SMS Evaluation Tool - v2 April2019

Safety Management System
(SMS)
Evaluation Tool
Version 2
April 2019
SMS Evaluation Tool Guidance
Introduction
The International Civil Aviation Organization’s (ICAO’s) Annex 19 promotes a common approach to Safety
Management across aviation domains; both for States and for organisations. The Safety Management
International Collaboration Group (SM ICG) has developed the SMS Evaluation Tool in direct support to this
common approach and accordingly, the following guidance explains the background, purpose, and
methodology relevant to the use of the tool.
This tool evaluates the overall effectiveness of the SMS; as a function of both compliance and performance,
through a series of indicators1 based on ICAO Annex 192 and ICAO Safety Management Manual (doc 9859)3
and is organised by the ICAO SMS Framework. Each indicator should be reviewed to determine whether it is
Present, Suitable, Operating, or Effective, using the definitions and guidance set out below.
This concept of evaluating SMS effectiveness supports the move from traditional, compliance-based
oversight to performance-based oversight that focuses on how the SMS is performing. It provides a common
baseline for SMS effectiveness evaluation that creates a sound basis for mutual acceptance of SMS.
When to Use the Tool

The evaluation tool is designed to be used by both Regulatory Authorities and by organisations. The
Regulatory Authority can use the tool for an initial approval or on-going oversight of an organisation. The
organisations can use it to evaluate the maturity and effectiveness of their own SMS for the purpose of
continuous improvement. The resulting evaluation could be presented to the Regulatory Authority to
demonstrate their self-evaluation of their SMS. Organisations may also use the tool to evaluate the SMS of
other organisations. Finally, organisations could use the tool as an SMS gap-analysis and accordingly develop
an informed, forward-looking plan regarding further implementation.
Initial certification/implementation
Before issuing an approval or certificate, the Regulatory Authority should make sure that all processes are
Present and Suitable, so that all the required enablers of a functioning SMS are implemented by the
organisation. In this initial certification phase, a large part of the SMS evaluation could be carried out by a
desktop review of relevant SMS documentation. However, carrying this out at the organisation provides an
opportunity for the inspector to advise and guide the organisation on its SMS implementation and support
standardised implementation.
Surveillance
After initial implementation, the organisation should start using the SMS as part of its operations. The
Regulatory Authority should allow enough time for the organisation’s SMS to mature before it carries out
ongoing surveillance that evaluates whether the processes are Present, Suitable, or Operating. An
organisation may eventually have Effective SMS processes. In order to check that SMS processes remain
Operating and/or Effective, the SMS should be re-evaluated on a regular basis to evaluate how well it is
performing. The review should evaluate all of the items in the evaluation tool which can be done by a
combination of organisational visits, meetings, and desktop reviews.
As an organisation’s SMS processes mature and moves to Operating and Effective, the Suitable criteria may
also need to be revisited. Changes to an organisation’s approval may also require a reconsideration of the
Suitable designation of the SMS processes. When significant changes take place, the Regulatory Authority
may determine the need to review the existing evaluation to ensure it is still appropriate.
1
The use of the term indicator in this tool should not be confused with the term “Safety Performance Indicator” used
in Annex 19.
2
ICAO Annex-19, Second Edition, July 2016, incorporating amendment 1.
3
ICAO Doc-9859 Safety Management Manual, Fourth Edition, 2018.
1
Credit for other surveillance activities

Valuable information about SMS effectiveness can be gained from other surveillance activities. This may
include such activities as routine compliance audits and inspections, occurrence investigations, and meetings
with the organisation. Regulatory Authorities may also consider giving credit when an organisation has
received accreditation for meeting an industry standard.
Defining the surveillance program

In the context of performance-based and risk-based oversight, the results of the SMS evaluation may be
considered along with other data and information to determine the type, scope, and frequency of
surveillance activities.
Dealing with multiple certificate holders

In the case of an organisation holding multiple certificates or approvals, the use of the SMS evaluation tool
should follow the 1-organisation = 1-evaluation rule. Therefore, if one organisation integrates all activities
within a single SMS, the evaluation should consider the SMS as a whole.
Yet, it may be the case that different teams of inspectors oversee the same SMS with regard to different
certificates, and a single evaluation may be impracticable. In such case, the different evaluations should be
shared with the various teams of inspectors and a common message from the Regulatory Authority, or
Authorities, should be provided to the organisation.
How to Use the Tool

Although the evaluation tool follows the SMS Framework in Annex 19, the order of the components has been
changed to start with Safety Risk Management. This is considered the most important component of an
organisation’s SMS and should therefore be given the most attention during the evaluation. In addition, a
section dedicated to interface management has been added, to reflect Annex 194.
However, users of the tool may choose to customise the order of the components to align it with the order
of Annex 19. During the evaluation, the user may choose to start with any of the components due to the
availability of personnel or resources, or to focus on a specific concern.
Users may decide to customise the evaluation tool to:
• Reflect organisational requirements;

• Reflect national SMS requirements or terminology; and/or
• Address a specific need that has been identified through the State Safety Programme (SSP).
The layout of the tool is shown below, with an accompanying legend defining the purpose of each box.
4
ICAO Annex 19, Second Edition, July 2016, Appendix 2, note 2.
2
Definitions used in the tool
Present (P): 4 There is evidence that the relevant indicator is documented within the organisation’s
SMS documentation.
Suitable (S): 4 7c The relevant indicator is suitable based on the size, nature, and complexity of the
organisation and the inherent risk in its activity.
Operating (O): 4 7d There is evidence that the relevant indicator is in use and an output is being
produced.
Effective (E): 4 7e There is evidence that the relevant indicator is achieving the desired outcome and
has a positive safety impact.
Generally, Present and Suitable are used for initial approval or certification. Operating and Effective are
expected to be found in a functioning SMS.
Due to the continuously changing and dynamic nature of aviation, during ongoing or subsequent evaluations
the Suitable designation should be re-evaluated considering any changes to the organisation and its activities.
An item cannot be considered Operating or Effective if it is not Present and it cannot be considered as Present
if it is not documented—documentation ensures consistent repeatable and systematic outcomes.
What to look for: 7a This section guides the evaluator when looking at each individual feature and is not
meant to be a checklist. The items listed are not specific to an individual Present, Suitable, Operating, or
Effective level, but remind the evaluator of areas they may want to consider. Some items in this column may
not be relevant depending on the size, type, or nature of the organisation.
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Level of detail to be recorded

