SMS Manual - 2010-01-31

COPY No 6004-k
GCAA Copy
Aerogulf Services Company (L.L.C.)
INTEGRATED SAFETY MANAGEMENT SYSTEM
This document is the property of Aerogulf Services. No part of this publication may be
reproduced, stored in a retrieval system in any form, or transmitted by any means,
without the prior written permission of the Accountable Manager.
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0.1 TABLE OF CONTENTS

PAGE
SECTION 0 INTRODUCTION 0-1
0.0 Cover Page 0-1
0.1 Table of Contents 0-2
0.2 List of Revisions 0-7
0.3 List of Effective Pages 0-8
0.4 Distribution List 0-9
0.5 Index and Revision Status 0-10
0.6 System Interaction – Associated Manuals 0-10
0.7 Manual Source Material 0-10
0.8 Operational Environment 0-10
0.9 Abbreviations and Definitions 0-11
SECTION 1.0 SCOPE OF SMS 1-1

1.1 Scope 1-1
1.2 Structure of Aerogulf SMS 1-2
1.3 Interface Documents and Safety Cases 1-2
1.4 Standards, Procedures and Documents 1-2
1.4.1 Standards and Procedures 1-2
1.4.2 National and International Regulations 1-3
1.4.3 Aerogulf Standards and Guidance Material 1-3
1.4.4 Contractual Standards and Contractor Management 1-4
1.5 Safety Data collection and Processing System (SDCPS) 1-4
SECTION 2.0 SAFETY POLICY AND STRATEGIC OBJECTIVES 2-1

2.1 Safety Policy 2-1
2.2 Safety Values 2-2
2.3 Safety Management System – Strategic Objectives 2-3
2.4 Policy Statements 2-4
2.5 Safety Plan (Annex 1) 2-4
SECTION 3.0 SAFETY ACCOUNTABILITIES 3-1

3.1 Management, Leadership, Commitment and Planning 3-1
3.2 Accountabilities 3-1
3.2.1 Organisational Chart 3-2
3.3 Individual Accountabilities 3-3
3.3.1 Accountable Manager 3-3
3.3.2 Director of Operations / Engineering Manager 3-3
3.3.3 Safety Focal Points 3-4
3.3.4 The Personnel Manager 3-4
3.3.5 Chief Pilot and Supervisors 3-4
3.3.6 The Individual Employee 3-5
3.4 Visibility 3-6
3.4.1 Planning 3-6
3.4.2 Communication 3-6
3.4.3 Co-ordination 3-7
3.5 Proactive Target Setting 3-7
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3.6 Informed Involvement 3-7

3.7 Change of Culture 3-8
3.7.1 The Role of Senior Management 3-8
3.7.2 The Safety Management System and Safety Culture 3-8
3.7.3 Changing the Culture 3-9
SECTION 4.0 KEY SAFETY PERSONNEL 4-1

4.1 Safety / Quality Assurance Manager (S/QAM) 4-1
4.1.1 Qualifications 4-1
4.1.2 S/QAM Terms of Reference 4-1
4.2 Flight Safety Officer 4-2
4.3 Safety Focal Points – Additional Duties 4-2
SECTION 5.0 DOCUMENTATION CONTROL 5-1

5.1 Management and Control of Documents 5-1
5.1.1 Company Documents 5-1
5.3.2 GCAA Approved Documents 5-2
5.2 Documentation ‘Software’ Components of System 5-2
5.2.1 The ‘Maintenance View’ Database System 5-2
5.2.2 The ‘Server’ Computer Network System 5-3
5.3 Documentation ‘Hardware’ Components of System 5-3
5.3.1 ISMS Manual 5-4
5.3.2 Quality Manual 5-4
5.3.3 Quality Procedure Manual 5-4
5.3.4 HSE Manual 5-5
5.3.5 MME / MOE 5-5
5.3.6 Operations Manual 5-5
5.3.7 SOP’s / EPM’s 5-5
SECTION 6.0 HAZARD IDENTIFICATION AND RISK MANAGEMENT 6-1

6.1 Hazard and Effects Management Process (HEMP) 6-1
6.1.2 Risk Assessment Procedure 6-2
6.2 The steps in the Hazard and Effects Management Process 6-2
6.2.1 Step 1 Identify Hazards and Potential Effects 6-3
6.2.2 Step2 Assess Risks 6-3
6.2.3 Step 3 Implement controls 6-3
6.2.4 Step 4 Compare with Objectives and Performance 6-4
Criteria
6.2.5 Step 5 Establish Risk Reduction Measures 6-4
6.2.6 Step 6 Implement Risk Reduction Measures 6-4
6.2.7 Step 7 Review Hazards and Risk Reduction Methods 6-4
6.3 The Risk Assessment Matrix (RAM) 6-5
6.3.1 Instructions for use of the RAM 6-6
6.3.2 Documented Demonstration of Reduction of Risks to 6-7
ALARP and the Safety Case
6.3.3 RAM – Workplace Hazard Control 6-7
6.4 Application of HEMP (Bowtie Analysis) 6-8
6.4.1 The HEMP Process depicted in diagram and the 6-8
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application of the RAM

6.5 Application of the HEMP to Aerogulf’s Operations and 6-9
Maintenance
6.6 Hazards and Effects Register 6-9
6.6.1 Managing the Hazards and Effects Register 6-11
6.7 HEMP, the Rule of Three, & the Application to Aviation 6-12
Accident Prevention
6.7.1 The Rule of Three 6-12
6.8 Demonstration of ALARP 6-13
6.9 Safety-Critical Operations Procedure 6-13
6.9.1 Limits to Permitted Operations 6-13
SECTION 7.0 SAFETY PERFORMANCE MONITORING 7-1

7.1 Performance Monitoring 7-1
7.2 Key Performance Indicators 7-1
7.3 Reporting ‘Hardware’ components of System 7-2
7.3.1 Safety / Hazard Reporting 7-3
7.3.2 Confidential Reporting Programme 7-3
7.3.3 Occurrence/Incident/Accident Report - for all 7-4
Mandatory Reports
7.3.4 Multi-Purpose Report Form 7-4
7.3.5 Mandatory Occurrence / Defect Report 7-4
7.3.6 Verbally 7-5
7.3.7 Load Sheet 7-5
7.4 Monitoring and Tracking (Feedback) 7-5
7.5 Follow-Up and Closure of Reports 7-5
7.6 Auditing 7-5
7.6.1 Internal Audit Safety Plan 7-5
7.6.2 Internal Auditor: Qualification, Responsibility and 7-6
Experience
7.6.3 Conducting the Audit 7-6
7.6.4 Remedial Action and Follow-Up 7-7
7.6.5 Reporting / Pooling of Reports 7-7
7.6.7 Audits by third Party / Regulatory Authority 7-7
7.7 Management Review 7-8
7.7.1 Aerogulf Safety Committee 7-8
7.7.2 DP/ Dugas Safety Committee 7-8
7.7.3 Safety Review Board 7-8
7.8 Non-Punitive Reporting and Just-Culture Discipline 7-9
7.9 GAP Analysis (Annex 3) 7-10
SECTION 8.0 EMERGENCY RESPONSE PLANNING 8-1

8.1 Coordination 8-1
8.2 Designation of Emergency Authority 8-1
8.3 Transition from Normal to Emergency Operations 8-2
8.4 Return to Normal Operations 8-2
8.5 Emergency Response Plan (Annex 4) 8-3
8.6 Accident / Incident Investigation Procedures 8-3
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8.7 Accident Investigation and Reporting 8-4

8.7.1 Aircraft Recovery post Accident 8-5
8.7.2 Bio-Hazards 8-5
8.7.3 Fuselage and Personal Belongings 8-6
8.7.4 Material Hazards 8-6
8.8 Personal Accident 8-6
8.9 Vehicular Accident; Company Cars 8-7
8.10 Vehicular Accident; Non-Company Cars 8-7
8.11 Sickness and First Aid Reporting 8-7
8.12 Near Miss or Potentially Hazardous Situation 8-8
SECTION 9 MANAGEMENT OF CHANGE (MoC) 9-1

9.1 Procedures 9.1
9.2 Introduction 9.1
9.3 Role Description 9-2
9.4 Step 1: Screen 9-2
9.4.1 Overview 9-2
9.4.2 Temporary Changes 9-2
9.4.3 Initiator Actions 9-3
9.4.4 Operations Leadership Actions 9-3
9.4.5 Technical Representative Actions 9-4
9.5 Step 2: Review 9-4
9.5.1 Overview 9-4
9.5.2 Reviewer Actions 9-4
9.5.3 Technical Representative Actions 9-5
9.6 Step 3: Approve 9-5
9.6.1 Overview 9-5
9.6.2 Approver Actions 9-5
9.7 Step 4: Implement 9-6
9.7.1 Overview 9-6
9.7.2 Pre-Start up Safety Review 9-6
9.7.3 Starting up a Change prior to completion of 9-6
Implementation
9.7.4 Implementation on Resource Actions 9-6
9.7.5 Owner Actions 9-7
9.7.6 Approver Actions 9-7
9.8 Step 5: Close 9-7
9.8.1 Overview 9-7
9.8.2 Owner Actions 9-7
SECTION 10 SAFETY PROMOTION 10-1

10.1 Safety Training 10-1
10.1.1 Safety Personnel training 10-1
10.1.2 Employee Training 10-1
10.2 Competence and Awareness 10-2
10.3 Safety Awareness 10-2
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APPENDIX Index Reference

Section
Appx 1 Safety Plan 2.5
Appx 2 GAP Analysis 7.9
Appx 3 Emergency Response Plan 8.5
Appx 4 Management of Change 9.1
Appx 5 Job Safety Analysis 6.3.3
Appx 6 Risk Assessment 6.3.3
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0.2 LIST OF REVISIONS
Rev. Date Sign Nature of revision
0 27-05-09 JSL ISSUE
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0.3 LIST OF EFFECTIVE PAGES
Section 0- 3-8 Rev 0 7-7 Rev 0

