, the system will be ineffective. The
diagram below shows how each of the regulatory requirements (per the list above) fit into the
SMS as a whole.
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Diagram 1Key Generic Features of an Effective SMS
A robust
system forassuring
safety
An effective
organizationfor delivering
safety
BA
A comprehensive
corporate
approach to
safety
F
E
D
E
D
B
AC
4.0 SMALL OPERATORS/ORGANIZATIONS GUIDE
(1) Due to the size and complexity of the infrastructure required to support large air operations, this
document is not applicable to:
(a) holders of an air operator certificate issued under CAR 705.07; or
(b) holders of an Approved Maintenance Organization (AMO) certificate issued under
CAR 573.02 whose certificate includes ratings for an aircraft of a type that, if operated in
commercial air transport, would be subject to CAR 705Airline Operations.
(2) Guidance for the large complex organizations indicated above can be found in TP 14343Safety
Management Systems Implementation Procedures Guide for Air Operators and ApprovedMaintenance Organizations.
4.1 Determining Complexity
(1) To assist organizations in developing their SMS using the guidance provided in this document, it
is necessary to determine the degree of complexity of the organization. In order to do so, various
factors, such as the number of employees, number of certificates held, number of bases, different
types of equipment operated as well as the operational environment, must be considered.
(2) There is no overall complexity formula that takes all variables into account. Determining where an
organization may fit in this guide is based on many factors and variables, including an
understanding of the operation itself and its environment. Users should consider factors affecting
their organization and then determine whether their operations are of minimal or moderate
complexity, as identified in Appendix A of this document. For example, a small organization thatoperates a heli-ski service will have different challenges than a similarly-sized fixed-wing air taxi
operation.
4.2 Appendix A: Safety Management Plan
(1) This guide and its associated appendices are to be used for guidance purposes in conjunction
with SI SUR-001.
(2) SI SUR-001 separates SMS into distinct component parts. This separation is necessary to allow
for an understanding of the components that make up the system. Organizations are free to keep
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components separate, or to combine them in any way that suits their operations, as long as the
system contains all of the required component parts. To illustrate one way components might be
grouped within the system, this guide combines the following elements:
(a) 1.6 Performance Measurementand 1.7 Management Review; and
(b) 2.2 SMS Documentationand 2.3 Records Management.
(3) The Minimal ComplexityOne-Person Operation column of Appendix A is based on a one-
person, single-certificate type air operator or AMO, as are the examples provided. Organizations
that fall between minimal and moderate complexity must review any additional SMS element
expectations outlined in SI SUR-001 for applicability.
(4) The Moderate Complexity column is based on a five- to ten-person, multiple-certificate type air
operator or AMO, with individuals identified as accountable executive, operations manager,
person responsible for maintenance and SMS manager. When an organizations complexity
increases beyond the moderately complex, SI SUR-001 must be used.
(5) Each section of the SMS element detailed in this guide has three distinct components:
(a) brief description of the SMS element;
(b) SMS element criteria requirements based on:
(i) Minimal ComplexityOne-Person Operation (left-hand column of Appendix A)
Score 3 element criteria (Appendix B of SI SUR-001) are used as the
basis for this component, and are identified by a hollow square bullet in
the attached Appendix A.
(ii) Moderate Complexity (right-hand column of Appendix A)
Score 3 element criteria (Appendix B of SI SUR-001) are used as the
basis for this component, and are identified by a hollow square bullet in
the attached Appendix A. Organizations may incorporate additional
expectations as identified in Appendix B of SI SUR-001, where such
expectations are considered to be relevant to the complexity of the
organizations systems. Examples of additional expectation from SI SUR-
001 Appendix B are identified by arrow-shaped bullets in the attachedAppendix A.
(iii) Bullets
(A) Elements that are common to both minimal and moderate complexity are
represented with the following symbol: (see example below); and
(B) Items found in the Moderate Complexity column that are deemed as
additional requirements to those indicated in the Minimal Complexity
column will be identified with the following symbol: (see example
below).