It is important that the evaluator records evidence of the evaluation. Evidence includes documentation,
reports, and records of interviews and discussions. For example, for an item to be designated Present the
evidence is likely to be documented only, whereas for an item to be designated Operating, the evaluation
may involve evaluating records as well as face to face discussions with personnel within an organisation.
Addressing findings and observations

For the initial evaluation or as part of a transition to new SMS requirements, all processes should be Present
and Suitable. If not, then the approval or certificate should not be granted or the transition should not be
accepted. Once an SMS is functioning and transition periods expired, a finding should be issued if a process
is found not to be Operating during the evaluation.
Where a feature is found not to be Effective, the inspectors may consider issuing an observation to give rise
to suggested improvements. However, findings should not be issued if the process is Operating but not
Effective.
The completed evaluation tool with the Regulatory Authority, or at least a summary of the SMS evaluation,
should be provided to the organisation along with a report that captures any findings and observations.
Providing the organisation with detailed comments of the evaluation will assist in continuous improvement
of the SMS and supports a positive safety culture at State level.
Scoring the SMS evaluation

The main objective of the Evaluation Tool is to assist in the evaluation of the SMS in terms of maturity and
effectiveness in a consistent way rather than to deliver a ‘score.’
The SM ICG does not recommend that the SMS be scored, but should the Regulatory Authority decide to
score the SMS evaluation across its industry, the following important considerations are needed:
• Scoring should not be linear but weighted or even exponential so that a higher score is achieved for
being Effective to encourage organisations to strive to achieve that level for their processes.
• Scoring should not be used as a pass/fail criterion but instead to help evaluate the maturity of the
SMS as a benchmark against other organisations and to aid continuous improvement.
• Regulatory Authorities should also be mindful; scoring may create the wrong behaviours in
organisations that could undermine a positive safety culture.
Training considerations
It is important that staff are competent to carry out the SMS evaluation and it is applied in a consistent way.
This is likely to involve additional training as the evaluation involves the inspectors making judgements that
may be subjective.
All inspectors and their managers should be trained and competent to use the tool. The training should
include practical case study examples based on real SMS documentation and actual industry events.
The tool should be used by staff with training and competency in:
• Safety Management Systems based on the ICAO SMS Framework;

• Auditing techniques;
• Interview techniques including communication skills;
• Understanding of the application of risk management;
• Appreciation of the difference between compliance and performance;
• Report writing techniques to allow narrative to be used to summarise the evaluation;
• Understanding of safety culture;
• Understanding of human factors; and
• State Safety Programme and State Safety Objectives.
4
It is recommended that as well as being trained to use the tool in the classroom environment, staff are
provided additional training during a live evaluation to familiarise themselves with the tool and its practical
use.
Standardisation
It is important that the SMS evaluation tool is used in a consistent manner. This can be achieved by having
the SMS evaluation being carried out by a team. The regulator should also develop a programme for
standardisation of how the evaluation tool is being used by its inspectors. This will help identify
inconsistencies in the approach and where additional training may be required. This should involve a
combination of desktop reviews to assess the completed evaluation tool, and any follow up actions and on-
the-job observations to assess how well the SMS evaluation is carried out.
Evaluation summary
The tool has been designed to evaluate the maturity and effectiveness of the SMS in a standardized manner.
In order to give the organisation an overall picture of its SMS performance, it is recommended to issue an
evaluation summary that is concise and reflects the level of progress achieved by the organisation.
An example of an evaluation summary is provided in Appendix 1.
5
Appendix 1 – Example of an evaluation summary
Initiating Present and Suitable Operating Effective Excellence
The SMS as a The SMS is at the All main elements of the The systems and processes The SMS is working in an The organisation is an industry leader
Whole implementation stage. SMS are in place. of the SMS are operating. effective way and is striving for and embraces and shares its best
continuous improvement. practices.
Safety Risk The safety risk A safety reporting system is The hazard and risk The organisation is continuously Key personnel throughout the
Management management processes in place and there is a registers are being built up identifying hazards and organisation are aware and understand
are not fully developed. process for how risks are and risks are starting to be understands its biggest risks and the risks relative to their responsibilities
assessed and managed. managed in proactive is actively managing them; this and are continuously searching out new
manner. can be seen in their safety hazards and risks and re-evaluating
performance. Safety Risk existing risks.
Management is proactive.
Safety Safety assurance Initial SPIs linked to the The organisation has The organisation assures itself The organisation is continuously
Assurance activities, including safety safety objectives have been established SPIs that it is that is has an effective SMS and is assessing its approach to safety
performance indicators identified and there is a monitoring and is auditing managing its risk through audit, management and is continuously
(SPIs) are not fully change management and assessing its SMS and assessment, and monitoring of its improving its safety performance and
developed. process in place. its outputs. safety performance. seeking out and embracing best
practices.
Safety Policy Policies, processes, and There are policies, There is a safety policy in Senior management are clearly The organisation is an industry leader
and Objectives procedures are not fully processes, and procedures place and senior involved in the SMS and the and embraces best practices.
developed. in place that detail how the management are safety policy sets out the
SMS will operate. committed to making the organisation’s intent to manage
SMS work and is providing safety. This is clearly evident in
appropriate resources to day to day operations.
safety management.
Safety Safety promotion There is a training The organisation has The organisation puts In addition, the organisation provides
Promotion activities are not fully programme and the means trained its people and has considerable resources and effort training and safety promotion to its
developed. to communicate safety several mediums for into training its people and contracted service providers and
information is in place. safety promotion that it publicising its safety culture and assesses the effectiveness of its safety
uses for passing on safety other safety information and promotion.
information. monitors the effectiveness of its
safety promotion.
Human Factors Human Factors are Human Factors policies and Human Factors are being Human Factors are integrated Human Factors are embedded into the
Management considered but not processes have been managed across the into the SMS and the operations day to day activities of the organisation
formally captured by the defined and documented organisation and are of the organisation. All staff and fully integrated into the SMS. This is
organisation. where required by starting to be integrated including management are aware evident throughout the organisation
regulation. into the organisation’s of Human Factors and apply it in from senior management to front line
SMS. the way they work. staff.
Note 1: In addition to Present, Suitable, Operating, and Effective, this example uses two additional maturity levels: Initiating and Excellence.
Note 2: A specific line for Human Factors has also been added in this example to highlight the importance of considering Human Factors as part of the SMS.
6
SMS Evaluation Tool
Organisation: Approval/Certificate Reference(s):
SMS or MS Manual Revision: Evaluator(s) (Name and Department):
Scope of Evaluation: Date of Evaluation: Evaluation Reference:
Table of contents
1. SAFETY RISK MANAGEMENT (Annex 19 component 2) ............................................................................................................................................................................................. 2
1.1 HAZARD IDENTIFICATION (Annex 19 element 2.1) ....................................................................................................................................................................................... 2
1.2 SAFETY RISK ASSESSMENT AND MITIGATION (Annex 19 element 2.2) ......................................................................................................................................................... 4
2. SAFETY ASSURANCE (Annex 19 component 3) .......................................................................................................................................................................................................... 6
2.1 SAFETY PERFORMANCE MONITORING AND MEASUREMENT (Annex 19 element 3.1) ................................................................................................................................ 6
2.2 THE MANAGEMENT OF CHANGE (Annex 19 element 3.2) .......................................................................................................................................................................... 10
2.3 CONTINUOUS IMPROVEMENT OF THE SMS (Annex 19 element 3.3) ......................................................................................................................................................... 11
3. SAFETY POLICIES AND OBJECTIVES (Annex 19 component 1) ................................................................................................................................................................................. 12
3.1 MANAGEMENT COMMITMENT (Annex 19 element 1.1) ............................................................................................................................................................................ 12
3.2 SAFETY ACCOUNTABILITY AND RESPONSIBILITIES (Annex 19 element 1.2)................................................................................................................................................ 16
3.3 APPOINTMENT OF KEY PERSONNEL (Annex 19 element 1.3) ..................................................................................................................................................................... 18
3.4 CO-ORDINATION OF EMERGENCY RESPONSE PLANNING (Annex 19 element 1.4) .................................................................................................................................... 20
3.5 SMS DOCUMENTATION (Annex 19 element 1.5) ........................................................................................................................................................................................ 21
4. SAFETY PROMOTION (Annex 19 component 4) ...................................................................................................................................................................................................... 22
4.1 TRAINING AND EDUCATION (Annex 19 element 4.1).................................................................................................................................................................................. 22
4.2 SAFETY COMMUNICATION (Annex 19 element 4.2) ................................................................................................................................................................................... 24
5. INTERFACE MANAGEMENT (Annex 19 note 2) ........................................................................................................................................................................................................ 25
Page 1 of 25
1. SAFETY RISK MANAGEMENT (Annex 19 component 2)
1.1 HAZARD IDENTIFICATION (Annex 19 element 2.1)
Indicators of compliance and performance P S O E How it is achieved Comments
1.1.1 There is a confidential reporting system to capture errors,
hazards, and near misses that is simple to use and accessible
Evaluation
to all staff.
1.1.2 There is a confidential reporting system that provides
appropriate feedback to the reporter and, where
appropriate, to the rest of the organisation.
1.1.3 Personnel express confidence and trust in the organisation’s
reporting policy.
What to look for
- Review the reporting system for access and ease of use.
- Check staff’s trust of and familiarity with the reporting system, and whether they know what should be reported.
- Review how data protection and confidentiality is achieved.
- Evidence of feedback to reporter, the organisation, and third parties.
- Assess volume and quality of reports, including whether personnel are reporting their own errors and mistakes.
- Review report closure rates.
- Check whether contracted organizations and customers are able to make reports.
- Review how reports in the system are analysed.
- Confirm that responsibilities with regards to occurrence analysis, storage, and follow-up are clearly defined.
- Check that relevant staff are aware of which occurrences should be mandatory.
- Assess how senior management engage with the outputs of the reporting system.
Guidance
Present Suitable Operating Effective