0-1 Rev 0 3-9 Rev 0 7-8 Rev 0
0-2 Rev 0 7-9 Rev 0
0-3 Rev 0 Section 4- 7-10 Rev 0
0-4 Rev 0 4-1 Rev 0
0-5 Rev 0 4-2 Rev 0 Section 8-
0-6 Rev 0 4-3 Rev 0 8-1 Rev 0
0-7 Rev 0 8-2 Rev 0
0-9 Rev 0 5-1 Rev 0 8-4 Rev 0
0-10 Rev 0 5-2 Rev 0 8-5 Rev 0
0-11 Rev 0 5-3 Rev 0 8-6 Rev 0
0-12 Rev 0 5-4 Rev 0 8-7 Rev 0
0-13 Rev 0 5-5 Rev 0 8-8 Rev 0
0-14 Rev 0 5-6 Rev 0
0-15 Rev 0 Section 9-
6-1 Rev 0 9-2 Rev 0
Section 1- 6-2 Rev 0 9-3 Rev 0
1-1 Rev 0 6-3 Rev 0 9-4 Rev 0
1-2 Rev 0 6-4 Rev 0 9-5 Rev 0
1-3 Rev 0 6-5 Rev 0 9-6 Rev 0
1-4 Rev 0 6-6 Rev 0 9-7 Rev 0
6-7 Rev 0 9-8 Rev 0
Section 2- 6-8 Rev 0
2-1 Rev 0 6-9 Rev 0 Section 10-
2-2 Rev 0 6-10 Rev 0 10-1 Rev 0
2-3 Rev 0 6-11 Rev 0 10-2 Rev 0
2-4 Rev 0 6-12 Rev 0
6-13 Rev 0 Annex 1 Rev 0
Section 3- Annex 2 Rev 0
3-1 Rev 0 Section 7- Annex 3 Rev 0
3-2 Rev 0 7-1 Rev 0 Annex 4 Rev 0
3-5 Rev 0 7-4 Rev 0
3-6 Rev 0 7-5 Rev 0
3-7 Rev 0 7-6 Rev 0
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0.4 DISTRIBUTION LIST
Copy No Holder
No: 6004-a Master Copy Safety / Quality Assurance Manager
No: 6004-b Accountable Manager
No: 6004-c Director of Operations / Flight Safety Officer
No: 6004-d Engineering Manager
No: 6004-e Chief Pilot / Security Manager
No: 6004-f Director of Training (Operations)
No: 6004-g Administration Manager
No: 6004-h Flight Operations
No. 6004-i Engineering Line Office
No. 6004-j Assistant Accountable manager
No. 6004-k GCAA
No. 6004-l Ground Operations Manager
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0.5 Index and Revision Status
This Safety Management System Manual is only valid if the pages are at the same
revision level as shown in Section 0, List of Revisions.
Revisions to this manual will be carried out by the Safety / Quality Assurance
Manager as required and highlighted by a black vertical line to the left of the revised
area. The revision numbers will follow consecutively unless the page has been
reissued where it will then be ‘0’. The list of revisions will be updated with the latest
revision and signed revision status of the individual pages within the Manual.
The revision along with source material as required, a transmittal page detailing the
nature of the revision and a GCAA Control page will be sent with an accompanying
letter for their approval.
Upon approval by the GCAA a transmittal note will be issued with the revised pages
and the transmittal page detailing the nature of the revision, this will be sent to all
manual holders as listed on the distribution list. On satisfactorily incorporating the
revision in to the manual they hold they will be required to sign and return the
transmittal note to Aerogulf Tech records.
0.6 System Interaction - Associated Manuals
The Safety Management System Manual should be read in conjunction with the
following regulatory and company manuals:
• UAE GCAA CAR’s
• The Aerogulf Operations Manual.
• The Aerogulf Maintenance Management Exposition / Maintenance
Organisation Exposition
• The Aerogulf Quality Manual
• The Aerogulf Health, Safety and Environment Manual
0.7 Manual Source Material
The following material has been used as a reference source in compiling Aerogulf
Services Integrated Safety Management System manual:
• GCAA CAR Part X
• Shell SMS
• International Helicopter Safety Team (IHST)
0.8 Operational Environment
Refer to Aerogulf Services MME / MOE section 0.2(1) and Operations Manual
Section A1(1.1.1.2).
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0.9 Abbreviations and Definitions
AAIB Air Accidents Investigation Branch (UK)

Accident (aircraft) An occurrence during the operation of an aircraft which
entails:
• A fatality or serious injury
• Substantial damage to an aircraft involving structural
failure or requiring major repair.
• The aircraft is missing or is completely inaccessible.
Activity Work to be carried out as part of a process characterised by
a set of specific inputs and tasks that produce a set of
outputs to meet customer requirements.
Accountabilities Statements of what the individual is required to deliver, either
directly or through supervision and management of others.
As Low As Reasonably To reduce a risk to a level, which is as low as reasonably
Practicable practicable involves balancing reduction in risk against the
(ALARP) time, trouble, difficulty and cost of achieving it. This level
represents the point, objectively assessed, at which the time,
trouble, difficulty and cost of further reduction measures
become unreasonably disproportionate to the additional risk
reduction obtained.
Assessment (or The process of analysing and evaluating hazards. It involves
evaluation) both causal and consequence analysis and requires
determination of likelihood and risk.
Asset integrity The technical integrity of aviation organisation assets to
include aircraft and any associated equipment as well as
hangars, workshops and storage facilities.
ATA Air Transport Association of America, The
Barrier A measure, which reduces the probability of realising a
hazards potential for harm and of reducing its consequence.
Barriers may be physical, (materials, protective devices
shields, segregation, etc) or non-physical (procedures,
inspection, training, drills).
“Bowtie” diagram A pictorial representation of how a hazard can be
hypothetically released and further developed into a number
of consequences. The left hand side of the diagram
involves those threats associated with the hazard, the
controls associated with each threat and any factors that
escalate likelihood. The right hand side of the diagram
shows the recovery preparedness measures and any
escalation factors to provide recovery and mitigate the
consequences.
Consequence analysis is shown at the far rights side and
involves escalation factors and recovery preparedness
measures. The centre of the bow tie is commonly referred to
as the “hazardous event”.
Compliance monitoring The act of carrying out an overview exercise of any work
process within an organisation. The objective is to identify
causal factors that encourage or require procedures and
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systems of work to be ignored or otherwise be unofficially

adapted.
Control (of hazards) Limiting the extent and/or duration of a hazardous event to
prevent escalation.
Continual Improvement A process of enhancing the safety management system to
achieve improvements in overall safety performance in line
with the organisations’ safety policy.
Critical Activities Those activities necessary to maintain barriers, controls, and
recovery measure necessary to manage risks to ALARP.
Defences All controls, barriers and recovery preparedness measures,
in place to manage a hazard
EASA European Aviation Safety Agency. An agency of the
European Union which has been given specific regulatory
and executive tasks in the field of aviation safety
Environment The surroundings and conditions in which a company
operates or which it may affect, including living systems
(human and other) therein.
Surroundings in which an organisation operates, including
air, water, land, natural resources, flora, fauna, humans, and
their interrelation.
Environmental Effect A direct or indirect impingement of the activities, products
and services of the company upon the environment, whether
adverse or beneficial.
Environmental Incident An incident connected with aircraft operations to include:
• Serious aircraft fires or accidents involving fuel spillage
and ignition
• Spillage during refuelling or de-fuelling of aircraft or
during deliveries of fuel or other bulk liquids to storage
tanks
• Gradual leakage from, or catastrophic failure of, fuel
or other bulk liquid storage tanks or pipe work
• Spillage of hazardous substances such as cleaning
fluids, paint, oil or solvents used for maintenance
• Escape of ozone depleting substances into the
environment
Escalation An increase in the consequences of a hazardous event.
Escalation Control Measures put in place to block or mitigate the effects of
escalation factors. Types include guards or shields (coatings,
firewalls,), separation (time and space), and non- physical or
administrative (procedures, warnings, training, drills).
Escalation Factor Conditions that lead to increased risk due to loss of controls or
loss of recovery capabilities (mitigation or life saving).
Escalation factors include: abnormal operating conditions, e.g.
maintenance mode, operating outside design envelope;
environmental variations, e.g. extreme weather; failure of
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barriers, e.g. maintenance failure, due to explosion or fire,

introduction of ignition source; human error, e.g. lapses, rule
violations; no barrier provided, e.g. not possible or too
expensive. Escalation Factors may concurrently affect the
control and/or recovery of more than one hazard.
Evaluation see “assessment”
Gap Analysis A process to compare required resources, such as facilities
and systems, and defences against hazards, with those
resources and defences that exist. The purpose being to
identify where there are gaps to be filled.
HAI Helicopter Association International
Hazard The potential to cause harm, including ill health and injury,
damage to property, products or the environment; production
losses or increased liabilities.
Hazard Analysis The systematic process of developing an understanding of
hazards. The process consists of hazard identification,
assessment and risk determination.
Hazardous Event The “release” of a hazard. The undesired event at the centre
point in a Hazard “Bowtie”.
An incident which occurs when a hazard is realised (e.g.
release of an un-airworthy aircraft, fire, loss of separation)
Hazards and Effects The structured hazard analysis methodology involving hazard
Management Process Identification, Assessment, Control and Recovery and
(HEMP) comparison with screening and performance criteria. To
manage a hazard completely requires that all four steps must
be in place and recorded.
Hazards and Effects A hazard management communication document that
Register demonstrates that hazards have been identified, assessed, are
being properly controlled and that recovery preparedness
measures are in place in the event control is ever lost.
IATA International Air Transport Association
IFACTCA International Federation of Air Traffic Controllers’ Associations
IFALPA International Federation of Airline Pilots’ Association
ISMS Integrated Safety Management System
Incident (other than An occurrence other than an accident, associated with the
aircraft accident) operation of an aircraft which affects, or could affect the safety
of operation. A serious incident is an accident involving
circumstances indicating that an accident nearly occurred.
Mitigation Measures taken to reduce the consequences of a potential
hazardous event.
Mitigation measures include:
• “active” systems intended to detect and abate
incidents (fire and smoke detection warning
systems,)
• “passive” systems intended to guarantee the
primary functions (fire walls, protective coatings, )
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and
• “operational” systems intended for emergency
management (contingency plans, training, drills).
• the limitation of undesirable effects of a particular event
Monitoring Activities all activities related to the prevention or mitigation of
hazardous events
MODR Mandatory Occurrence and Defect Report
GCAA form used to report an accident or incident as defined
within AWN 20
NTSB National Transportation Safety Board (USA)
OGP International Association of Oil and Gas Producers
OSHA Occupational safety and Health Administration *USA)
Performance Criteria Performance criteria describe the measurable standards set by
company management to which an activity or system element
is to perform. (Some companies may refer to performance
criteria as goals or targets.)
Key Performance Comparative, quantitative measures of actual events, against
Indicator (KPI) previously specified targets, which provide a qualitative
indication of future projected performance based on current
achievement.
Prevention Completely eliminating a threat, escalation factor or a hazard.
Procedure A series of steps to be carried out in a logical order for a
defined operation or in a given situation
Recovery All technical, operational and organisational measures that
Preparedness limit the chain of consequences arising from the first
Measures hazardous event. These can (1) reduce the likelihood that the
hazardous event will develop into further consequences and
(also “recovery (2) provide life saving capabilities should the 'hazardous event'
measures”) develop further.
Responsibilities Those duties which describe the purpose of what an individual

is required to do.
Risk The likelihood of injury to personnel, damage to equipment or
structures, loss of material, or reduction of ability to perform a
prescribed function, measured in terms of probability and
severity.
Risk Assessment The matrix portraying risk as the product of probability
Matrix (RAM) and consequence, used as the basis for qualitative risk
determination. Considerations for the assessment of
probability are shown on the horizontal axis.
Considerations for the assessment of consequence are
shown on the vertical axis. Four consequence categories
are included: impact on people, assets, environment and
reputation. Plotting the intersection of the two
considerations on the matrix provides an estimate of the
risk.
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Safety Is the state in which risk is reduced to, and maintained at

or below, an acceptable level through a continuing
process of hazard identification and risk management.
Safety Assessment A particular application of the risk management process
to assess a system that is new or about to undergo a
major change.
Safety Case A demonstration of how the Company Safety objectives
are being met at a specific operational location in a
methodical and auditable reference document.
Safety Critical Activities that have been identified by the Hazards and
Activities Effects Management Process as vital to ensure asset
integrity, prevent incidents, and/or mitigate adverse HSE
effects. These activities provide the barriers or recovery
preparedness measures in the bowtie model.
Safety Management A systematic approach to managing safety, including the
System necessary organisational structures, accountabilities,
policies and procedures.
Safety Performance Expansions of safety policies and related to safety
Indicator culture, these lead to a commitment to action as detailed
in the SMS process. A key safety measure used to
express the level of safety, performance achieved in a
system.
Safety Performance The expression of an acceptable level of safety for a
Target specific element of the operation, such as procedures,
technology, systems or programmes, and against which
achieved performance can be measured, using Safety
KPI’s.
Safety Programme An integrated set of regulations and activities aimed at
improving safety.
Safety Survey A systematic mechanism to examine particular
organizational elements or the process used to perform
specific operation either generally or from a particular
safety perspective. They are particularly useful in
assessing attitudes of selected populations. Safety
surveys seek feedback from front-line personnel about
areas of dissatisfaction and unsatisfactory conditions that
may have accident potential.
Serious Incident ICAO Annex 13 defines a serious incident as an incident
involving circumstances indicating that an accident nearly
occurred.
Service Provider Any organisation certified to provide aviation related
services. The term encompasses aircraft operators,
maintenance organisations, air traffic service providers and
aerodrome operators, as applicable.
Severity One of three considerations in the assessment of risk
(probability and exposure being the other two). The rate of
exposure, or time period exposed to a hazard, can be
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regarded as another dimension of probability.