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(c) SMS manual examples:
3. Safety Oversight 3.4 Risk Management
Minimal ComplexityOne-Person Operation Moderate Complexity
(Item a)When a hazard has been identified, andthe requirement for a risk assessment determined
(Item b)Risk management should: include a process for
include criteria
include a process
(Item c)Example:
(Item a)When a hazard has been identified, andthe requirement for a risk assessment determined
(Item b)Risk management should: include a process for
include criteria
include a process
include a description
(Item c)Example:
4.3 Appendices B to E
Appendices B through E are provided as examples of different recording and reporting methods
in a SMS.
5.0 CONTACT OFFICE
For more information, please contact the:
Chief, Technical & National Programs (AARTT)
Phone: 613-952-7974
Fax: 613-952-3298
E-mail: [email protected]
Suggestions for amendment to this document are invited, and should besubmitted via the Transport Canada Civil Aviation Issues Reporting
System (CAIRS) at the following Internet address:
www.tc.gc.ca/CAIRS
or by e-mail at: [email protected]
Original signed by Don Sherritt on June 17, 2008
D.B. Sherritt
Director, Standards
Civil Aviation
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1. Safety Management Plan 1.1 Safety Policy
Minimal ComplexityOne-Person Operation Moderate C
All managers and employeesfor their actions and safety peCEO and accountable executhink and work safely at all timperceived pressures to do ot
To prevent accidents and to have implemented and mainsystem (SMS). Our objectiveidentifiable hazards, the redureasonably practicable, and twith our stakeholders.
Signed: _________________
CEO and Accountable Execu
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1. Safety Management Plan 1.2 Non-Punitive Safety Reporting Policy
Minimal ComplexityOne-Person Operation Moderate C
The non-punitive aspect of a reporting policy in a one-person operation
is unnecessary, as it adds no value to the process.
By removing the threat of disciplinary
reporting policy encourages a healthy
The non-punitive safety reporting pol
immunity from disciplinary ac
hazards, incidents or acciden
conditions under which punit
considered (e.g. illegal activit
are clearly defined and docum
the policy is widely understoo
there is evidence that the org
the policy is applied througho
areas of the organization.
Example:
NON-PUNITIVE SAFETY RE
Our organization fully supporopenness and trust between achieved unless employees fhazards without the fear of uoccurrences or hazards shouemployees.
Only with full awareness can in a timely manner. Employereport unsafe conditions with
organizations primary goal iscondition that exists within, o
Personnel reporting safety-rewill not be subject to punitivethey were personally involve
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1. Safety Management Plan 1.2 Non-Punitive Safety Reporting Policy
Minimal ComplexityOne-Person Operation Moderate C
the safety concern.
The only cases where discipl
negligence;
wilful or intentional disreg
criminal intent; and
use of illicit substances.
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1. Safety Management Plan 1.3 Roles and Responsibilities
Minimal ComplexityOne-Person Operation Moderate C
safety authorities, responsibi
personnel and third parties a
descriptions.
Example:
ROLES AND RESPONSIBIL
We ensure that all SMS rolesemployee involvement are iddocumented and periodicallyappropriate and functioning w
In addition to safety responsiday operations, the accountaemployees have additional reoperation and maintenance o
The accountable executive is
establishing and impleme
ensuring the required sa
establishing and adherin
promoting and supporting
ensuring that the SMS re
The SMS manager is respon
managing the operation
collecting and analyzing
manner; monitoring and evaluatin
ensuring that risk assessapplicable;
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1. Safety Management Plan 1.3 Roles and Responsibilities
Minimal ComplexityOne-Person Operation Moderate C
determining the adequac
authority to delegate spe
within the organization;
ensuring that periodic revthe effectiveness of the s
monitoring the industry fothe program; and
ensuring safety-related ingoals and objectives, arethrough established com
Employees are responsible f
following established saf
immediately dealing with
identifying and reporting operational irregularities,timely manner; and
being familiar with the or
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1. Safety Management Plan 1.4 Communication
Minimal ComplexityOne-Person Operation Moderate C
Clients:
o safety briefings, safety cards and customer feedback,
etc.