There is a confidential reporting The reporting system is accessible and The reporting system is being used by There is a healthy reporting system
system to capture mandatory easy to use by all personnel. all personnel. based on the volume of reporting and
occurrences and voluntary reports that Responsibilities, timelines, and format There is feedback to the reporter of the quality of reports received.
includes a feedback system and stored for the feedback are meaningful and any actions taken (or not taken) and, Safety reports are acted on in a timely
on a database. well defined. where appropriate, to the rest of the manner.
The process identifies how reports are Data protection and confidentiality is organisation. Personnel express confidence and
actioned, and timescales are specified ensured. Reports are evaluated, processed, trust in the organisations’ reporting
and addressed. analysed, and stored. policy and process.
Staff are aware of and fulfil their The reporting system is being used to
responsibilities in respect to the make better management decisions
reporting system. and continuously improve.
Reports are processed within the The reporting system is available for
defined timescales. third parties to report (partners,
suppliers, and contractors).
Page 2 of 25
1.1.4 There is a process that defines how hazards are identified
from multiple sources through reactive and proactive
methods (internal and external).
1.1.5 The hazard identification process identifies human
Evaluation
performance related hazards.

1.1.6 There is a process in place to analyse safety data and safety
information to look for trends and gain useable
management information.
1.1.7 Safety investigations are carried out by appropriately trained
personnel to identify root causes (why it happened, not just
what happened).
What to look for
- Review how hazards are identified, analysed, addressed, and recorded.
- Review structure and layout of hazard log.
- Consider hazards related to:
o Possible accident scenarios;
o Human and organisational factors;
o Business decisions and processes;
o Third party organisations; and
o Regulatory factors.
- Review what internal and external sources of hazards are considered such as safety reports, audits, safety surveys, investigations, inspections, brainstorming,
management of change activities, commercial and other external influences, etc.
- Review whether safety investigations identify human and organisational contributing factors.
Guidance