Shortfall An area for improvement.
SOP Standard Operating Procedures
Statement of Fitness An affirmation by the accountable manager that Safety
conditions are satisfactory to continue operation.
Task A set pattern of operations, which alone, or together with
other tasks, may be used to achieve a goal.
Threat A possible cause that will potentially release a hazard and
produce an incident. Threat classes include damage
caused by: thermal (high temperature), chemical
(corrosion), biological (bacteria), radiation (ultraviolet),
kinetic (fatigue), electrical (high voltage), climatic condition
(poor visibility), uncertainty (unknowns) or human factors
(competence).
Tolerability Criteria Expresses the level of risk deemed tolerable for a given period
or phase of activities.
May be expressed qualitatively or represented quantitatively
on the Risk Matrix by shaded areas.
Worst Case The worst possible consequences in terms of harm resulting
Consequence from a hazardous event.
For this to occur, all critical defences, barriers or controls in
place must have failed.
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INTERGRATED SAFETY MANAGEMENT SYSTEM MANUAL
1.0 SCOPE OF AEROGULF’S SAFETY MANAGEMENT SYSTEM
1.1 System – Scope and Function

Ref: CAR OPS-3 and CAR 145
Aerogulf Services being the holder of an AOC and AMO approval as issued by the UAE
GCAA has implemented as a ‘Service Provider’ an ‘Integrated Safety Management
System’ (ISMS) for both Operations and Maintenance to comply with the requirements of
GCAA CAR Part IV Operations Regulations, CAR Part V Airworthiness Regulations and
CAR Part X (section 7(f)) Safety Management System.
This manual is intended to serve as a guide for Safety related processes and activities
within Aerogulf Services and is specifically oriented and focused on the impact of safety
considerations as they apply to air operations and maintenance. It also acknowledges the
importance of the development of safety practices in all areas of the company. The
manual includes reference and guidance to areas that may not have been historically
included in the safety department, such as Emergency Response and Auditing. The
manual strongly emphasises the importance of independence and authority of the Safety
Management function in the company.
The Safety and Quality department ensures that standards, as specified in this manual
(and the Quality Manual) and the safety policy are maintained. All employees shall
maintain these standards as part of their responsibilities as defined within the MME/MOE
and Operations Manual.
There will always be hazards, both real and potential, associated with the operation of
any aircraft. To address and control them the establishment of a safety programme
ensures that by recording and monitoring any adverse trends preventative measures can
be implemented.
The Safety / Quality Assurance Manager and the Flight Safety Officer, are independent
and answerable directly to the Accountable Manager. They are also the co-ordinators of
the Company’s safety programme and have the responsibility to promote safety
awareness and to ensure that the prevention of accidents is the priority throughout the
company and to:
• Identify safety hazards and assesses and mitigate risks

• Ensure that remedial action necessary to maintain an acceptable level of safety is
implemented.
• Provide for continuous monitoring and regular assessment of the safety level
achieved.
• Aim to make continuous improvement to the overall level of safety.
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1.2 Structure of Aerogulf SMS
The structure of the Safety Management system is graphically displayed below. The
linkages between the Safety Case and the SMS are shown. This manual details the
means of managing safety in the organisation and how that is to be achieved.
Safety Management System Structure

Safety Management System Safety Case
Introduction and Structure Mgt. Summary & Introduction
Management, Leadership,
Commitment & Planning Description of the Operation
covered by this Case
Policy and Strategic Objectives
Description of how the SMS
pertains to this Case
Resources, Training and
Competence Assurance
Hazard Analysis & Register, and
Listing of Safety Critical activities
Hazard Management Programme
Standards, Procedures and Remedial Action Plan

Documents relative to this Case
Audit and Independent Conclusions & Statement of

Verification Programme Fitness of operations in this Case
Workplace Safety
1.3 Interface Documents and Safety Cases
A part of the Safety Management System structure is the Safety Cases. The Safety
Cases are management’s assurance that for a specific part of the business, the major
hazards/risks have been identified and are under control or actions are in place to bring
them under control to levels that are ‘As Low As Reasonably Practicable’ (ALARP).
1.4 Standards, Procedures and Documents
1.4.1 Standards and Procedures

Aerogulf Services standards and procedures are contained within the following
documents these documents are drawn from a number of sources that are national and
international regulations.
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1.4.2 National And International Regulations (Including Manufacturers Standards).
Operations Operations Manual UAE Air Law, GCAA CAR Part IV
Procedures
Maintenance MME / MOE UAE Air Law, GCAA CAR Part IV sub-
Requirements part M, CAR Part V
Maintenance MME / MOE UAE Air Law, GCAA CAR Part IV sub-
Organisations part M, CAR Part V
Aircrew licensing Training Manual CAR Part II section 1
Engineer Licensing MME / MOE CAR Part II section 7
Training Training Needs GCAA CAR-147
establishments Analysis
Human Factors Ops and MME / MOE GCAA CAR-145
Manual
Accident investigation HSE Manual ICAO Annex 13
Carriage of Dangerous Operations Manual ICAO Dangerous Goods publication
Goods
Flight time and duty Operations Manual GCAA CAR –OPS 3 sub part Q
limitation
Quality Assurance Quality Manual ISO9001/2 + JAR Ops and JAR 145
Airside Safety DCAA Airside Ramp Safety Rules
1.4.3 Aerogulf Standards and Guidance Material

Safety Management SMS Manual Aerogulf Services SMS Policy
Systems
Personnel Experience Operations Manual Aerogulf Experience and qualification
Levels and MME/MOE requirements
Refuelling standards RPM Air BP, OGP and CAP 437
Insurance As promulgated by Customer
requirements Insurance requirements
Human Factors Operations Manual GCAA CAR Part 145
and MME/MOE
Accident investigation HSE Manual GCAA, NTSB and AAIB
Aircraft Minimum Aerogulf Minimum CAR Part IV
Equipment Equipment – flight
Manual
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1.4.4 Contractual Standards & Contractor Management
Aerogulf currently has no work contracted out within Operations or Maintenance, CAR
OPS-3, CAR-145 and GCAA Part M continuing Airworthiness would need to be complied
with.
In the event that work was contracted out, the establishment of contractual standards and
their subsequent management as part of managing safety would be required and applied.
Each contract would require a detailed specification of the services or equipment to be
supplied and embedded in this is the standards that are required, in particular where the
service has been assessed as safety critical. In such cases the contract will be reinforced
with the development of an interface document that identifies and mutually agrees,
between the two parties, who is responsible for what and what the potential hazard is.
Contract management is the responsibility of the contract holder or a specifically

appointed person who has defined accountabilities for the management of that contract.
Contract review requirements are covered in the Quality Assurance Manual.
1.5 Safety Data Collection and Processing System (SDCPS)

The Aerogulf Safety Management System has an established Safety Data Collection and
Processing system that includes reactive, proactive and predictive methods of safety data
collection that can be found within the following sections of the ISMS:
• Section 5.2 Documentation ‘Software’ Components of System and
• Section 7.3 Reporting ‘Hardware’ Components of System.
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INTEGRATED SAFETY MANAGEMENT SYSTEM MANUAL
SECTION 2.0 SAFETY POLICY AND STRATEGIC OBJECTIVES
2.1 SAFETY POLICY
The Accountable Manager and Management Team of Aerogulf Services holds the
view that neither economic nor operational priorities shall overrule safety
considerations. And through the implementation of a proactive Safety Management
System shall endeavour to continuously improve the safety culture and in turn to
protect employees, customers, assets, facility and the environment from harm by:
 Commitment of all employees to safe work practices.

 Promotion of a confidential, ‘Non-Punitive’ reporting of real or
potential hazards, incidents, or accidents.
 An internal disciplinary ‘Just culture policy’.
 Attainable goals as set by the Safety Review Board.
 The dissemination of safety related information to all employees and
customers.
 Open encouragement of ‘two way’ communication between
management and employees.
 The ‘Involvement of People’ to determine risks and mitigations.
 Adherence to customer, company, and regulatory requirements at all
times.
 Adoption of ‘best-practice’ through consultation, customer, and
regulatory audits.
 Training to improve skills, awareness, and competency as and where
required.
“All employees shall strive to work safely, such as to protect their co-workers,
customers, assets, facility and the environment from harm.”
Robert Denehy
_____________________________
Accountable Manager
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2.2 SAFETY VALUES
CORE SAFETY VALUES

Among our core values, we include:
• Safety, health and the environment
• Ethical behaviour
• Valuing people
FUNDAMENTAL BELIEFS
Our fundamental safety beliefs are:
• Safety is a core business and personal value
• Safety is a source of our competitive advantage
• We will strengthen our business by making safety excellence an integral part of all
flight and ground activities
• We believe that all accidents and incidents are preventable
• All levels of line management are accountable for our safety performance, starting
with the Accountable manager
CORE ELEMENTS OF OUR SAFETY APPROACH

The five core elements of our safety approach include:
Senior Management Commitment

• To actively implement the safety management system
• To the management of safety risks
• To encourage employees to report safety issues
• Senior management will hold all employees accountable for safety performance
Responsibility & Accountability of All Employees

• Safety performance will be an important part of our management/employee
evaluation system
• We will recognise and reward flight and ground safety performance
• Before any work is done, we will make everyone aware of the safety rules and
processes as well as their personal responsibility to observe them
Clearly Communicated Expectations of Zero Incidents

• We will have a formal written safety goal, and we will ensure everyone
understands and accepts that goal
• We will have a communications and motivation system in place to keep our people
focused on the safety goal
Auditing & Measuring for Improvement

• Management will ensure regular safety audits are conducted and that everyone will
participate in the process
• We will focus our audits on the behaviour of people as well as on the conditions of
the operating area
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• We will establish both leading and trailing performance indicators to help us
evaluate our level of safety
Responsibility of All Employees

• Each of us will be expected to accept responsibility and accountability for our own
behaviour
• Each of us will have an opportunity to participate in developing safety standards
and procedures
• We will openly communicate information about safety incidents and will share the
lessons with others
• Each of us will be concerned for the safety of others in our organisation
2.3 SAFETY MANAGEMENT SYSTEM - STRATEGIC OBJECTIVES

• Commitment of management to implement the safety management system.
• Commitment to the management of safety risks
• Commitment to encourage employees to report safety issues
• The establishment of clear standards for acceptable behaviour.
• The identification of responsibilities of management and employees with respect to
safety performance.
• The proactive identification, controls and mitigations of hazards.
• The continual improvement goal through active monitoring of safety performance
indicators, attainment of safety performance targets and exceedence of safety
requirements.
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2.4 Policy Statements
Aerogulf’s Safety Policy on page 2-1 is displayed throughout the facility. The policy
statement is developed in liaison with the management team by the ‘accountable
manager' who in turn signs the statement to demonstrate his personal commitment to the
policy. All employees are expected to know the safety policy and act accordingly in their
actions to ensure that they and their fellow workers comply. This process is mirrored in
all other policies (Quality and HSE Principles) issued.
2.5 Safety Plan (Appendix 1)

Aerogulf’s safety-training requirements, safety meetings, HSE assessments,
management safety review board meetings, audits (internal and customers) and links to
the safety / quality audit programme forms the basis of the Safety Plan. Specific
objectives may also have their own project plans and are also reflected in the Safety Plan.
The intent of the Safety Plan is to ensure that the company as a whole meets its safety
performance targets and maintains senior management’s involvement in safety as a
prime business imperative.
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SECTION 3.0 – SAFETY ACCOUNTABILITIES
3.1 Management, Leadership, Commitment and Planning

