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CAP 795 Contents
Contents
Introduction 2
Safety accountabilities 6
Safety committees 8
SMS documentation 10
Hazard identification 12
Safety communication 21
Introduction
This document meets ICAO Annex 19 requirements and is a UK CAA alternative means of
compliance for the EASA management system requirements in respect of safety
management. We will assess for compliance and effectiveness of an SMS using the CAA
SMS evaluation tools that can be found on the CAA website.
A safety management system is a systematic and proactive approach for managing safety
risks. As with all management systems, SMS includes goal setting, planning, and
measuring performance. An effective safety management system is woven into the fabric
of an organisation. It becomes part of the culture; the way people do their jobs.
It is important to recognise that SMS is a top down driven system, which means that the
accountable manager of the organisation is responsible for the implementation and
continuing compliance of the SMS. Without the wholehearted support and ownership of
the accountable manager the SMS will not be effective. However, safety is a shared
responsibility across the whole organisation and needs the involvement of all staff.
There is not a ‘one size fits all’ model for SMS that will cater for all types of organisations.
Organisations should tailor their SMS to suit the size, nature and complexity of the
operation, and the hazards and associated risks inherent with its activities. Guidance for
smaller non-complex organisations is contained in CAP 1059 that can also be found on the
CAA SMS Home page at www.caa.co.uk/sms as well as other useful information.
Where an organisation is part of a group that has several approvals a single Group SMS
may be developed provided that there is clear accountability between the group and the
subsidiary companies.
Chapter 1
Safety Management System (SMS)
SMS is a proactive and integrated approach to managing safety including the necessary
organisational structures, accountabilities, policies and procedures. It is more than a
manual and a set of procedures and requires safety management to be integrated into the
day to day activities of the organisation. It requires the development of an organisational
culture that reflects the safety policy and objectives.
At the core of the SMS is a formal risk management process that identifies hazards and
assesses and mitigates risk. It is important to recognise that even with mitigations in place,
some residual risk will remain and an effective SMS will enable organisations to manage
this.
Risks generated by contracted activities and other third parties should also be considered.
Therefore, when the organisation has a formal agreement with another organisation this
should include provisions for the management of safety. This should also include reporting
procedures for safety related matters.
Where gaps have been identified these should be included in an implementation plan. The
plan should detail the gaps and the actions to be taken (what, when and by whom) to
implement an SMS. The plan should be developed to allow prioritising of the different
elements over a period of time. Building an SMS overnight will be far too challenging and a
step by step approach will deliver a more effective SMS in the end.
Chapter 2
The key components of a safety management system
c) Safety assurance;
d) Safety promotion.
Whilst the four components above appear to be separate, it is important to recognise that
they are all interrelated. They can only function effectively if all four are built on a
foundation of a positive safety culture. This should be driven from the top of the
organisation by the accountable manager and the senior management team
Each of these four components will now be considered in the following sections.
Chapter 3
Safety policy and objectives
The safety policy and objectives can be divided into the following five areas:
b) Safety accountabilities;
e) SMS documentation.
The safety policy outlines the aims and objectives that the organisation will use to achieve
the desired safety outcomes. It should declare the principles and philosophies that lay the
foundation for the organisation’s safety culture and be communicated to all staff
throughout the organisation. The creation of a positive safety culture begins with clear,
unequivocal direction and ownership from the accountable manager.
In preparing a safety policy, senior management should consult with the key safety
personnel, and where appropriate, staff representative bodies (employee forums, trade
unions, for example). Consultation will ensure that the safety policy and stated objectives
are relevant to all staff. It will generate a sense of shared responsibility for the safety
culture in the organisation. A positive safety culture is one where all staff are responsible
for, and consider the impact of, safety on everything they do.
a) Corporate authority for ensuring all activities can be financed and carried
out to the required standard;
a) Develop the safety policy, which is endorsed and actively supported by the
accountable manager;
b) Continuously promote the safety policy to all staff and demonstrate their
commitment to it;
b) Comply with all applicable legal requirements, meet all applicable standards
and consider best practice;
e) Ensure that the policy is implemented and understood at all levels, both
internally and externally.
The safety policy should actively encourage effective safety reporting by defining a just
culture. This should define the line between acceptable and unacceptable performance
and provide fair and just protection to all personnel.
Safety accountabilities
The organisation should clearly define the lines of safety accountability throughout the
organisation. This should include the direct accountability for safety on the part of the
accountable manager and senior management. There is also a need to define the safety
responsibilities and expected behaviours of key personnel (nominated post-holders, safety
manager, safety officers, safety committee members, for example). Safety is everyone’s
responsibility and all staff should be aware of their safety roles and responsibilities.
The accountable manager, together with the senior management team, set the standard
for the organisation’s safety culture. Without this commitment and leadership, SMS will be
ineffective.
It is important to note that accountability for the SMS rests with the accountable manager
not the safety manager.