There is a process that defines how Multiple sources of hazards (internal The hazards are identified and The organisation has a register of the
hazards are identified though reactive and external) are considered and documented. Human and hazards that is maintained and
and proactive methods. reviewed, as appropriate. organisational factors related to reviewed to ensure it remains up-to-
The triggers for safety investigations The data analysis process enables hazards are being identified. date. It is continuously and proactively
are identified. gaining useable safety information. Safety investigations are carried out identifying hazards related to its
Hazards are documented in an easy-to- and recorded. activities and the operational
understand format. environment and involves all key
The level of sign-off for safety personnel and appropriate stakeholders
investigations is defined and adequate including external organisations.
to the level of risk. Hazards are continuously assessed in a
systematic and timely manner.
Safety investigations identify
causal/contributing factors that are
acted upon.
Page 3 of 25
1.2 SAFETY RISK ASSESSMENT AND MITIGATION (Annex 19 element 2.2)
1.2.1 There is a process for the management of risk that includes
the analysis and assessment of risk associated with
Evaluation
identified hazards expressed in terms of likelihood and

severity (or alternative methodology).
1.2.2 There are criteria for evaluating the level of risk the
organisation is willing to accept and risk assessments and
ratings are appropriately justified.
What to look for
- Review the risk classification scheme and procedures.
- Check that severity and likelihood criteria are defined (or that an alternative methodology is described).
- Review whether risk assessments are carried out consistently.
- Sample an identified hazard and review how it is processed and documented.
- Review what triggers a risk assessment.
- Check any assumptions made and whether they are reviewed.
- Review how issues are classified when there is insufficient quantitative data available.
- Check that the process defines who can accept what level of risk.
- Check that the risk register is being reviewed and monitored by the appropriate safety committee(s).
Guidance
- Evidence of risk acceptability being routinely applied in decision making processes.

There is a process for the analysis and Severity and likelihood criteria are Risk analysis and assessments are Risk analysis and assessments are
assessment of safety risks. clearly defined and fit the service carried out in a consistent manner reviewed for consistency and to
The level of risk the organisation is provider’s actual circumstances. based on the defined process. identify improvements in the
willing to accept is defined. The risk matrix and acceptability The defined risk acceptability is being processes.
criteria are clearly defined and usable. applied. Risk assessments are regularly
Responsibilities and timelines for reviewed to ensure they remain
accepting the risk are clearly defined. current.
Risk acceptability criteria are used
routinely and applied in management
decision making processes and are
regularly reviewed.
Page 4 of 25
Evaluation
1.2.3 The organisation has a process in place to make decisions
and apply appropriate and effective risk controls.
1.2.4 Senior management have visibility of medium and high risk
hazards and their mitigation and controls.
What to look for
- Risk controls consider human and organisational factors.
- Evidence of risk controls being actioned and follow up.
- Aggregate risk is being considered.
- Check whether the risk controls have reduced the residual risk.
- Risk controls are clearly identified.
- Review the use of risk controls that rely solely on human intervention.
Guidance
- Check that new risk controls do not create additional risks.

- Check whether the acceptability of the risks is made at the right management level.
The organisation has a process in place Responsibilities and timelines for Appropriate risk controls are being Risk controls are practical and
to decide and apply risk controls. determining and accepting the risk applied to reduce the risk to an sustainable, applied in a timely
controls are defined. acceptable level including timelines manner, and do not create additional
and allocation of responsibilities. risks.
Human Factors are considered as part Risk controls take Human Factors into
of the development of risk controls. consideration.
Page 5 of 25
2. SAFETY ASSURANCE (Annex 19 component 3)
2.1 SAFETY PERFORMANCE MONITORING AND MEASUREMENT (Annex 19 element 3.1)
Evaluation
2.1.1 Safety performance indicators (SPIs) linked to the

organisation’s safety objectives have been defined,
promulgated, and are being monitored and analysed for
trends.
What to look for
- Evidence that SPIs are based on reliable sources of data.
- Evidence of when SPIs were last reviewed.
- The defined SPIs and targets are appropriate to the organisation’s activities, risks, and safety objectives.
- SPIs are focused on what is important rather than what is easy to measure.
- Consideration of any State SPIs.
- Review whether any action has been taken when an SPI is indicating a negative trend (reflecting a risk control or an inappropriate SPI).
- Evidence that results of safety performance monitoring are discussed at the senior management level.
- Evidence of feedback provided to the Accountable Executive.
Guidance
There is a process in place to measure SPIs are focused on what is important The safety performance of the SPIs are demonstrating the safety
the safety performance of the rather than what is easy to measure. organisation is being measured and performance of the organisation and
organisation including SPIs and targets Reliability of data sources is meaningful SPIs are being continuously the effectiveness of risk controls based
linked to the organisation’s safety considered in the design of SPIs. monitored and analysed for trends. on reliable data.
objectives and to measure the SPIs are linked to the identified risks SPIs are reviewed and regularly
effectiveness of safety risk controls. and safety objectives. updated to ensure they remain
Frequency and responsibility for the relevant.
trend monitoring of SPIs are Where the SPIs indicate that a risk
appropriate. control is ineffective, appropriate
Realistic targets have been set. action is taken.
State SPIs are considered, as
applicable.
Page 6 of 25
Evaluation
2.1.2 Risk mitigations and controls are being verified/audited to
confirm they are working and effective.
2.1.3 Safety assurance takes into account activities carried out by
all directly contracted organisations.
What to look for
- Evidence of risk controls being assessed for effectiveness (e.g., audits, surveys, reviews, SPIs and safety performance targets [SPTs], reporting systems).
- Evidence of risk controls applied by contracted organisations being assessed and overseen (e.g., quality check, reviews, and regular meetings).
- Information from safety assurance and compliance monitoring activities feeds back into the safety risk management process.
Guidance
- Review where risk controls have been changed as a result of the assessment.
There is a process in place to assess Responsibilities, methods, and Risk controls are being verified to Risk controls are assessed and actions
whether the risk controls are applied timelines for assessing risk controls are assess whether they are applied and taken to ensure they are effective and
and effective. defined. effective. delivering a safe service.
Contracted organisations are included
in the safety assurance process.
Page 7 of 25
2.1.4 Responsibilities and accountability for ensuring compliance
with safety regulations are defined and applicable
requirements are clearly identified in organisation manuals
and procedures.
Evaluation
2.1.5 There is an internal audit programme including details of the

schedule of audits and procedures for audits, reporting,
follow up, and records.
2.1.6 Responsibilities and accountabilities for the internal audit
process are defined and there is a person or group of
persons with responsibilities for internal audits with direct
access to the Accountable Manager.
What to look for
- Review how senior management ensure the organisation remains in compliance.
- Review job descriptions for compliance responsibilities.
- Evidence that senior management take action on internal and external audit results.
- Review how independence of the internal audit function is achieved.
- Review how the internal audit function interacts with:
o Senior management,
o Line managers, and
o The safety management staff.
Guidance
- Assess the contents of the programme against any regulatory requirements.