The management of Aerogulf Services are committed to the safety programme that
establishes and maintains our Safety Management System. We will support this
management process actively and use it with other processes e.g. Human Factors to
manage the business, giving leadership to the programme and demonstrating to staff and
others, through our everyday actions the corporate commitment to safety, and its priority
in the achievement of the business. The processes in place in the management system
will include active involvement for all staff and in particular all levels of management who
through planning and review will continue to drive efforts for continuing improvement in
safety and safety performance. For the purposes of this manual but in line with common
terminology in aviation the term “Safety Management” should be taken to mean Safety,
Health and Environmental management and is used in conjunction with the company
HSE manual. The key thrust however, is the safe operation of airworthy aircraft.
3.2 Accountabilities
The company organisational chart as found within the Quality Manual defines the
reporting line / accountabilities of all company personnel and shows their responsibilities
and duties within the company; in short the lines of accountabilities are from:
• The Managing Director who delegates to
• the Accountable Manager, who in turn delegates responsibility for managing the
SMS to
• the Safety / Quality Assurance Manager (S/QAM) with assistance from
• Flight Safety Officer and
• Each department manager / supervisor.
Aerogulf management fulfil their responsibility by establishing:

• A company safety policy and actively endorsing it,
• A Management Team (refer to Quality Manual)
• Responsibilities of management and employees (Operations and MME/MOE
Manual)
• By actively encouraging two way communications throughout all levels of the
company.
• ‘Leading by example’.
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3.2.1 Organisational Chart
Ref: Quality Manual
Accountable
manager
Asst Gen
Manager
Safety/Quality
Manager
Ground Director of Director of Engineering Aviation Admin/

Operations Operations Flight Trg Manager Security Accounts
Ground Chief Pilot / Type Rating Engineers

Staff Safety Officer Examiners
Pilots Stores Normal reporting

Formal reporting
Flight Operations Manager

(Director of Operations)
Chief Pilot Director of

Flight Training
Type Rating
Examiners
Pilots
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3.3 Individual Accountabilities
3.3.1 Accountable Manager

The Accountable Manager is accountable to the Company Chairman for:
• Ensuring that all Aerogulf Services operations are carried out with due regard to
Aerogulf Company policy and in accordance with current United Arab Emirates
Health, Safety and Environmental Legislation.
• The provision of adequate consultation between Aerogulf Services Management
and Customer representatives for the encouragement of effective co-operation in
the promotion of Health and Safety at Work and monitoring achievement.
• The continuation of effective consultation and co-ordinated action by the senior
managers on policy matters, which affect the Health and Safety related activities of
staff.
• The provision of suitable and adequate resources to enable the full compliance
with Health, Safety and Environmental Legislation.
• Overseeing a programme of Safety meetings with both internal and with customer
committees, monitoring performance, steering activities and ensuring timely
responses to action items set out by the committee.
• Full control of the human resources required for the operation authorised to be
conducted under the operations certificate.
• Full control of the financial resources required for the operations authorised to be
conducted under the operations certificate.
• Final authority over operations authorised to be conducted under the operations
certificate.
• Direct responsibility for the conduct of the organisation’s affairs
• Final responsibility for all safety issues.
3.3.2 Director of Operations / Engineering Manager

The Director of Operations and the Engineering Manager are accountable to the
Accountable Manager and shall ensure, as far as reasonably practicable, the
observance of all current Safety requirements. Particular attention should be paid
to:
• The provision and maintenance of equipment and systems which are Safe and
without risks to Health.
• Arrangements for ensuring Safety and absence of risks to Health in connection
with the use, handling, storage and transport of hazardous substances.
• The provision of such information, instruction, training and supervision as is
necessary to ensure the Health and Safety at Work of all employees.
• The maintenance of any place of work in a condition which is Safe and without risk
to Health. Means of access to and egress from places of work, which are Safe,
and without such risks should be provided and maintained.
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• The provision and maintenance of a working environment for all employees which
is Safe, without risks to Health and adequate as regards facilities and
arrangements for Welfare at work.
• Ensuring detailed arrangements are made for the Health and Safety aspects of
activities under their control which may affect staff, Contractors, members of the
public, visitors or passengers for whom they are responsible. Awareness should
also be shown of any activities of their own Departments, which may affect the
Safety at Work of the Staff of other Departments.
• The suitable provision of Medical Surveillance through local resources; such as is
required by the local labour laws.
• The provision of suitable and adequate arrangements for the notification of
accidents, incidents, dangerous occurrences and incidents and the collection,
assessment and distribution of relevant statistical data.
3.3.3 Safety Focal Points
Ref: Section 4
Whilst endorsing the concept of safety as a Management Responsibility, the Safety

Focal Points (Safety / Quality Assurance Manager and Flight Safety Officer refer to
Section 4 “Key Safety Personnel”):
• Safety / Quality Assurance Manager
• Flight Safety Officer
Have been appointed in order to ease administration and give a central reference
point responsible for the provision of advice regarding Safety.
3.3.4 The Personnel Manager
The Personnel Manager will ensure that, where appropriate for the protection of
the Health and Safety of employees, suitable Surveillance is carried out and
records are kept by the Personnel Office.
Surveillance is to be carried out in accordance with the requirements of:
a) The local labour laws
b) The UAE Federal Law
3.3.5 Chief Pilot and Supervisors

Are accountable to their department managers, for ensuring that all of the activities
within their section comply fully with Aerogulf’s Safety requirements, and are
carried out in such a manner that will ensure the Health and Safety of all staff,
passengers or members of the public.
In particular they should:
a) Ensure that the correct and serviceable equipment is provided for the
employee to carry out any allotted task safely. Adequate Safety Precautions
must also be taken or provided.
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b) Ensure that employees are adequately trained or experienced and are
competent and authorised to carry out a particular task using the correct
equipment.
c) Provide adequate supervision depending on the complexity of the task and
bearing in mind the experience and ability of the employee. Particular care
is to be given to the instruction and supervision of new or inexperienced
employees.
d) Give due consideration to the physical capabilities of employees with
relation to a task, particularly when manual handling or lifting requirements
are involved. This also involves obtaining information about the capabilities
of the individual employee.
e) Ensure that the correct Personal Protective Equipment for the task allotted
is provided and worn by the individual, and that instruction has been given
in the correct use of that equipment.
f) Provide employees with all information relevant to carrying out a task safely
in order to comply with the local labour law. The information is to include all
necessary Material Safety Data Sheets.
g) Ensure that Hearing Protection is worn and maintained in a serviceable and
clean condition at all times.
h) Ensure that, where lifting is required, manual handling is kept to a minimum,
the correct lifting techniques are used, and suitable mechanical lifting
devices are employed whenever possible.
i) Ensuring that prior to the commencement of safety control tasks involving
several members of staff, contractors or third parties, meetings of all those
involved are held. These have various benefits but the prime target is to
highlight the known risks for the proposed task.
j) Ensure that the level of work given to individuals is appropriate to their
capacity and training and that where possible signs of stress are noticed
and allowed for.
3.3.6 The Individual Employee

All individuals are accountable to management and the Safety Focal Points any
safety matters which in their opinion constitute a hazard.
Individuals may raise their queries verbally in the first instance but if satisfactory
action is not taken this should be followed by Safety / Hazard Report form or Multi-
purpose report form. The supervisor, Safety / Quality Assurance Manager or
Flight Safety Officer will then suggest a timetable for dealing/reviewing the issue
and liaise back with the originator / author. Normally, the response will address
the issue but in extreme cases the individual is free to raise the matter further with
their supervisor and if required to the Aerogulf Accountable Manager however,
individuals must give their supervisors prior notice of their intention to do this.
There will be a “Non-punitive culture" and management will not in any way alter
their working assessment of the individual raising the safety issue.
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All employees are also expected to:
a) Conduct their own work in a manner that is both safe to themselves and
others.
b) Inform others if in their opinion the other person is acting in an unsafe
manner.
c) Act personally to rectify minor safety hazards that can be remedied without
requiring prior authorisation from a supervisor e.g. removing tripping
hazards. For safety remedies that may have a knock on effect to other
employee’s individuals should inform their supervisor and Safety Focal
Points as indicated above.
d) Raise a Safety report, in confidence if necessary to the Safety Focal point.
This can be either written, verbal or through the Confidential Reporting link
found within the Operations pilots or line office engineers computer.
3.4 Visibility
To achieve its role Aerogulf Services operates and maintains its fleet of Helicopters under
one management team. The ‘team’ is a representative cross section of all departments
within Aerogulf who show by active involvement and through leading by example their
commitment to the Aerogulf safety policy and objectives of managing risk and reducing
harm to people, assets, environments and the company reputation. As a result of this
open commitment by management, the open communications upwards and downwards
and the ‘involvement of people’; employees are proactively committed to the company’s
vision.
The examples of management’s commitment to safety management include:
3.4.1 Planning
• the inclusion of safety on the agenda of meetings;

• the active involvement of managers in safety activities and reviews;
• managers actively aiding in the development of a “just and learning” culture;
• allocation of the necessary resources, such as time and money, to safety matters;
• review of safety performance data regularly at management meetings;
• Nomination of competent and trained staff for safety positions.
3.4.2 Communication
• communication of the importance of safety considerations in business decisions;

• promotion of safety topics in company publications;
• setting of personal examples in day-to-day work;
• recognition of performance when safety objectives are achieved;
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• invitation and encouragement of employees' suggestions for measures to
improve safety performance through hazard / safety reports;
• ensuring that the importance of safety, in all aspects of flight safety, ground
safety and airworthiness, is clearly understood by the staff;
• Attendance at company and customer (e.g. DP & Dugas) safety meetings.
• By actively encouraging two way communications throughout all levels of the
company.
3.4.3 Co-ordination
• participation in internal and external safety initiatives, especially with the customer
Dubai Petroleum and Dugas;
• becoming informed by reading and acting on safety reports;
• development of an open approach to external liaison with the GCAA;
• addressing of safety review and analysis at Management Safety Review Board
(SRB) meetings;
• spending time offshore and on the hangar floor;
• Development of safety information exchange initiatives with other relevant
operators through active involvement with Gulf Flight Safety Committee (GFSC)
and the International Helicopter Safety Team (IHST).
3.5 Proactive Target Setting

The Safety Management System Manual, Quality Manual, Operations Manual and the
MME / MOE contain all the key elements of Functional Objectives, Deliverables,
Performance Indicators, Targets and Milestones, Staffing Levels, Training Requirements,
etc. Regular Management meetings in conjunction with the Safety Review Board and
Management Evaluation Review meetings, assesses overall performance and
achievement of safety targets against the targets as set at the beginning of the year.
3.6 Informed Involvement