I document communications by keeping simple paper records ormaking entries in the organizations black book. All records arestored in a secure location.
Internal:
o quarterly (or as requ
reports;
o face-to-face on an in
o organization memos
o safety bulletin board;
o amendments to docu
TCCA:
o participation in relevaforums.
Industry:
o participation in relevaforums;
o other organizations a
o manufacturers.
Clients:
o safety briefings;
o safety cards; and
o customer feedback.
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1. Safety Management Plan 1.5 Safety Planning
Minimal ComplexityOne-Person Operation Moderate C
also confirm that the organization objectives and goals arelinked.
Our current objectives and goals are:
Objective A: Reduce hazards and associated risks.
o Goal 1: Identify a larger percentage of existing hazardsannually through increased documentation of identifiedhazards.
Objective B: Reduce occurrence-related losses.
o Goal 1: Ensure documentation of occurrences.
o Goal 2: Ensure risk management process has beenimplemented when applicable.
Objective C: To prevent damage and injury to non-
organization personnel and property resulting from ouroperations.
o Goal 1: Placement of new passenger informationnotices and signage in office and on ramp.
o Goal 2: Standardized passenger briefings.
hazards and risks;
financial, operational and
views of interested partie
industry-wide safety risk
Example:
SAFETY PLANNING OBJEC
The aim of establishing attainensure the effectiveness andsafety. Annually, objectives aupdated in accordance with omanagement review processthat the organization objectiv
process for establishing goal business plan;
results of internal audits;
occurrence and hazard r
Our current objectives and go
Objective A: Reduce haz
o Goal 1: Receive an iof existing latent hazreporting.
o
Goal 2: Increase the received by 5 percen
Objective B: Continue to development of effective
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1. Safety Management Plan 1.5 Safety Planning
Minimal ComplexityOne-Person Operation Moderate C
o Goal 1: Provide addicause analysis traini
o Goal 2: SMS managtraining to other pers
Objective C: To reduce lonumber and severity of a
o Goal 1: Increase the received by 5 percen
o Goal 2: Join the locaengineer (AME) asso
o Goal 3: Provide St. Jextinguisher training it.
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1. Safety Management Plan 1.6 Performance Measurement and 1.7 Managemen
Minimal ComplexityOne-Person Operation Moderate C
Example:
PERFORMANCE MEASUREMENT AND MANAGEMENT
REVIEW
Annually, I utilize aspects of the quality assurance self-audit toconduct my management review, measure safety performance,assess SMS effectiveness and verify continuous improvement inaccordance with the following process:
identifying trends;
evaluating effectiveness of corrective actions;
updating safety objectives and goals;
monitoring and updating safety performance measures;
allowing for risk-based allocation of resources;
reviewing safety-critical functions; and
reviewing the Emergency Response Plan.
The safety performance measures for this year are:
continued absence of serious injury and damage to non-organization personnel and/or property;
50-percent reduction in minor injury and damage to non-organization personnel and/or property; and
25-percent reduction in damage to organization property.
the implementation and m
established by the organ
there is a process to evaluateactions resulting from the firs
The organization has establis
board, appropriate for the siz
organization, consisting of a
representatives including cer
parties that review the manag
Example:
PERFORMANCE MEASUREREVIEW
Annually, management revie
measure safety performanceverify continuous improveme
Components of the process i
identifying trends throughsharing;
evaluating effectiveness
updating safety objective
monitoring and updating
allowing for risk-based al
reviewing quality issues;
reviewing the Emergency
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1. Safety Management Plan 1.6 Performance Measurement and 1.7 Managemen
Minimal ComplexityOne-Person Operation Moderate C
Our safety performance mea
number of hazards identi
number of incident and avs. previous years;
provision of SMS training
reduction in minor injury personnel and/or propert
reduction in damage to oprevious years.