Responsibilities and accountabilities The internal audit programme covers The compliance monitoring Individuals are proactively identifying
for compliance are defined. all applicable regulations and includes programme is being followed and and reporting potential non-
The organisation has an internal audit details of the schedule of audits. regularly reviewed. compliances.
programme and procedures for audits, Independence of the internal audit All staff are aware of their The Accountable Executive and senior
reporting, and records. function is achieved. responsibilities and accountabilities for management actively seek feedback
A person or group of persons with compliance and to follow processes on the status of internal and external
responsibilities for internal audits has and procedures. audit activities.
been identified and they have direct Internal and external audit results are
access to the Accountable Executive. reported to the Accountable Executive
and senior management.
Page 8 of 25
Evalu
ation
2.1.7 After an audit, there is appropriate analysis of causal factors
and corrective/preventive actions are taken.
What to look for
- Review the methods used for causal analysis
- Check that the method is used consistently.
- Review any repeat findings and check for actions have not been implemented or are overdue.
- Check for timely implementation of actions.
- Review senior management awareness of the status of significant findings and related corrective/preventive actions.
- Check that appropriate personnel participate in the determination of causes and contributing factors.
- Look for consistency between internal audit results and external audit results.
Guidance
- Review whether causal factors are considered as potential hazards.

The process for the identification and Responsibilities and timelines for The identification and follow-up of The organisation investigates the
follow-up of corrective/preventive determining, accepting, and following- corrective/preventive actions is carried systemic causes and contributing
actions are defined. up the corrective/preventive action out in accordance with the procedures factors of findings.
The interface between internal audits are defined. including causal analysis to address The organisation proactively reviews
and the safety risk management Compliance monitoring includes root causes. the status of corrective/preventive
processes is described. contracted activities. The status of corrective/preventive actions.
actions is regularly communicated to Effectiveness of the
relevant senior management and staff. corrective/preventive actions is
verified.
Page 9 of 25
2.2 THE MANAGEMENT OF CHANGE (Annex 19 element 3.2)
2.2.1 The organisation has a process to identify whether changes
have an impact on safety and to manage any identified risks
in accordance with existing safety risk management
Evaluation
processes.
2.2.2 Human Factor (HF) issues have been considered as part of
the change management process and, where appropriate,
the organisation has applied the appropriate HF/human-
centred design standards to the equipment and physical
environment design.
What to look for
- Key stakeholders are involved in the process.
- Review what triggers the process.
- Review recent changes that have been through the risk assessment process.
- Check that change is signed off by an appropriately authorised person.
- Transitional risks are being identified and managed.
- Review follow up actions such as whether any assumptions made have been validated.
- Review whether there is an impact on previous risk assessments and existing hazards.
- Review whether consideration is given to the accumulative effect of multiple changes.
- Review that business-related changes have considered safety risks (organisational restructuring, upsizing or downsizing, IT projects, etc.).
- Evidence of HF issues being addressed during changes.
- Review impact of change on training and competencies.
- Review previous changes to confirm they remain under control.
Guidance
- Consider how the changes are communicated to those people impacted by the change.
The organisation has established a Triggers for the change management The change management process is The change management process is
change management process to process are defined. being used and includes hazard used for all changes that may impact
identify whether changes have an The process also considers business identification and risk assessments safety, including HF issues, and
impact on safety and to manage any related changes and interfaces with with appropriate risk controls being considers the accumulation of multiple
identified risks in accordance with other organisations/departments. put in place before a decision to make changes. It is initiated in a planned,
existing safety risk management The process is integrated with the risk the change is taken. timely, and consistent manner and
processes. management and safety assurance HF issues have been considered and includes follow up action that ensures
processes. been addressed as part of the change the change was implemented safely.
Responsibilities and timelines are management process. The change is communicated to those
defined. affected.
Risk control and mitigation strategies
associated with changes are achieving
the planned effect.
Page 10 of 25
2.3 CONTINUOUS IMPROVEMENT OF THE SMS (Annex 19 element 3.3)
Evaluation Indicators of compliance and performance P S O E How it is achieved Comments
2.3.1 The organisation is continuously monitoring and assessing its
SMS processes to maintain or continuously improve the
overall effectiveness of the SMS.
What to look for

- Review the information and safety data used for management decision making and continuous improvement.
- Evidence of:
o Lessons learnt being incorporated into SMS and operational processes;
o Best practices being sought and embraced;
o Surveys and assessments of organisational culture being carried out and acted upon;
o Data being analysed and results shared with Safety Committees; and
o Follow-up actions.
- Information from external occurrences, investigation reports, safety meetings, hazard reports, audits, and safety data analysis all contribute towards
Guidance
continuous improvement of the SMS.

There is a process in place to monitor The SMS is periodically reviewed, and There is evidence of the SMS being The assessment of SMS effectiveness
and review the effectiveness of the the review is supported by safety periodically reviewed to support the uses multiple sources of information
SMS using the available data and information and safety assurance assessment of its effectiveness and including the safety data analysis that
information. activities. appropriate action being taken. supports decisions for continuous
Senior management and different improvements.
departments are involved.
The decision making is data informed.
External information is considered in
addition to internal information.
Page 11 of 25
3. SAFETY POLICIES AND OBJECTIVES (Annex 19 component 1)
3.1 MANAGEMENT COMMITMENT (Annex 19 element 1.1)
3.1.1 There is a safety policy, signed by the Accountable Manager,
which includes a commitment to continuous improvement;
observes all applicable legal requirements and standards;
Evaluation
and considers best practices.