To demonstrate leadership and commitment, Aerogulf senior management show
involvement in Safety issues by demonstrating active involvement in the safety oversight
process as demonstrated by:
• reviewing the progress both in the development and content of Safety Cases, e.g.
by active involvement and leadership initiatives in safety activities and reviews, at
company, away from base and offshore operations;
• making available the appropriate resources and expertise to meet targets
(e.g. finance, technology, skills and training);
• undertaking relevant initial and recurrent training to develop knowledge of safety
management and aviation safety issues;
• being fully aware of the high priority areas for sa fe ty improvement
particularly in relation to GCAA, customer and company requirements and the
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status of the follow up actions;
• being personally involved in the improvement efforts arising from the
Management meetings and the Safety Review Board.
In addition to senior management involvement, managers and supervisors shall

demonstrate commitment by:
• informing senior management if safety targets are not achievable;
• undertaking relevant training to develop knowledge of safety management and
aviation safety issues;
• Being personally involved in the review of internal and customer audit results.
3.7 Change of Culture
3.7.1 The Role of Senior Management
Both within aviation and throughout the world it is becoming clear that a solidly
implemented safety management system is an essential basis for good safety
performance, but that outstanding safety performance can only be achieved if the
"culture" is right.
Aerogulf employees look to their leadership for their direction, priorities and coaching.
Perceptions of the commitment of leadership towards safety rather than just their
intentions have a strong influence on their behaviours and performance. It is not
enough to write the safety policy and objectives on paper, senior management’s actions
must support their policies and objectives.
World-class safety performance w i t h i n A e r o g u l f requires more than e v e r y o n e
j u s t s i m p l y working safely because they have been ordered to; it needs everyone
in the organisation, from the top down and bottom up working safely because they want
to. In order to create and sustain the right “culture”, senior management will lead by
example, provide encouragement and continuously review the behaviour of staff and
seek ways of improving the safety culture. This is also achieved by ‘involvement of
people’; through inviting and encouraging employees to come up with new ideas for work
methods, responding to incidents and then rewarding staff for their involvement in the
process.
The consequences of inappropriate behaviour or incorrect actions must also be made
clear, but within the context of operating a “just and learning culture”.
3.7.2 The Safety Management System and Safety Culture

Aerogulf employees are all involved in the development and maintenance of t h i s
culture, by ensuring there is:
• A comprehensive corporate approach to safety management within all Aerogulf
departments;
• involvement at all levels of Aerogulf for delivering safety and achieving
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environmentally sound practices;
• In place throughout Aerogulf, robust procedures to provide assurance that ‘safe
and environmentally sound practices’ are being achieved and improved upon.
Demonstration of strong leadership in safety leads to a culture that supports the
Aerogulf’s Safety Management System. This is achieved through communicating the
safety policy, strategies and action plans and through the recognition of individual
contributions of all employees. Management will also create the necessary safe
working conditions, systems of work, and procedures to encourage a pro-active safety
culture. Absence of these arrangements may otherwise result in employee
dissatisfaction, a poor safety culture and a negative impact on performance.
3.7.3 Changing the Culture

The company shall encourage the development of a just and learning culture that
supports the Safety Management System and which reflects:
• a genuine belief in the company’s commitment to improve safety performance;
• motivation to improve personal safety performance;
• recognition of individual responsibility and accountability for safety performance;
• participation and involvement at all levels in safety and HSE management;
• Company-wide commitment to operating in accordance with Aerogulf’s Safety
Management System.
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4.0 KEY SAFETY PERSONNEL
4.1 Safety / Quality Assurance Manager (S/QAM)

The Safety / Quality Assurance Manager is appointed and directly accountable to the
Accountable Manager. He is independent of the operations and maintenance structure and
authorised to conduct audits in all parts of the organisation.
The Safety / Quality Assurance Manager has the delegated authority of the Accountable
Manager to represent the company regarding the safety management system, and is
responsible for ensuring that it meets the conditions required for compliance with GCAA
CAR Part X regulatory requirements.
The Safety / Quality Assurance Manager has the delegated authority of the Accountable
Manager to:
a) Ensure that the processes needed for the Safety Management System are
established, implemented and maintained.
b) Report to the Accountable Manager on the performance of the Safety Management
System and on any need for improvement.
c) Ensure safety promotion throughout Aerogulf.
d) Determine whether proposed policies and practices meet the requirements, are
suitable for meeting the business needs and ensure that non-compliances are being
corrected.
e) Determine and communicate the effectiveness of the safety system
f) Report on the safety performance of the organisation quarterly to the Safety Review
Board and the GCAA.
g) Identify and manage programmes for improvement in the safety system
h) Promote the awareness of customer requirements throughout the organisation and
communicate the importance in meeting these requirements (together with
regulatory and statutory requirements).
i) Interface with the General Civil Aviation Authority.
4.1.1 Qualifications
The minimum qualifications required are:
• Attendance of a Safety Management Course

• Auditor training
• Accident investigation training
• Have an aviation background
• Experience of the operation under which the safety system is to be managed and
implemented.
4.1.2 Terms of Reference

To enable the Safety / Quality Assurance Manager and Flight Safety Officer to implement
and control the company safety programme they will have access to all departments at all
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levels. The primary responsibility is to provide information and advice on safety matters
to the Accountable Manager.
The Safety / Quality Assurance Manager is responsible to the Accountable Manager for:
• Maintaining the air safety occurrence reporting database

• Monitoring corrective actions and safety trends
• Co-ordinating the regulatory authority’s Mandatory Occurrence and Defect
Reporting scheme
• Liaising with the heads of all departments company-wide on safety matters
• Acting as Chairman of the Company Safety Committee, arranging its meetings
and keeping records of such meetings
• Disseminating safety-related information company-wide
• Maintaining an open liaison with manufacturers’ customer safety departments,
government regulatory bodies and other safety organisations world-wide
• Assisting with the investigation of accidents and conducting and co-ordinating
investigations into incidents
• Carrying out safety audits and inspections as per safety plan
• Maintaining familiarity with all aspects of the Company’s activities and its
personnel
• Planning and controlling the Safety budget
• Managing or have oversight of the Data acquisition Programme
To assist the Safety / Quality Assurance Manager to maintain oversight of the Operational
aspects of the company will be the ‘Flight Safety Officer’.
4.2 Flight Safety Officer
Is the Director of Operations; a Pilot with currency on company type aircraft. He will be
responsible directly to the Safety / Quality Assurance Manager, but will also have direct
communication with the Accountable Manager, and shall also comply with the requirements
as defined above for the Safety / Quality Assurance Manager.
4.3 Safety Focal Points - additional duties
The functions of the Safety Focal Points (S/QAM and Flight Safety Officer) whose
responsibilities are defined within Section 4 will include:
a) The Co-ordination of Safety matters, and for monitoring Safety problems in
order to identify any trends.
b) Assisting the Accountable Manager in the investigation of any accidents,
incidents or near misses, with the aim of identifying and protecting against the
causes leading to the occurrence.
c) Organising the provision of First Aid resources, monitoring and arranging First
Aid training, and keeping records for the Company.
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d) Advising Contractors of the Safety requirements they must comply with whilst
working at Company facilities.
e) Advising on training with regard to the provision and correct use of fire-
fighting equipment. Advising and monitoring the compilation of Fire,
Emergency and Evacuation Procedures for all Company locations.
f) Implementation of Bomb Threat with the company Security Officer (GCAA
CAR Part VII) and Emergency Evacuation Procedures.
g) Liaising with the Emergency Services as required.
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5.0 DOCUMENTATION CONTROL
5.1 Management and Control of Documents

Ref: Procedure P 422 Documentation Management
The documentation management procedure P 422 within the Quality Procedure

Manual describes the method of:
a) Approving documents of either internal or external origins, for adequacy prior to
issue and allocation of a control number.
b) Submission of documents to the GCAA that require their approval.
c) Reviewing and updating documents
d) Ensuring that changes and the current revision status of documents are identified
e) Verifying revision status of documents with revisions more than 5 years old
f) Ensuring that relevant versions of applicable documents are available at points of
use
g) Ensuring that documents remain legible and readily identifiable
h) Ensuring that documents of external origin are identified and their distribution
managed
i) Preventing the unintended use of obsolete documents; which are either
destroyed or marked ‘Uncontrolled - Not Revised’ on their binder if they are
retained.
Changes in the documents will be reviewed and approved through Tech Records by
the Quality Manager who will have access to the relevant background information.
All documents are controlled through the central data base (Maintenance View) by
Technical records, responsibilities for revisions and approvals are:
5.1.1 Company Documents

Manual / Document Revised by Approved by
Engineering Procedures Manual Department supervisors QA
(EPM) Department
Quality Procedure Manual (QPM) Safety / QA Manager QA
Department
Health, Safety and Environment Safety / QA Manager QA
(HSE) Manual Department
Away from Base operations manual Safety / QA Manager QA
Department
Refueling Procedure Manual Safety / QA Manager QA
(RPM) Department
Offshore Refueling Equipment Safety / QA Manager QA
Maintenance Schedule Department
Vendor Manuals: Maintenance Vendors / OEM QA
manuals, O/H manuals, SRM, Department
CR&O manuals, IPC, etc.
Red Folders (Documents) Chief Pilot Director of
Operations
5.1.2 GCAA Approved Documents
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Manual / Document Revised by Approved by
Integrated Safety Management Safety / QA Manager GCAA
System (ISMS) Manual Operations
Abu Dhabi
Security Manual GCAA GCAA
Safety &
Security
Abu Dhabi
CAR’s, AIP, Info Bulletins, CAAP’s, GCAA GCAA
NOTAM’s, AWN, etc.
Aircraft Maintenance Schedules Safety / QA Manager GCAA
(AMS) Bell 206 & 212. Airworthiness,
Dubai
Maintenance Management Safety / QA Manager GCAA
Exposition and Maintenance Airworthiness,
Organisation Exposition (MME / Dubai
MOE)
Operations Manual Director of Operations GCAA
Operations,
Abu Dhabi
Operation Specifications (Op GCAA GCAA
Specs) Operations,
Abu Dhabi
Quality Procedure Manual P702 C Safety / QA Manager GCAA
of A renewal procedure Airworthiness,
Dubai
Flight Manuals OEM GCAA
Operations,
Abu Dhabi
5.2 Documentation ‘Software’ Components of System

Refer also to Chapter 7.3 Reporting
5.2.1 The ‘Maintenance View’ Database System.
Aerogulf’s Aviation Management Software data base programme has been

developed using the Lotus Approach Database and contains the following features:
a) Aircraft Set up Data

b) Aircraft Update Data
c) Component Data
d) Component Log Card Data
e) Publications Received
f) Aircraft AD/ASB/Mods
g) Controlled Tools and Equipment
h) Engineer Licence Data
i) All controlled Manuals; Revision Data and location
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From this database, various reports can be generated and printed depending on the
information required, such as:
a) All scheduled maintenance due on a selected aircraft in ascending order of hours

due.
b) All scheduled maintenance due within 100 flying hours on all aircraft.
c) Date report of calendar items due on selected or all aircraft.
d) Aircraft Status Report in ATA order.
e) Controlled Tools and Equipment List.
f) All Tools and their Calibration dates.
g) Manual Revision Reports, giving previous and current revision status, last revised
by whom, control number and location.
5.2.2 The ‘Server’ Computer Network System
This is the working ‘system’ for Aerogulf and contains files for all departments,
however access to some of these files are either ‘Read-Only’ or ‘Administration’
dependant on the computer location and user.
For all controlled manuals go to ‘QA Manuals’ and for all reports go to ‘QA System’
(See chapter 7), full administration access to both is limited to the Safety / Quality
Assurance Manager, QA department and Technical Records. All other users are
‘Read only’ in order to prevent tampering of controlled records and data. This data is
backed up every working day through the use of a tape; which in turn is stored within
a fire proof cupboard in Tech Records. Each tape is identified by the day of the
week, therefore it is overwritten once a week, this reduces the number of tapes
required but also permits the retention of records for at least a one week period, from
experience this has been found to be sufficient to redress any errors.
5.3 Documentation ‘Hardware’ Components of System