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2. Documentation 2.1 Identification and Maintenance of Applicable Regulat
Minimal ComplexityOne-Person Operation Moderate C
Bi-annual review of CARsummary), including appchange as appropriate;
When received, additionaCanada Labour Code anAct, 1997, will be revieweand
Pertinent regulatory and to all personnel through t
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2. Documentation 2.2 SMS Documentation and 2.3 Records Managemen
Minimal ComplexityOne-Person Operation Moderate C
Records and output (information gathered through the SMS) willbe stored in a secure filing cabinet and kept for a minimum oftwo audit cycles.
The SMS manual will be kept with the other required manualsand updated as required. Information in the SMS manual isreviewed during the annual internal quality assurance audit.Additionally, information in the SMS manual is reviewed on anas-required basis, i.e. to identify issues and trends betweenaudit intervals.
The following policy, processkept in a location easily acceupdated as required:
SMS manual;
maintenance control man
company operations man
Records and output (informawill be stored in a secure filinof two audit cycles.
The SMS manual will be kepand updated as required. Inforeviewed during the annual in
Additionally, information in thas-required basis, i.e. to idenaudit intervals. Information restored for a period of two aud
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3. Safety Oversight 3.1 Reactive Processes-Reporting
Minimal ComplexityOne-Person Operation Moderate C
o Part B is the incident/accident analysis process.
o Part C is the corrective action plan and includes the
requirement to determine if a risk assessment is to becompleted.
When Parts A, B and C have been completed, the incidentand hazard record book will be updated with a narrative ofthe process results.
Completed forms will be stored in a secure location andretained for two audit cycles.
Example:
REACTIVE PROCESSES
As a component of our continprocess, we maintain an occu(reactive/proactive) to collectinvestigations. All reports wilidentified reporters will receivsubmission within 5 days, anupon process completion. Thbelow.
When an occurrence (incidenbe documented by completinAND HAZARD IDENTIFICAT
The process is as follows: Complete Parts A, B and
o Reporter completes responsible for safetydata, occurrence narrecommendations.
o The person responsiinvestigation and comanalysis).
o The person responsidevelopment of corre
Part C, including follorequirement to carry
o A risk assessment is
trend analysis shactions have not
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3. Safety Oversight 3.1 Reactive Processes-Reporting
Minimal ComplexityOne-Person Operation Moderate C
it is not clear wha
the issue is comp
the potential loss
the person respopersonnel feel it
When Parts A, B and C hdocumentation will be fileaudit cycles.
This information will be umeasurement and mana
The following must be report
any incident or accident ipersonnel, equipment or
any incident or accident iorganization personnel, efrom organization operat
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3. Safety Oversight 3.2 Proactive Processes-Hazard ID
Minimal ComplexityOne-Person Operation Moderate Co
Note:
In an organization of minimal complexity, a simpledocumentation tool such as an incident and hazard recordbook for proactive process management may beconsidered.
Example:
PROACTIVE PROCESSES
When a hazard is identified, it must be documented bycompleting the OCCURRENCE REPORT AND HAZARDIDENTIFICATION FORM located in Appendix B.
The process is as follows:
Complete Parts A and C as soon as practicable.
o Part A consists of tombstone data, hazard narrative andpreliminary recommendations.
o Part C is the corrective action plan and includes therequirement to determine if a risk assessment is to becompleted.
When Parts A and C have been completed, the incident andhazard record book will be updated with a narrative of theprocess results.
Completed forms will be stored in a secure location andretained for two audit cycles.
mergers; and
management/bargaining
the organization has a clearly
analyses; and
the organization will develop a
hazards listed on the hazard
the organization has a proces
when required;
the range and scope of safety
reported are explained and de
all proactive reports are subje
determine their level of priorit
extent of further action.