3.1.2 The safety policy includes a statement to provide
appropriate resources and the organisation is managing
resources by anticipating and addressing any shortfalls.
3.1.3 There are policies in place for safety critical roles relating to
all aspects of Fitness for Duty (for example, Alcohol and
Drugs Policy or Fatigue).
What to look for
- Interview the Accountable Executive to assess their knowledge and understanding of the safety policy.
- Check that the safety policy is reviewed periodically for content and currency.
- Confirm that the safety policy meets the requirements.
- Interview staff to determine to what extent the safety policy is known, as well as how readable and understandable it is.
- Review available resources including personnel, equipment, and financial.
- There are sufficient and competent personnel.
- Review planned resources versus actual resources.
Guidance
- Check how a positive safety culture is encouraged and impacts the overall effectiveness.
There is a safety policy, signed by the The safety policy is easy to read. The safety policy is reviewed The Accountable Executive is familiar
Accountable Manager, which includes The content is customised to the periodically to ensure it remains with the contents of the safety policy
a commitment to continuous organisation. relevant to the organisation. and endorses it.
improvement; observes all applicable There is a process for assessing The organisation is assessing the The organisation is reviewing and
legal requirements and standards; and resources and addressing any resources being provided to deliver a taking action to address any forecasted
considers best practices. The safety shortfalls. safe service and taking action to shortfalls in resources.
policy includes a statement to provide address any shortfalls.
appropriate resources.
Page 12 of 25
3.1.4 There is a means in place for the communication of the
Evaluation safety policy.
3.1.5 The Accountable Executive and the senior management
team promote a positive safety/just culture and
demonstrate their commitment to the safety policy through
active and visible participation in the safety management
system.
What to look for
- Review how the safety policy is communicated.
- Safety policy is clearly visible to all staff including relevant contracted staff and third-party organisations.
- Question managers and staff regarding knowledge of the safety policy.
- All managers are familiar with the key elements of the safety policy.
- Evidence of senior management participation in safety meetings, training, conferences, etc.
- Feedback from safety surveys that include specific just culture aspects.
- Relationship with regulator and other stakeholders.
Guidance
- Review how a positive safety and just culture are promoted.

There is a means in place for the The safety policy is clearly visible to all The safety policy is communicated to People across the organisation are
communication of the safety policy. staff (consider multiple sites). all personnel (including relevant familiar with the policy and can
The management commitment to The safety policy is understandable contract staff and organisations). The describe their obligations in respect of
safety is documented within the safety (consider multiple languages). The Accountable Executive and the senior the safety policy. Decision making,
policy. Accountable Executive and the senior management team are promoting actions, and behaviours reflect a
management team have a well-defined their commitment to the safety policy positive safety/just culture and there is
role in the safety management system. through active and visible participation good safety leadership that
in the safety management system. demonstrates commitment to the
safety policy.
Page 13 of 25
Evaluation
3.1.6 The safety policy actively encourages safety reporting.
3.1.7 A just culture policy and principles have been defined that
clearly identifies acceptable and unacceptable behaviours to
promote a just culture.
What to look for
- Evidence of when the just culture principles have been applied following an event.
- Evidence of interventions from safety investigations addressing organisational issues rather than focusing only on the individual.
- Review how the organisation is monitoring reporting rates.
- Review the number of aviation safety reports appropriate to the activities.
- Safety reports include the reporter’s own errors and events they are involved in (events where no one was watching).
- Feedback on just culture from staff safety culture surveys.
- Interview staff representatives to confirm that they agree with just culture policy and principles.
Guidance
- Check that staff are aware of the just culture policy and principles.
A just culture policy and principles The just culture policy clearly identifies There is evidence of the just culture The just culture policy is applied in a
have been defined. acceptable and unacceptable policy and supporting principles being fair and consistent manner and staff
behaviours. applied and promoted to staff. trust the policy.
The principles ensure that the policy There is evidence that the line
can be applied consistently across the between acceptable and unacceptable
whole organisation. behaviour has been determined in
The just culture policy and principles consultation with staff and staff
are understandable and clearly visible. representatives.
Page 14 of 25
3.1.8 Safety objectives have been established that are consistent
Evaluation with the safety policy and they are communicated
throughout the organisation.
3.1.9 The State Safety Programme (SSP) is being considered and
addressed as appropriate.
What to look for
- Assess whether the safety objectives are appropriate and relevant.
- Objectives are defined that will lead to an improvement in processes, outcomes, and the development of a positive safety culture.
- Assess how safety objectives are communicated throughout the organisation.
- Safety objectives are being measured to monitor achievement through SPIs and SPTs.
Guidance
- Assess if the safety objectives have considered the State safety objectives in the SSP.
Safety objectives have been Safety objectives are relevant to the Safety objectives are being regularly Achievement of the safety objectives is
established that are consistent with organisation and its activities. reviewed and are communicated being monitored by senior
the safety policy and there is a means Safety objectives are understandable throughout the organisation. management and action taken to
to communicate them throughout the and clearly visible. ensure they are being met.
organisation. Safety objectives are aligned with the
SSP.
Page 15 of 25
3.2 SAFETY ACCOUNTABILITY AND RESPONSIBILITIES (Annex 19 element 1.2)
Evaluation 3.2.1 An Accountable Executive has been appointed with full
responsibility and accountability to ensure the SMS is
properly implemented and performing effectively.
3.2.2 The Accountable Executive is fully aware of their SMS roles
and responsibilities in respect of the safety policy, safety
standards, and safety culture of the organisation.
What to look for
- Evidence that the Accountable Executive has the authority to provide sufficient resources for relevant safety improvements.
- Evidence of decision making on risk acceptability.
- Review SMS activities are being carried out in a timely manner and the SMS is sufficiently resourced.
- Evidence of activities being stopped due to unacceptable level of safety risk.
- Look for evidence that Accountable Executive actions are consistent with the active promotion of a positive safety culture in the organisation.
An Accountable Executive has been The Accountable Executive has control The Accountable Executive ensures The Accountable Executive ensures
Guidance
appointed with full responsibility and of resources. that the SMS is properly resourced, that the performance of the SMS is
ultimate accountability for the SMS. implemented, and maintained, and has being monitored, reviewed, and
the authority to stop the operation if improved.
there is an unacceptable level of safety
risk.
The Accountable Executive is fully
aware of their SMS roles and
responsibilities.
The Accountable Executive is
accessible to the staff in the
organisation.
Page 16 of 25
Evaluation
3.2.3 Safety accountabilities, authorities, and responsibilities are
defined and documented throughout the organisation and
staff understand their own responsibilities.
What to look for

- Question managers and staff regarding their roles and responsibilities.
- Confirm senior managers are aware of the organisation’s safety performance and its most significant risks.
- Evidence of managers having safety related performance targets.
- Look for active participation of the management team in the SMS.
- Evidence of appropriate risk mitigation, action, and ownership.
Guidance
- The levels of management authorised to make decisions on risk acceptance are defined and applied.
- Check for any conflicts of interest and that they have been identified and managed.
The safety accountability, authorities, Individuals have access to their safety Everyone in the organisation is aware The Accountable Executive and the
and responsibilities are clearly defined accountability, authorities, and of and fulfil their safety senior management team are aware of
and documented. responsibilities (for example, through responsibilities, authorities, and the risks faced by the organisation and
job descriptions or organisational accountabilities and are encouraged to SMS principles exist throughout the
charts). contribute to the SMS. organisation so that safety is part of
the everyday language.
Page 17 of 25
3.3 APPOINTMENT OF KEY PERSONNEL (Annex 19 element 1.3)
3.3.1 A competent safety manager who is responsible for the
implementation and maintenance of the SMS has been
Evaluation
appointed with a direct reporting line to the Accountable