Refer also to Chapter 7.3 Reporting
Ref: Procedure P 421, SMS and Quality System Documents
P 422, Documentation Management
P 423, Control of Quality Records
The activities governed by the SMS System are identified and documented. These
documented procedures / manuals are controlled by the Safety / Quality Assurance
Manager to ensure that our products meet regulatory and both internal and external
customer requirements. The SMS System is defined and supported in the following
controlled documents / manuals:
a) ISMS Manual (Approved by GCAA)

b) Quality Manual (Approved in-house)
c) Quality Procedure Manual (Approved in-house)
d) Health, Safety and Environment Manual (Approved in-house)
e) Maintenance & Management Organisation Exposition (Approved by GCAA)
f) Operations Manual (Approved by GCAA)
g) Procedure Manuals (Approved in-house) required by GCAA CAR’s
h) Aircraft Maintenance Schedule’s (Approved by GCAA)
i) Quality records required by GCAA CAR’s
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Where the term "documented procedure" is used in this manual, the procedure is
established, documented and maintained within and by the relevant department (e.g.
the overhaul procedures, safety equipment procedures, Operations manual, etc.).
The Quality department oversees all these documents to ensure that they all meet
their objectives.
The extent of the Integrated Safety Management System is based on:
a) Aerogulf’s size and type of activities

b) Process complexity including their interactions, and
c) Personnel competency
5.3.1 ISMS Manual
The company has established and maintains this SMS manual including:
a) The scope of the Safety Management System.

b) Reference to the documented procedures established for the quality
management system as per the Quality Manual and Quality Procedure Manual.
5.3.2 Quality Manual
The Quality Manual documents our quality system to demonstrate Aerogulf’s ability
to consistently provide parts and services that meet both internal and external
customer and regulatory quality and safety requirements. Reference is made
throughout the ISMS to the Quality Manual in documentation Control and auditing.
The Quality Manual establishes compliance with GCAA CAR requirements and
applies to both maintenance and operation activities.
The Quality Manual should be read in conjunction with the Operations Manual,
Maintenance Organisation Exposition, HSE Manual and Integrated Safety
Management System Manual which covers specific safety issues within operations
and maintenance.
5.3.3 Quality Procedure Manual
Procedures have been defined and documented within the Quality Procedures
Manual and covers areas such as document control, auditing, training, management
review, etc.
The Quality Procedure Manual should be read in conjunction with the Operations
Manual, Maintenance Organisation Exposition, HSE Manual, Quality Manual and
Integrated Safety Management System Manual which covers specific safety issues
within operations and maintenance.
5.3.4 HSE Manual
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The purpose of the Health Safety and Environment (HSE) manual is to set out the
specific HSE procedures, responsibilities and processes that are relevant to Aerogulf
Services.
The intention is to reflect those practices and policies which have been highlighted,
listing the legal and company rules pertaining to safety.
.
The intention is that the HSE manual will be a live document and updated as and
when new procedures appear. Normally however, there should be relatively few
changes from year to year but when that is the case the Accountable Manager will
reaffirm the company's commitment to the policies contained by annually updating
and signing the Health, Safety and Environment Policy at the front of this manual.
It should be noted that the HSE manual should be read in conjunction with the
Operations Manual, Maintenance Organisation Exposition, Quality Manual and
Integrated Safety Management System Manual which covers specific safety issues
within operations and maintenance.
5.3.5 Maintenance & Management Organisation Exposition (MME/MOE)
Defines maintenance management and certifying personnel; their expected role

within the company, their duties, responsibilities, authority and also the policy and
procedures as laid down to ensure all engineering activities conform to UAE GCAA
Regulations, company standards, and also satisfy company safety and quality
objectives.
The MME/MOE manual should be read in conjunction with the Operations Manual,
Quality Manual, HSE Manual and Integrated Safety Management System Manual
which covers specific safety issues within operations and maintenance
5.3.6 Operations Manual
The Operations Manual, which is carried in each aircraft & in the Operations Room,
is written in accordance with all relevant parts of the UAE CAR’s. For all flight crew
the instructions, requirements, procedures and directions, detailed in this Manual in
regard to flight operations are mandatory and aircraft are to be operated
accordingly…. Aerogulf operating policy is that safety is of prime importance.
5.3.7 Standard Operating Procedures (SOP) / Engineering Procedures Manual

(EPM)
Where in the organisation there are specific risks that need to be drawn to the
attention of the staff and line management, but is considered inappropriate for
inclusion in the Operations or MME / MOE Manual, and then a local Standard
Operating Procedure (SOP) or Engineering Procedure Manual (EPM) will be raised.
These will remain as controlled documents and will form part of the standard
procedures and practices that employees would be expected to follow. Refer to
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Operations Manual and MME/MOE for further details regarding SOP and
MME/MOE.
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6.0 HAZARD IDENTIFICATION AND RISK MANAGEMENT

6.1. Hazard and Effects Management Process (HEMP)
Aerogulf’s accident prevention programme and commitment to the management of risk to
ALARP is a systematic and process-based approach. The use of such an approach
provides confidence that hazards within all of Aerogulf’s activities have been identified.
The diagram below depicts Aerogulf’s process approach to risk management that is similar
to the Plan, Do, Check, Act quality process:
HEMP is central to the effective implementation of Aerogulf’s Safety Management

System. The process ensures that hazards and potential effects are fully evaluated. To
do this the hazards are first identified, the risk assessed and then mitigation and recovery
preparedness measures put in place to reduce the consequences of any remaining risk.
The process is applied in a logical and rigorous way, setting acceptance criteria and
screening against the potential hazards and effects. The arrangements identified as
necessary to manage assessed threats and potential consequences and effects are then
incorporated in Aerogulf’s Safety Management system.
An assessment first takes place comparing the existing arrangements or controls to the
hazards identified. If the necessary controls do not exist then remedial action is taken and
all necessary procedures are incorporated into the Safety Management system.
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6.1.2 Risk Assessment Procedure
6.2. THE STEPS IN THE HAZARDS AND EFFECTS MANAGEMENT PROCESS

The principles of “identify”, “assess”, “control” and “review”' are the basis of HEMP, with
the individual stages summarised in the following steps:
1. Identify hazards
2. Assess risks
3. Controls - Implement
4. Compare with objectives and performance criteria.
5. Establish risk reduction measures
6. Implement risk reduction measures
7. Review hazards and risk reduction measures
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6.2.1 Step 1: IDENTIFY - Hazards & Potential Effects

The first step is to identify the hazards and effects that may affect activities. The scope
should include Quality, Health, Safety, Security and Environment and identification
should consider routine and non-routine operating conditions and potential incidents and
emergency situations, including those arising from:
• equipment/material failures;
• operational or planning failures;
• weather and other external natural events;
• sabotage and breaches of security;
• human factors.
Operations and maintenance employees are involved in the identification of hazards and
effects as this encourages their active involvement and commitment to the safety
programme.
6.2.2 Step 2: ASSESS - risks

Evaluate (assess) the risks from the identified hazards. This is done by first evaluating the
severity of the potential consequences times the likelihood of these consequences to the
following four groups:
• People,
• Environment,
• Assets and
• Reputation.
The risks are then compared against criteria such as the Safety strategic objectives,
S a f e t y policy a n d s a f e t y V a l u e s o f Aerogulf’s operation and maintenance,
therefore the focus is on the prevention of aircraft accidents (safety), all elements of
risk must be considered to include risks associated with deviation from limits.
All those hazards and effects identified as significant in relation to the screening criteria
are recorded in one of the following ‘Hazard and effects’ documents:
• Rotary Wing Hazardous Events

• Rotary Wing Offshore Hazardous Events
6.2.3 Step 3: CONTROLS - Implement

The Flight Manual, Operations Manual, MME/MOE, Aircraft Maintenance Schedule and
Maintenance Manual covers and controls most Hazards as defined within the ‘Hazards
and Effects’ documents, but certain aspects of the operation, such as the application and
interpretation of adverse weather policies or failure of components, are recorded
separately as part of Aerogulf’s:
• Away From Base Seismic Safety Case
• Offshore Safety Case
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6.2.4 Step 4: Compare with objectives and performance criteria

The evaluated risks a r e c o m p a r e d against the detailed safety objectives and
targets. For all cases these targets are maintained and consistent with the safety policy
and objectives. Performance standards at all levels s h a l l meet the criteria set in the
Safety Case which in turn will comply with the Aerogulf’s Safety Management System.
6.2.5 Step 5: Establish risk reduction measures

The appropriate measures are evaluated and selected to reduce or eliminate risks. Risk
reduction measures include those to prevent or control incidence (i.e. reducing
probability of occurrence) and to mitigate effects (i.e. reducing the consequences).
Mitigation measures include steps to prevent escalation of developing abnormal situations
and to lessen adverse effects on Quality, Health, Safety, Security, and the Environment.
Risk reduction measures also include recovery preparedness measures, which address
emergency procedures.
The hierarchy of control in selecting and implementing risk reduction measures should
focus attention, in order of priority, on eliminating the hazard if possible (determine if the
task/operation is necessary), changing the technology (modifications), changing the work
procedure or method and personal protection devices or equipment.
6.2.6 Step 6: Implement risk reduction measures

Implement selected measures to reduce or eliminate risks. This may include changing
existing procedures, creating new procedures or changing equipment as necessary.
6.2.7 Step 7: REVIEW - hazards and risk reduction measures

Once the Risk Reduction Measures have been successfully implemented, a systematic
review shall take place to ensure that the measures are indeed effective. This will include
a review of the hazards, comparing once again with the objectives, and finally ensuring
that the risk reduction measures were implemented and that the measures actually
reduced the risk to ALARP.
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6.3 THE RISK ASSESSMENT MATRIX (RAM)

The Risk Assessment Matrix is a 6 by 5 matrix that is used for qualitative assessments of
risk and for prioritisation of activities and resources. It is based on the concept of applying
experience of events or incidents in the past to predict risks in the future. In using past
experience, it is important to utilise all resources of information available. For example,
when an occurrence report is generated, the incident or occurrence should be compared
to the risk assessment matrix to determine the level of actual risk at that moment in time
and to prioritise the remedial actions and resources necessary to prevent recurrence.
The ‘Consequences (PEAR)’ vertical axis represents increasing ‘Severity levels (0 to 5)’
in terms of harm to people, effect on the environment, damage to assets and impact on
reputation.
The horizontal axis represents ‘Increasing Likelihood (levels A to E)’ of the consequence
under consideration.
Boxes in the matrix represent ‘Levels of Risk (Low, Medium, High)’, increasing from top
left to bottom right corners of the matrix. The matrix is divided into red - high, yellow -
medium and blue - low areas, as depicted below.
Consequences (PEAR) Increasing likelihood

A B C D E
Never Heard of Has Has Has
E - Environment
heard of in in the happened happened happened

the Industry in the at the more than
R - Reputation
Industry Company Location once per

P - People
A - Assets
or more or more year at the

Severity
than once than once Location

per year in per year in
the Industry the
Company
No injury No effect No damage No impact
0 or health
effect
Slight injury Slight Slight Slight LOW

1 or health effect damage < impact
effect Dhs 100K LEVEL
Minor injury Minor Minor Minor
2 or health effect damage > impact
effect Dhs 500K
Major injury Moderate Moderate Moderate MEDIUM
3 or health effect damage < impact
effect Dhs 2.5M LEVEL
PTD or up Major Major Major
4 to 3 effect damage < impact
fatalitiesMajor injury Moderate Moderate
Dhs 10M
3 or health damage effect
More than effect Massive Massive Massive HIGH
5 3 fatalities effect
PTD or up Major
damage >
Major
impact
Major
4 to 3 damageDhs 10M
effect impact LEVEL
fatalities
NOTE: Read from Consequence (PEAR), Severity (0-5), Likelihood (A-E), Level (L, M, H) e.g. P2AL
More than Massive Massive Massive
5 3 fatalities damage effect impact
Low Manage through normal SMS procedures
Medium Incorporate risk reduction measures
High Intolerable
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6.3.1. Instructions for use of the RAM

The starting point for a RAM assessment is an understanding of the hazard in its context
(activity, location etc.), or an understanding of the particular O ccu rr en ce / incident
being considered. An assessment consists of the following steps.
Step 1: Identify potential consequences
Identify the consequences that could develop from a release of the hazard under the
prevailing conditions. Ask the question “What could happen if the controls don’t work or
they fail?”
For example, during takeoff, a failure could occur, such as the failure of an electrical
component in the cockpit. Some of the consequences that could result are:
• smoke in the cockpit;