Example:
PROACTIVE PROCESSES
When a hazard is identified, icompleting the OCCURRENCIDENTIFICATION FORM loca
The process is as follows:
Complete Parts A and C
o Reporter completes Presponsible for safetydata, hazard narrativ
recommendations.
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3. Safety Oversight 3.2 Proactive Processes-Hazard ID
Minimal ComplexityOne-Person Operation Moderate C
o The person responsidevelopment of prevPart C, including follorequirement to carry
o A risk assessment is
trend analysis shactions have not
it is not clear wha
the issue is comp
the potential loss
the person respopersonnel feel it
When Parts A and C havdocumentation will be fileaudit cycles.
This information will be umeasurement and mana
The following must be report
any identified hazards thaccident involving injury personnel, equipment or
any identified hazards th
accident involving injury personnel, equipment or organization operations.
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3. Safety Oversight 3.2 Proactive Processes-Hazard ID
Minimal ComplexityOne-Person Operation Moderate C
Reactive and Proactive Pro
Even though the reactive pro
already happened and the prproblems, the methods used
these processes are separate
choose to combine them as m
similarities.
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3. Safety Oversight 3.3 Investigation and Analysis
Minimal ComplexityOne-Person Operation Moderate C
Example:
INVESTIGATION AND ANALYSIS
The ability to investigate, analyze and identify the cause orprobable cause of hazards and occurrences documentedthrough the SMS is an important component of my continuoussafety improvement process. Investigation and analysis arecomponents of the reactive, proactive and risk-managementprocesses. Details can be found in those sections.
there is evidence that the org
complete the investigation an
established timeframe.
Note:
If the investigation and anaalready detailed somewherethose areas should be suffici
Example:
INVESTIGATION AND ANAL
The ability to investigate, anaprobable cause of hazards a
through the SMS is an imporsafety improvement process.components of the reactive, pprocesses. Details can be fou
The person responsible for sanalysis of occurrences and
determine the cause;
develop and implement cand
evaluate corrective actio
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3. Safety Oversight 3.4 Risk Management
Minimal ComplexityOne-Person Operation Moderate C
the probability or severity risk rating is determined;
risk control strategies, including timelines, are developedand a revised risk rating is determined;
risk control strategies are implemented;
implemented risk controls are assessed;
when the process has been completed, the SMS file isupdated with a narrative of the results; and
the completed forms are stored in a secure location.
the associated risks are
the probability or severity
risk control strategies, inand a revised risk rating
risk control strategies are
implemented risk control
when the process has beupdated with a narrative
the completed forms are
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4. Training 4.1 Training, Awareness and Competence
Minimal ComplexityOne-Person Operation Moderate C
information on ch
a review of all re
including recommor preventative a
SMS training validation/p
o Assessment of the obe determined by:
the person respolevel of learning
any internal auditraining in the co
Additional SMS training:
o Where it is shown to during the internal qutraining will be under
When any new rnew or modified
Emergency preparednes
o The person responsipersonnel are trainedresponsibilities withinResponse Plan; and
o
The organization hasproviders on its operemergency response
Training records:
o A record of all traininpersonnel files.
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5. Quality Assurance 5.1 Operational Quality Assurance
Minimal ComplexityOne-Person Operation Moderate C
o Training;
o Emergency preparedness and response; and
o Review of safety critical functions.
Additional SMS audit component training will be provided ifrequired.
o Safety planning obje
o Safety policy;
o Non-punitive reportin
o Roles, responsibilitie
o Communications;
o Performance measu
o Identification and maregulations;
o SMS documentation
o Reactive and proactianalysis;
o Risk management;
o Training;
o Emergency prepared
o Review of safety criti
Additional SMS audit comas required.
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6. Emergency Preparedness 6.1 Emergency Preparedness and Respons
Minimal ComplexityOne-Person Operation Moderate C
organization has implemented a documented EmergencyResponse Plan (ERP).