Executive.
3.3.2 The organisation has allocated sufficient resources to
manage the SMS including, but not limited to, competent
staff for safety investigation, analysis, auditing, and
promotion.
What to look for
- Review safety manager role including credibility and status.
- Review the training that the safety manager has received.
- Evidence of maintained competency.
- Review how the safety manager gets access to internal and external safety information.
- Review how the safety manager communicates and engages with operational staff and senior management.
- Review the safety manager’s workload/allocated time to fulfil role.
- Check there are sufficient resources for SMS activities such as safety investigation, analysis, auditing, safety meeting attendance, and promotion.
- Review of safety report action and closure timescales.
Guidance
- Interviews with Accountable Executive and safety manager.

- Check for any conflicts of interest and that they have been identified and managed.
A safety manager who is responsible The safety manager is competent. The safety manager has implemented The safety manager is competent to
for the implementation and Sufficient time and resources are and is maintaining the SMS. The safety manage the SMS and identifies
maintenance of the SMS has been allocated to maintain the SMS. manager is in regular communication improvements in a timely manner.
appointed with a direct reporting line with the Accountable Executive and There is a close working relationship
to the Accountable Executive. escalates safety issues when with the Accountable Executive and
appropriate. the safety manager is considered a
The safety manager is accessible to trusted advisor and given appropriate
staff in the organisation. status in the organisation.
Page 18 of 25
Evaluation
3.3.3 The organisation has established appropriate safety
committee(s) that discuss and address safety risks and
compliance issues and includes the Accountable Executive
and the heads of functional areas.
What to look for
- Review safety committee and meeting structure and Terms of Reference for each committee/meeting.
- Review meeting attendance levels.
- Review meeting records and actions.
- Check that outcomes are communicated to the rest of the organisation.
- Evidence of safety objectives, safety performance, and compliance are being reviewed and discussed at meetings.
- Participants challenge what is being presented when there is limited evidence.
- Senior management are aware of the most significant risks faced by the organisation and the overall safety performance of the organisation.
Guidance
The organisation has established Safety committee(s)’ structure and There is evidence of meetings taking Safety committees include key
safety committee(s). frequency supports the SMS functions place detailing the attendance, stakeholders. The outcomes of the
across the organisation. discussions, and actions. meetings are documented and
The scope of the safety committee(s) The safety committee(s) monitor the communicated and any actions are
includes safety risks and compliance effectiveness of the SMS and agreed, taken, and followed up in a
issues. compliance monitoring function by timely manner. The safety
The attendance of the highest-level reviewing there are sufficient performance and safety objectives are
safety committee includes at least the resources. reviewed and actioned as appropriate.
Accountable Executive and the heads Actions are being monitored and
of functional areas. appropriate safety objectives and SPIs
have been established.
Page 19 of 25
3.4 CO-ORDINATION OF EMERGENCY RESPONSE PLANNING (Annex 19 element 1.4)
Evaluation 3.4.1 An appropriate emergency response plan (ERP) has been
developed and distributed that defines the procedures,
roles, responsibilities, and actions of the various
organisations and key personnel.
3.4.2 The ERP is periodically tested for the adequacy of the plan
and the results reviewed to improve its effectiveness.
What to look for
- Review emergency response plan.
- Review how coordination with other organisations is planned.
- Review how ERP is distributed and where copies are held.
- Interview key personnel and check they have access to the ERP.
- Check that different types of foreseeable emergencies have been considered.
- Review when the plan was last reviewed and tested and actions taken.
A coordinated ERP has been developed Key personnel have easy access to the The ERP is reviewed and tested to The results of the ERP review and
Guidance
and defined. relevant parts of the ERP at all times. make sure it remains up-to-date. There testing are assessed and actioned to
The ERP defines the procedures, roles, is evidence of coordination with other improve its effectiveness.
responsibilities, and actions of the organisations as appropriate.
various organisations and key
personnel.
The frequency and methods for testing
the ERP are defined.
The coordination with other
organisations (including non-aviation
organisations) is defined with
appropriate means.
Page 20 of 25
3.5 SMS DOCUMENTATION (Annex 19 element 1.5)
3.5.1 The SMS documentation includes the policies and processes
that describe the organisation’s safety management system
Evaluation
and processes and is readily available to all relevant

personnel.
3.5.2 SMS documentation, including SMS related records, are
regularly reviewed and updated with appropriate version
control in place.
What to look for
- Review the SMS documentation and amendment procedures.
- Check for cross references to other documents and procedures.
- Check availability of SMS documentation to all staff.
- Check that staff know where to find safety-related documentation including procedures appropriate to their role.
- Review the supporting SMS documentation (hazard logs, meeting minutes, safety performance reports, risk assessments, etc.).
- Check how safety records are stored and version controlled.
- Check appropriate staff are aware of the records control processes and procedures.
Guidance

The SMS documentation includes the SMS documentation is readily available Changes to the SMS documentation SMS documentation is proactively
policies and processes that describe to all relevant personnel. are managed. reviewed for improvement.
the organization’s SMS and processes. SMS documentation is Everyone is familiar with and follows SMS records are routinely used as
The SMS documentation defines the comprehensible. the relevant parts of the SMS inputs for safety management-related
SMS outputs and which records of SMS SMS documentation is consistent with documentation. tasks and continuous improvement of
activities will be stored. other internal management systems SMS activities are appropriately stored the SMS.
Records to be stored, storage period, and is representative of the actual and found to be complete and
and location are identified. processes in place. consistent with data protection and
Data protection and confidentiality confidentiality control rules.
rules have been defined.
Page 21 of 25
4. SAFETY PROMOTION (Annex 19 component 4)
4.1 TRAINING AND EDUCATION (Annex 19 element 4.1)
4.1.1 There is a training programme for SMS in place that includes
initial and recurrent training. The training covers individual
safety duties (including roles, responsibilities, and
Evaluation
accountabilities) and how the organisation’s SMS operates.