• crew being unable to establish visual reference with the ground;
• control of the aircraft is lost and the aircraft impacts the ground.
Consequences identified in this step are equivalent to several consequences in a bow-tie
diagram that arise from a hazard release (hazardous event).
Step 2: Estimate the severity of each potential consequence
For each of the identified consequences assess the severity (0-5) in the four consequence
categories - people, environment, assets and reputation (PEAR).
In the example above, for the consequence in which an electrical fault results in
smoke within the cockpit, the crew becomes unable to maintain visual reference and the
aircraft impacts the ground, there could be impacts in all consequence categories –
people, environment, asset and reputation.
Step 3: Estimate the likelihood
For each of the potential consequences make an estimate of the likelihood of the
consequence in terms of the likelihood levels A to E.
The likelihood level should be judged from past experience, by asking the question “How
often in the past has a hazard release resulted in a consequence similar to the one that we
are considering?” The approach is one of applying history to predict the future.
The estimate of likelihood should be based on the likelihood of the particular consequence
under consideration, not on the likelihood of the hazard being released or incident
occurring.
In the example above, an estimate should be made of the likelihood of an electrical
component failing causing the cockpit to fill with smoke resulting in the inability of the
pilots to maintain visual reference and the aircraft impacting the ground, not the likelihood
that an electrical component will fail.
The reliability of the likelihood estimate, and therefore of the RAM assessment, depends to
a large extent on the availability of data on previous incidents and on the knowledge and
experience of the assessors. It is therefore important to maintain databases of previous
incidents and make them available to everyone in the company who will be making RAM
assessments. It is also necessary to utilize external databases within the aviation industry
to make an informed assessment (e.g. NTSB, UKAAIB, Airclaims CASE database, OGP).
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The hazard release scenario or the incident under consideration will often not be identical
to the previous incidents that are being used to predict likelihood. Also, detailed
information on previous incidents outside Aerogulf, or even outside the Gulf region, may
not be readily available. Therefore, a combination of available information and judgement
from experience has to be applied to make a best estimate of the likelihood level A to E.
Step 4: Estimate the risk rating
For each potential consequence determine the risk rating for each of the applicable PEAR
categories in terms of the product of the consequence severity and the likelihood. The risk
ratings (up to 4 for each potential consequence) can be plotted on the matrix to provide a
visual representation of the risk profile of the hazard release scenario under consideration.
The recommended convention for expressing risk ratings is in the form “People 2B
Low” or “Reputation 4C Medium”.
Risk ratings derived in this way reflect the controls that have typically been applied at
Aerogulf over the period for which previous incidents were used to estimate likelihood.
There is normally insufficient data on these previous incidents to allow the likelihood
estimates, and therefore the RAM ratings, to be re-estimated for the situation with
additional controls in place. The effect of additional controls on the level of risk can be
assessed by asking questions such as: “have we done enough to move the risk out of
the Red area?” The residual risk after applying additional controls should be judged
against tolerability criteria such as legal limits, company policies and standards,
contractual requirements and the ALARP process.
6.3.2. RAM - Documented Demonstration of Reduction of Risks to ALARP and the
Safety Case
Aerogulf requires a documented demonstration that Safety risks in the red and yellow
areas of the RAM have been reduced to ALARP. When the RAM is used for this
purpose the three areas are typically described as follows:
Blue Low Apply controls that are specified in the SMS
Yellow Medium Demonstrate control through the SMS and hazard control
sheets
Red High Demonstrate control through a Safety Case
6.3.3. RAM - Workplace Hazard Control (Appendix 5 and Appendix 6)
The RAM is applied in the planning of non-routine operations, maintenance, and ground
handling activities to assess the risks of the proposed work and to decide how much time
and resource should be spent on analysing the hazards.
After identifying the hazards of the proposed work the associated risks are assessed on
the RAM. The resultant planning and control actions are typically as follows:
Blue Apply the location controls, such as Safety Meetings, work orders, supervision,
Flying Staff Instructions, Read and Sign and work team discussions.
Yellow Conduct a Job Safety Analysis (form AGS/QA/042) Appendix 5. To be done
by the supervisor to identify any controls needed in addition to the location controls.
The resulting controls and instructions are communicated to the work team before the
work starts.
Red Conduct a detailed Risk Assessment (form AGS/QA/044) Appendix 6. To be
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done either by the supervisor controlling the work, supported by engineers and/or safety
department and endorsed by management. The resulting controls and instructions are
communicated to the work team before the work starts.
Any relevant health hazards, which have been identified and assessed through the
Health Risk Assessment process, should be included in the JHA and resultant controls.
The need and extent of hazard analysis will be determined not only by the RAM
assessment but also by how non-routine and complex the work is and by whether
procedures or an existing job hazard analysis are available for the proposed work.
6.4. APPLICATION OF HEMP (“BOWTIE ANALYSIS”)
Before Hazardous Event After Hazardous Event
6.4.1. The HEMP Process Depicted in Diagram and the Application of the RAM
The bowtie is a linear approach to HEMP and involves a detailed analysis of a
hazardous event and associated threats and controls. Once all of the hazards and effects
have been identified and documented and the level of risk is evaluated, further analysis is
conducted by the Safety / Quality Assurance Manager to identify all possible threats and
controls for each hazard. The purpose of the bowtie tool is to facilitate the selection of
controls and recovery preparedness measures and provides the methodology to develop
Aerogulf’s Safety Case.
It begins with the identification of the hazardous event, which is the first release of the
hazard. Working to the left of the “hazardous event”, a hazard is identified and then the
threats are identified which could result in the release of the hazard. Controls, escalating
factors and secondary controls are then identified which would prevent the release of the
hazard and thus the result: a hazardous event.
On the right side of the “bowtie” is the sequence of measures once the “hazardous event”
has actually occurred. This combination of measures will mitigate the consequences of
the hazardous event. Recovery measures are identified to enable a degree of recovery
once the hazardous event has occurred. Escalation factors are identified which may
“escalate” the situation thus making recovery difficult or unlikely. Controls are then
identified which would prevent the escalation of the hazardous event. If the controls fail
and escalation does occur, the consequences of the hazardous event are identified
and mitigation measures are then identified and implemented.
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6.5. Application of the Hazards And Effects Management Process to Aerogulf’s

Operations and Maintenance
HEMP is easily applied by using the above explanation and the example provided
below (see section 6.7.1). To complete the bowtie analysis, experienced and
knowledgeable staff from both engineering and operations meets for brainstorming
sessions.
There are three ways to approach the bowtie analysis:
• Through a rigorous, systematic review of all activities and tasks using
business processes, diagrams or maps to guide the approach;
• Through brainstorming the hazards that could affect the particular operation in
an alternative systematic manner (e.g. by focusing on the individual phases of
preparing an aircraft for operation and then each phase of flight etc.);
• Through the use of a Hazard list as defined within the Hazards and Effects
register.
6.6. HAZARDS AND EFFECTS REGISTER
Aerogulf’s Hazards and Effects Register is a quality record which demonstrates that
hazards and effects have been identified, are understood, and are being properly
controlled.
The Hazards and Effects Register forms part of the Safety Case and is therefore a live
document and is continuously reviewed as standards change, new operations begin, new
technology is introduced or incidents occur. Not all of the hazards and effects identified will
be included in the Safety Case. Only those with major accident potential are required to be
included in the Safety Case. In other words, a health or physical safety hazard that can be
managed through normal operating procedures does not need to be included in the Safety
Case.
Using the Hazards and Effects Register, the Safety Case demonstrates that:
• all hazards, effects and threats have been identified;
• the likelihood and consequences of a hazardous event have been assessed;
• controls to manage potential causes (threat barriers) are in place;
• Recovery preparedness measures to mitigate potential consequences have been
taken.
The structure and content of Aerogulf’s Hazard Register has been developed to cover
offshore operations, main base of operation and away from base seismic operations, and
documents all major and other safety significant hazards/threats that could be encountered
in normal operations as well as any potential operations outside the normal scope of
activity.
The following information is documented in the Hazards and Effects Register.
1. Description of the hazard
2. Assessment of the hazard

This includes when and where the hazard is encountered (e.g. cruise flight,
maintenance activities), and the possible hazardous events that could result from loss
of control (e.g. injuries, fatalities, destruction of aircraft, damage to reputation)
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3. Hazardous event.
Describe the situation or event that represents the release of the hazard from defined
control limits. If this situation or event can be prevented through active controls
no scenario can develop which could lead to a consequence or effect as defined by
Case objectives.
4. Locations and acceptance criteria
List the locations where the hazard (or effect) is present. For each location the
acceptance criteria is defined, in other words, what is deemed suitable and
sufficient control of threats and what are suitable and sufficient recovery
preparedness measures
5. Threats and threat controls
The identification of all possible causes of release of the hazard or deviation from
control limits, resulting in the hazardous event. For each threat there is a description
of the necessary control or barrier that would prevent the release of the threat.
6. Consequences and risk assessment

Describes the possible consequences or potential effects that could result if the
hazard is released or the control limits are exceeded. Consequences may vary
according to the availability and effectiveness of the recovery measures. For
instance, an aircraft engine fire may result in damage to the engine itself, followed
by securing the engine and a precautionary landing. Or, it could result in catastrophic
failure of additional aircraft components, resulting in aircraft ditching, aircraft
destruction and fatalities. Assess the risks associated with each consequence. The
Risk Assessment Matrix can be used to do this. As a minimum, the worst case, most
severe consequences shall be determined both with all recovery measures available
and working and with all possible recovery measures not available and not working.
See paragraph 6.3.1 for instructions on the use of a Risk Assessment Matrix
7. Recovery preparedness measures.

Describes the recovery preparedness measures that are required to meet the
acceptance criteria. These are the t e ch n i ca l , operational and
o r g a n i s a t i o n a l me a su r e s , wh i ch a r e necessary to prevent a hazardous event
from developing further. In other words, mitigating the consequences or effects and
recovering a degree of control. These measures are reactive in the sense that they
respond to a situation that has already occurred and are intended to block further
development of the accident scenario and to provide for emergency response and
management.
8. Escalation factors and controls.

Describes the factors, or conditions which could lead to the loss of either the threat
controls or the recovery preparedness measures. These are called escalation
factors because they escalate the probability of a hazardous event and escalate the
likelihood or severity of consequences or effects if the hazardous event actually
occurs e.g. adverse weather, violation of procedure, ambiguous procedure,
improper maintenance. For each escalation factor, the controls are in place to “back-
up” the defeated control or recovery preparedness measure.
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Any shortfalls in escalation controls are highlighted and recorded. A cross-

reference is provided to Safety Critical activities providing or maintaining the controls.
This is essential to maintain adequate oversight and management of these controls.
9. Reference documents.
All the documents, procedures, standards, and assessments used or referred to in
developing the information entered for the hazard or effect are recorded. Controls,
recovery preparedness measures and escalation controls are also cross-referenced
to these documents.
10. Deficiencies or shortfalls.

Records all shortfalls identified with respect to the management of the hazard or
effect recorded. These shortfalls are included in the remedial action, and included in
the documentation of the safety case and considered in the assessment of the
overall statement of fitness for the organisation. The remedial action is carried out
within the Internal audit procedure to ensure that progress towards resolving any
shortfalls is tracked and any outstanding issues are resolved as soon as possible.
11. Custodian and authorisation.

The Safety / Quality Assurance Manager will ensure that the information recorded for
the hazard or effect has been checked and found to be factual and consistent both
internally and with other parts of the Safety Case. He will then endorse the risk
assessment made and any shortfalls identified and sign controlled copies of the
Hazards and Effects records. The Safety / Quality Assurance Manager will then
monitor the validity of the information recorded with periodic reviews as part of the
Safety / Quality plan, updating as necessary. If the Safety / Quality Assurance
Manager changes, the Hazards and Effects Register information shall be
reviewed and endorsed by the new Safety / Quality Assurance Manager.
6.6.1. Managing the Hazards and Effects Register.