The safety manager should be a full-time employee although in a small complex or non-
complex organisation it may be a part time role shared with other duties. They may also be
the compliance monitoring / quality manager, but in such cases there will need to be
independent compliance monitoring of the SMS.
f) ensure that there is safety management training available and that it meets
acceptable standards;
Safety committees
Safety Review Board (or equivalent safety committee)
The Safety Review Board (SRB) is a high level committee which considers strategic safety
functions. The accountable manager should be actively involved in the SRB and normally
chairs the meeting. The SRB should normally include the senior management of the
organisation. Membership of the board and frequency of meetings should be defined.
The SRB ensures that appropriate resources are allocated to achieve the established
safety performance and gives strategic direction to the safety action group. It should also
look to the Safety Action Group (SAG) to highlight significant risk issues and provide an
input to the high level strategy.
In very large organisations more than one safety action group may be established that
focus on specific areas.
In small complex organisations of less than 20 full time equivalents a single safety
committee may be established combining the functions of the SRB and SAG.
An Emergency Response Plan (ERP) should be established that provides the actions to
be taken by the organisation or individuals in an emergency. The emergency response
plan should be integrated into the SMS and reflect the size, nature and complexity of the
activities performed by the organisation.
Where organisations, such as aerodromes, are subject to other ERP requirements these
should be adhered to and may be cross referred to. In many cases there will be a need for
liaison with other relevant parties to agree coordination of emergency response
arrangements and testing of the plan.
The ERP should set out the responsibilities, roles and actions for the various agencies and
personnel involved in dealing with emergencies. It may include checklists and contact
details and the ERP should be regularly reviewed and tested. Key personnel should have
easy access to the ERP at all times.
SMS documentation
Documentation for a SMS should be appropriate to the size, nature, and complexity of the
organisation and normally consists of:
c) SMS manual.
The organisation’s SMS manual should be the key instrument for communicating the
approach to safety for the whole of the organisation. It should document all aspects of the
SMS, including the safety policy, objectives, procedures and individual safety
accountabilities. The SMS should be constantly evolving and therefore the SMS manual
should be a living document and should be reviewed regularly to ensure that it remains
accurate and appropriate. The SMS manual may be incorporated into existing manuals or
expositions. Contents should include:
c) Safety accountabilities;
k) Safety promotion;
l) Contracted activities;
Chapter 4
Safety risk management
The safety risk management component of a SMS can be divided into three areas:
Safety risk management is the heart of the SMS. The process starts with identifying
hazards affecting aviation safety and then assessing the risks associated with the
hazards in terms of severity and likelihood. Once the level of risk is identified,
appropriate remedial action or mitigation measures can be implemented to reduce the
level of risk to an acceptable level. Mitigation measures should then be monitored to
ensure that they have had the desired effect. It is important to apply a common standard
and process for risk assessment and control throughout the organisation. Appropriate
training and communication will enable a clear understanding on how to deliver this.
Hazard identification
A hazard is any condition that can cause or contribute to an aircraft incident or
accident. A hazard identification process enables the collecting, recording, analysing,
acting on and generating feedback about hazards that affect the safety of the
operational activities of the organisation. In a mature SMS hazard identification is an
ongoing process.
There are many sources of hazard identification from reactive events to a more proactive
approach.
Subject matter expert judgement can also contribute to hazard identification through
workshops and safety committee meetings. Organisations should carry out an initial
hazard identification exercise on its current operations to create a baseline safety case or
an initial risk register. Hazard identification then becomes an ongoing activity and hazard
logs and risk registers should be continuously reviewed and updated. Organisations
should look externally for possible hazards from accident reports, MOR publications,
industry trade associations or the CAA Safety Plan.
Safety Reporting
A confidential reporting system should be established to encourage safety reporting. This
should be supported with a just culture providing appropriate protection for the reporter.
This should also include an effective feedback process to the individual and to the wider
organisation where appropriate. This approach should encourage staff at all levels to
proactively report errors, near misses and hazards.
Staff need to have confidence in the just culture and the reporting system. They must
know that confidentiality will be maintained and that the information they submit will be
acted upon, otherwise they will decide that there is no benefit in their reporting.
Following the identification of a hazard, a risk assessment is carried out to determine the
potential for harm or damage. This involves the following considerations:
Organisations may use barrier models such as bow-tie for their risk management process.
A diagram showing the hazard analysis and risk assessment process is shown below:
Risk assessment Is the consequent risk acceptable and within the organisation’s
Acceptability safety performance criteria?
YES NO
A system should be developed for assessing and analysing the data collected or derived
from the actions outlined above. Information provided by the analysis should be distributed
to those with a responsibility for operational safety in the organisation.
Risk assessment
The risk assessment process should determine the acceptability of a risk. This is normally
done by defining a Risk Tolerability Matrix that should be used across the whole
organisation. An example of a risk tolerability matrix and its definitions is provided below 1.