4.1.2 There is a process in place to measure the effectiveness of
training and to take appropriate action to improve
subsequent training.
4.1.3 Training includes human and organisational factors including
just culture and non-technical skills with the intent of
reducing human error.
What to look for
- Review the SMS training programme including course content and delivery method.
- Check training records against the training programme.
- Review how the competence of the trainers is being assessed and maintained.
- Training considers feedback from external occurrences, investigation reports, safety meetings, hazard reports, audits, safety data analysis, training, course
evaluations, etc.
- Review how training is assessed for new staff and changes in position.
- Review any training evaluation.
- Check that the training includes human and organisational factors.
Guidance
- Ask staff about their own understanding of their role in the organisation’s SMS and their safety duties.
- Check that all staff are briefed on compliance.
There is an SMS training programme in The training covers individual safety The SMS training programme is SMS training is evaluated for all
place that includes initial and recurrent duties (including roles, responsibilities, delivering appropriate training to the aspects (learning objectives, content,
training. and accountabilities) and how the different staff in the organisation and teaching methods and styles, tests,
organisation’s SMS operates. is being delivered by competent etc.) and is linked to the competency
Training material and methodology are personnel. assessment.
adapted to the audience and include Training is routinely reviewed to take
human factors. feedback from different sources into
All staff requiring training are consideration.
identified.
Page 22 of 25
4.1.4 There is a process that evaluates the individual’s
Evaluation competence and takes appropriate remedial action when
necessary.
4.1.5 The competence of trainers is defined and assessed and
appropriate remedial action taken when necessary.
What to look for
- Review how competence assessment is carried out on initial recruitment and recurrently.
- Check it includes safety duties and responsibilities, as well as compliance management.
Guidance
A competency framework is defined There is a process in place to There is evidence of the process being The competence assessment
for all personnel, including trainers. periodically assess the actual used and being recorded. programme and process is routinely
competency of personnel against the reviewed and improved.
framework. The competence assessment takes
appropriate remedial action when
necessary and feeds into the training
programme.
Page 23 of 25
4.2 SAFETY COMMUNICATION (Annex 19 element 4.2)
Evaluation 4.2.1 There is a process to determine what safety critical
information needs to be communicated and how it is
communicated throughout the organisation to all personnel,
as relevant. This includes contracted organisations and
personnel where appropriate.
What to look for
- Review the sources of information used for safety communication.
- Review the methods used to communicate safety information (e.g., meetings, presentations, emails, website access, newsletters, bulletins, posters, etc.).
- Assess whether the means of communication is appropriate.
- The means for safety communication is reviewed for effectiveness and material used to update relevant training.
- Significant events, changes, and investigation outcomes are being communicated.
- Check accessibility to safety information.
- Ask staff about any recent safety communication.
- Review whether information from occurrences are timely communicated to all relevant personnel (internal and external) and has been appropriately
Guidance
disidentified.
There is a process to communicate The process determined what, when, Safety critical information is being The organization analyses and
safety critical information. and how safety information needs to identified and communicated communicates safety critical
be communicated. throughout the organisation to all information effectively through a
The process includes contracted personnel, as relevant, including variety of methods as appropriate to
organisations and personnel where contracted organisations and maximise it being understood.
appropriate. personnel where appropriate. Safety communication is assessed to
The means of communication are determine how it is being used and
adapted to the audience and the understood and to improve it where
significance of what is being appropriate.
communicated.
Page 24 of 25
5. INTERFACE MANAGEMENT (Annex 19 Appendix 2 note 2)
Evaluation Indicators of compliance and performance P S O E How it is achieved Comments
5.1.1 The organisation has identified and documented the
relevant internal and external interfaces and the critical
nature of such interfaces.
What to look for

- Review how interfaces have been documented. It may be included in a system description.
- Evidence that:
o Safety critical issues, areas, and associated hazards are identified;
o Safety occurrences are being reported and addressed;
o Risk control actions are applied and regularly reviewed; and
o Interfaces are reviewed periodically.
- Training and safety promotion sessions are organised with relevant external organisations.
- External organisations participate in SMS activities and share safety information.
Guidance
- Check the identified interfaces (e.g., interfaces with aerodromes, airlines, Air Traffic Control [ATC], training organisations, contracted organisations, and the
State).
The organisation has identified and All relevant interfaces are addressed. The organisation is managing the The organisation has a good
documented the relevant internal and The way the interfaces are managed is interfaces through hazard understanding of interface
external interfaces and the critical appropriate to the criticality in terms identification and risk management. management and there is evidence
nature of such interfaces. of safety. There is an assurance activity to assess that interface risks are being identified
The means for communicating safety risk mitigations being delivered by and acted upon.
information is defined. external organisations. Interfacing organisations are sharing
safety information and take actions
when needed.
Page 25 of 25

SMS Evaluation Tool - v2 April2019

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Safety Management System

When to Use the Tool

Credit for other surveillance activities

Defining the surveillance program

Dealing with multiple certificate holders

How to Use the Tool

Users may decide to customise the evaluation tool to:

• Reflect organisational requirements;

Definitions used in the tool

Level of detail to be recorded

Addressing findings and observations

Scoring the SMS evaluation

• Safety Management Systems based on the ICAO SMS Framework;

An example of an evaluation summary is provided in Appendix 1.

SMS or MS Manual Revision: Evaluator(s) (Name and Department):

Scope of Evaluation: Date of Evaluation: Evaluation Reference:

Present Suitable Operating Effective

performance related hazards.

Present Suitable Operating Effective

identified hazards expressed in terms of likelihood and

- Evidence of risk acceptability being routinely applied in decision making processes.

- Check that new risk controls do not create additional risks.

2.1.1 Safety performance indicators (SPIs) linked to the

2.1.5 There is an internal audit programme including details of the

- Assess the contents of the programme against any regulatory requirements.

- Review whether causal factors are considered as potential hazards.

What to look for

continuous improvement of the SMS.

and considers best practices.

- Review how a positive safety and just culture are promoted.

What to look for

appointed with a direct reporting line to the Accountable

- Interviews with Accountable Executive and safety manager.

and processes and is readily available to all relevant

Present Suitable Operating Effective

accountabilities) and how the organisation’s SMS operates.

What to look for

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