The ERP is:
periodically examined as part of the management review;
distributed to all parties who have a role to play in the eventof an emergency;
exercised in co-operation with local authorities on an annualbasis;
updated as required by exercises and reviews; and
a required training item for all personnel who may beinvolved in the event of an emergency.
Example:
EMERGENCY PREPAREDN
The organization recognizes can suffer loss. In order to reproperty damage after an accoccurred, the organization haResponse Plan (ERP).
The ERP is:
periodically examined as
communicated and distriwatch personnel and loca
exercised in co-operation
annual basis; updated as required by e
a required training item finvolved in the event of a
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APPENDIX BOCCURRENCE REPORT AND HAZARD IDENTIFICATION FORM
PART A
Note:
Part A must be completed as soon as practical after an occurrence is reported or ahazard is identified. Submit completed reports to the person responsible for safety
as soon as practicable.
Name: __________________________
Date: __________________________
Location: __________________________
Report No.: __________________________
Hazard Identification Report: __________________________
Occurrence Report: __________________________
Note:
If reporting an occurrence, Part B must be completed as soon as practicable. In all
cases, Part C must be completed as soon as practicable.
Details of occurrence: __________________________
Preliminary recommendations to prevent a future occurrence or eliminate hazard:
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APPENDIX CINCIDENT/ACCIDENT ANALYSIS
PART BCan the occurrence be attributed to one or more causes listed below? If yes, estimate a percentage for
each cause and state what may have prevented it.
NO YES % Prevention1. Lack of communication
2. Complacency
3. Lack of knowledge
4. Distraction
5. Lack of teamwork
6. Fatigue
7. Lack of resources
8. Pressure from:
self
peers
organization
schedule
9. Lack of assertiveness10. Stress
11. Lack of awareness
12. Norms
13. Additional
14. Additional
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APPENDIX DCORRECTIVE/PREVENTATIVE ACTION PLAN
Is a risk assessment required? Yes______ No_______
Note:
If a risk assessment is required, complete it before determining short- and
long-term corrective action plan.
Short-term corrective/preventative actionto be completed within 30 days:
Long-term corrective/preventative actionincluding due date and follow-up requirements:
Follow-up:
Was the corrective/preventative action effective? Yes ________ No ________
Note:
If no, a revised corrective action plan is to be determined, documentedand its effectiveness is to be determined.
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APPENDIX FRISK MATRIX
This risk matrix is designed to help determine the level of risk for a particular hazard by providing
objective criteria relating to probability and severity.
Low
Medium
High
5 5 10 15 20 25
4 4 8 12 16 20
3 3 6 9 12 15
2 2 4 6 8 10
1 1 2 3 4 5Probability
1 2 3 4 5
Severity
Values Risk Levels Action
15 Low Proceed after considering all elements of risk.
612 Medium Continue after taking appropriate mitigating action.
1325 High STOP: do not proceed until sufficient control measures have been
implemented to reduce risk to an acceptable level.
Severity (S)
Level 1 No damage or injury or adverse consequences.
Level 2 Personnelfirst aid injury; no disability or lost time
Publicminor impact
Environmentcontained release
Equipmentminor damage; potential organizational slowdown or potential downtimeLevel 3 Personnellost time injury; no disability
Publicgreater than minor impact, loss of confidence; some injury potential
Environmentsmall uncontained release
Equipmentminor damage; leads to organizational slowdown or minor downtime
Level 4 Personneldisability or severe injury
Publicexposed to a hazard that could or will produce injuries
Environmentmoderate uncontained release
Equipmentmajor damage; results in major slowdown or downtime
Level 5 Personnelfatal, life-threatening injury
Publicexposed to life-threatening hazard
Environmentlarge uncontained release
Equipmentloss of critical equipment, or shutdown of organization
Probability (P)
Level 1 Mishap almost impossible.
Level 2 Postulated event (may be possible, but not known to have occurred).
Level 3 Has occurred rarely (known to have happened, but a statistically credible frequency