While the severity of the consequences can be defined, the likelihood of occurrence may
be more subjective where data is limited. The assessment process should be recorded at
each stage including any assumptions made or supporting information. As risk
assessments can be subjective they should be verified by at least one other person or by
one of the safety committees.
1 For Air Navigation Service Providers reference should be made to the severity definitions in the Single
European Sky Common Requirements.
Severity of consequences
Likelihood of occurrence
Severity
Catastrophic 5 10 15 20 25
5
Review Unacceptable Unacceptable Unacceptable Unacceptable
Hazardous 4 8 12 16 20
4
Acceptable Review Unacceptable Unacceptable Unacceptable
Major 3 6 9 12 15
3
Acceptable Review Review Unacceptable Unacceptable
Minor 2 4 6 8 10
2
Acceptable Acceptable Review Review Unacceptable
Negligible 1 2 3 4 5
1
Acceptable Acceptable Acceptable Acceptable Review
Extremely
Improbable Remote Occasional Frequent
improbable
1 2 3 4 5
Likelihood
Risk classification
Acceptable The consequence is so unlikely or not severe enough to be of concern; the risk
is acceptable. However, consideration should be given to reducing the risk
further to as low as reasonably practicable in order to further minimise the risk
of an accident or incident.
Review The consequence and/or likelihood is of concern; measures to mitigate the risk
to as low as reasonably practicable should be sought. Where the risk is still in
the review category after this action then the risk may be accepted, provided
that the risk is understood and has the endorsement of the individual ultimately
accountable for safety in the organisation.
Unacceptable The likelihood and severity of the consequence is intolerable. Major mitigation
will be necessary to reduce the likelihood and severity of the consequences
associated with the hazard.
Risk mitigation
Risks should be managed to an acceptable level. This should be balanced against the
time, cost and difficulty of taking measures to reduce or eliminate the risk. The level of risk
can be lowered by reducing the severity of the potential consequences, reducing the
likelihood of occurrence or by reducing exposure to that risk. It is easier and more common
to reduce the likelihood than it is to reduce the severity.
Corrective action should take into account any existing defences and their inability to
achieve an acceptable level of risk. This may result in a review of previous risk
assessments that may have been impacted by the corrective action. Risk mitigations and
controls will need to be verified / audited to ensure that they are effective.
Investigation methodology
The investigation process should take place as soon as possible after the event. The
objective of the investigation is to understand why an event happened and the contributing
causes and not to apportion blame. The investigation should include:
c) Interviews;
e) Data analysis.
Safety recommendations
An organisation should have procedures to communicate the results of any safety
investigations and where appropriate to address any identified hazards. This should
include incorporating lessons learnt into procedures, training and safety promotion.
Chapter 5
Safety assurance
Safety assurance assesses the safety performance of the organisation and enables
continuous improvement. The three aspects of safety assurance are:
A key function of the SMS is assurance that the system is working and is effective. This
involves:
Note: These all require safety and quality (compliance monitoring) to be integrated or
working closely together.
Safety objectives need to have been established before setting SPIs. This allows the
safety performance of the organisation to be measured against its safety policies and
objectives. Organisations should review the CAA Safety Plan as this may provide ideas for
SPIs.
Once safety objectives have been set then SPIs can be established. SPIs can be used to
measure the performance of the SMS and the operational safety performance. SPIs will
require the monitoring of data from various sources such as;
b) Safety reports;
c) Safety studies;
e) Audits;
f) Surveys;
Safety audits are used to ensure that the structure of the SMS is sound in terms of:
Safety and cultural surveys should be carried out as a matter of routine, to provide
assurance to managers of safe operational activity. They are used to identify issues or
problems in daily operations. They can also be used to gather the views and opinions of
operational personnel. Surveys may involve the use of:
b) Questionnaires;
Safety culture surveys allow an organisation to identify behaviours and attitudes of staff.
This may identify human conditions that can impact an organisation’s safety performance.
Survey information is subjective and should therefore be verified before any corrective
action is initiated but may provide a valuable source of safety information.
Organisations should define the types of changes that would require a formal management
of change process. This should also include who makes the decision to start the process
and who has the authority to sign it off.
Chapter 6
Safety promotion
All staff should receive safety training as appropriate for their safety roles and
responsibilities. In particular all operational staff, managers, supervisors, senior managers
and the accountable manager should be trained and be competent to perform their duties.
This provides an opportunity to reinforce the safety policy, gain the necessary
management buy-in and for establishing the expected attitudes and behaviours for all
levels of staff in the organisation. This should involve initial training as well as continued
maintenance of competence. Training should include human and organisational factors
Safety communication
Safety communication is an essential foundation for the development and maintenance of
an adequate safety culture. Types of communication may include:
c) Presentations;
a) Ensure that all staff are fully aware of the SMS and the organisation’s safety
culture;