The above information is presented as a bowtie diagram as depicted in paragraph 6.4 and
therefore does not need to be repeated, simply cross-reference the Hazards and Effects
Register with the appropriate bowtie diagram (‘Before’ and ‘After’ Hazardous Event). This
information shall be readily accessible to Director of Operations, chief pilot,
Engineering manager and all those responsible for safety critical activities within the
Aerogulf. Managing the effectiveness of these controls is an essential element of
managing the business risk to ALARP. The Quality Audit plan and Safety Plan will carry
out a review of the effectiveness of threat controls, recovery preparedness measures, and
escalation controls. Any findings where controls are deemed ineffective or have been
removed will result in an immediate restriction of Operations and tasks, in order to prevent
any unnecessary increase in exposure to risk.
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6.7 HEMP, THE RULE OF THREE, & THE APPLICATION TO AVIATION ACCIDENT
PREVENTION
The application of the HEMP provides Aerogulf with a systematic approach to risk
management in order to prevent accidents. Through a systematic approach, hazard
identification looks at the entire organisation as well as those factors, which are external to
t h e o r g a n i s a t i o n . Operational and Maintenance procedures and practices,
communication, personnel recruiting and training, organisational pressures, allocation of
resources, work environment factors, regulatory oversight and the provision of warning
systems, all combine to form the scope of Aerogulf’s accident prevention. By utilising a
systematic approach such as HEMP, it is possible to ensure that the scope of accident
prevention encompasses all organisational elements and therefore any hazard that may
affect the safe operation of aircraft.
Applying HEMP and Risk Management principles may also improve operational decision
making thus preventing an unsafe situation from escalating.
6.7.1 The Rule of Three
It is generally accepted that, for an accident to occur, there are usually several
contributory factors leading up to the actual event. In its theory on the “Rule of Three”,
Leiden University concluded: that if one or two limits are reached, the ability of an
individual to manage the situation was generally possible. If the operation approached a
third limit, this would dramatically increase the possibility of the loss of control of the
situation and an incident/accident was likely. For example, such a situation can occur
during pre-flight checks if unserviceability were to occur preventing departure, and
requiring the crew to revert to a standby aircraft. The proposed flight is now running
late, additional paperwork has to be completed, flight plans resubmitted and perhaps
personnel and baggage have to be transferred. In the event that this were to occur
nearing the end of the crews permissible duty day, and was further complicated by
deteriorating weather, then the three factors combined may well be more than the crew
can reasonably be expected to cope with without putting the flight at undue risk in the
event that any further complications were to arise. It is therefore essential that, as the
limits are approached, there is an assessment made as to their combined potential to
cause an incident or accident and a decision to fly or not duly made i.e. a risk
assessment is carried out.
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Example:
A helicopter is operating in weather just bad enough that other aircraft are grounded but it
is within company limits. The flight plan is changed to accommodate operational
requirements, going to an additional four platforms. The crew is very close to their flight
time duty limits. They decide to do one last stop before they start the half-hour return flight
to base.
Should the crew press on and take the additional changeover shift home or should they
advise that another crew needs to take over and return to base?
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6.8 DEMONSTRATION OF ALARP

To reduce a risk to ALARP involves balancing reduction in risk to a level, objectively
assessed, where the trouble, difficulty and cost of further reduction measures become
unreasonably disproportionate to the additional risk reduction obtained.
ALARP is not just a demonstration that risks of the preferred or selected option are
acceptable and/or comparable to other similar developments. Demonstrating ALARP
requires consideration of fundamentally different options to provide assurance that
A e r o g u l f gets best value for money over the lifetime of an operation. There is no
scientific formula to calculate ALARP. Demonstrating ALARP requires consideration of
all the hard and soft issues related to a range of options and a judgmental decision at the
right level in the organisation with the full knowledge of all the options, and associated
risks and costs. It is not only a decision for today, it is also for the future, when goalposts
move and being ALARP today may avoid costly retrofit. Should A e r o g u l f be
subjected to scrutiny following an accident, for example, it should then be possible to
demonstrate that the right decisions have been made.
The predefined limits are found in legislation, contractual and Aerogulf standards.
Targets or acceptance criteria are normally more stringent than those of legislation. In the
process of continuous improvement over time A e r o g u l f ’ s targets are improved.
These improvements are made balancing the cost of improvement against the benefits
achieved (ALARP).
6.9 SAFETY-CRITICAL OPERATIONS PROCEDURE
Some of the control and recovery sections in the Hazards Register refer to specific
operating procedures. These procedures will, in almost all cases, already exist in some
form (e.g. Operations Manual) but are specifically highlighted within the Safety Case with
a location reference.
6 . 9 . 1 Limits to Permitted Operations

These are derived from the hazard analysis and define the limits of safe operation
permitted for specified hazardous conditions. The Flight Manual, SO P’s, Operations
Manual, Maintenance Schedule and Maintenance Manual should cover most
circumstances, but certain aspects of the operation, that are not defined in these manuals
will require a specific Safety Case to be raised.
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7.0 PERFORMANCE MONITORING
7.1 Performance Monitoring

Performance monitoring is a department management / supervisors responsibility and as
part of the duty of care for its staff and in line with their accountabilities the routine
monitoring of the workplace is undertaken.
Operations monitoring is through the use of the line checks and Internal Audits of pilot /
Ops personnel’s practice’ versus published procedure. This is carried out by the Director
of Operations with the assistance of the Chief Pilot, Director of Training, flight Safety
Officer, TRE’s and the QA department.
Maintenance monitoring is through the use of training appraisal, maintenance reviews

and internal audits annually and daily of engineering personnel’s practice’ versus
published procedure e.g. completion of work sheets, manuals used, etc. This is carried
out by the Engineering manager and QA department.
It is accepted that all levels of management must fully support the continued development
of a just culture within the organisation, and that this will stem from sound leadership and
from motivation of staff.
7.2 Key Performance Indicators

The current performance measure used to evaluate Aerogulf’s safety is that of either any
recurring issues or by measuring the cost of any human factor accidents or incidents. If
the annual cost exceeds Dirhams 6,000, this is deemed to be below target. A threshold
performance would be a cost of between Dirhams 3,000 and Dirhams 6,000, ideally on
target would be a cost between zero and Dirhams 3,000. A near miss with no cost would
be an above target performance and finally, no events would be a good performance.
These performance measurements will need to be amended, if only because they do not
truly reflect a just culture philosophy. If withholding a report is apparently rewarded, then it
is highly probable that withholding will occur, and if near miss events are not reported, an
opportunity to learn from those events and to put other controls into place will be lost.
As part of Aerogulf’s safety improvement plan key performance indicators are used
throughout the safety and Quality reporting system. KPI’s are used to measure recurrency
of findings, follow-up action and its affectivity. The results are presented at safety
meetings, safety review board meeting and management reviews. But importantly it will
provide a ‘close-out’ loop back from management back to the report author in order to
instil confidence and the sense of active involvement in the company safety culture.
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7.3 Reporting ‘Hardware’ components of System
Refer also to Chapter 5.2 Documentation
All employees can and are encouraged to report safety or hazard concerns. The Aerogulf
reporting procedure uses various forms which are further defined within the Quality
Manual, Operations Manual and MME/MOE:
• Safety/Hazard report form
• Confidentiality Safety report form
• Occurrence/Incident/Accident Report which is used for all Mandatory Reports.
• Multi-Purpose Report Form (MPRF)
• Mandatory Occurrence / Defect Report
• Verbally.
• Flight Load Sheet
Any event or situation with the potential to result in significant degradation of safety and
can cause damage and/or injury should be reported. In addition the following list details
examples of occurrences which would justify a report being raised. If there is any doubt
contact the Safety / QA Manager. A report shall be filed within 72 hours of the occurrence
if possible:
• As defined within GCAA AWN 20 MODR

• System defect occurs which adversely affects the handling characteristics of the
aircraft and renders it unfit to fly or results in the flight being diverted or terminated
early.
• Warning of fire or smoke
• An emergency is declared
• Safety equipment or procedures are defective or inadequate
• Deficiencies exist in operating procedures, manuals or navigational charts
• Incorrect loading of fuel, cargo or dangerous goods
• Operating standards are degraded
• An engine has to be shut down in flight
• Ground damage occurs
• A rejected take-off is executed after take-off is commenced
• Significant handling difficulties are experienced
• A navigation error involving a significant deviation from track
• An exceedance of the limiting parameters for the aircraft configuration occurs
• Communications fail or are impaired
• Aircraft is evacuated
• Aircraft lands with reserve fuel or less remaining
• An Near miss (Airmiss) or TCAS event, ATC incident or wake turbulence event
occurs
• Significant turbulence, wind shear or other severe weather is encountered
• Crew or passengers become seriously ill, are injured or become incapacitated
• Difficulty in controlling violent, armed or intoxicated passengers or when restraint
is necessary
• Any part of the aircraft or its equipment is sabotaged or vandalised
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• Security procedures are breached
• Bird strike or Foreign Object Damage (FOD)
• Aircraft Commanders Discretion reports in event of exceeding Flight Duty
limitations
• Or any other event considered to have serious safety implications
7.3.1 Safety / Hazard reporting

The Safety / Hazard reporting system is non-punitive, confidential, simple, direct and
convenient. Once safety / hazards are identified and reported to the Safety / QA Manager
they are acknowledged, allocated a number from the Hazard database and investigated.
Recommendations and actions taken are recorded with a close out loop back to the
originator. By ensuring a confidential, non–punitive system with feedback of action taken
to the originator, confidence in the system will be maintained which encourages hazard
reporting.
The reporting system is confidential between the person (originator) reporting the hazard
and the Safety / Quality Assurance Manager and/or Flight Safety Officer. Any safety
information distributed as a result of a report will be de-identified.
Safety / Hazard reports will be submitted in the first instance to the Safety / Quality
Assurance Manager or the Fight Safety Officer. They shall:
• Be responsible for investigation of the report and for maintaining their
confidentiality.
• While maintaining confidentiality, the Safety department must be able to follow-up
on a report to clarify the details and the nature of the problem
• Acknowledge receipt of the report and assign it a tracking number.
• Complete the reverse of the report with action taken, by whom and final resolution.
• The report will be raised at Management meetings for deliberation and action, If
necessary.
• After investigation, make widely available for the benefit of all staff (Pilots and/or
Engineering meetings), the de-identified safety report and recommendations.
• Update the database and close out.
• Return completed form in confidence to the originator, if applicable.
7.3.2 Confidential Reporting Programme
Reports are recorded electronically and also held as hard copies. This method ensures
that departments are made aware of incidents as they occur by the issue of a hard copy,
and the status of any investigation together with required follow-up action by both hard
and soft copy to prevent recurrence can be monitored.
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7.3.3 Occurrence/Incident/Accident Report - for all Mandatory Reports
Ref: MME/MOE Section 2.18(3)
Maintenance personnel should report any incident or occurrence to the Engineering
Manager and also the Quality Assurance Department using a Maintenance Defect Report
form (on reverse of the ‘Occurrence / Incident report’ form) for recording and corrective
action.
The Safety / Quality Assurance Manager is responsible for determining those

occurrences that are required to be submitted to the GCAA. (See GCAA Airworthiness
Notice No 20 for guidance on Occurrences to be reported and section 7.3.5). Reporting
shall be carried out using the GCAA ‘Mandatory Occurrence / Defect Report’ form.
In respect of Aerogulf Services operations, any events or occurrences during the period
that an aircraft is under the control of a pilot shall also be filed using an ‘Occurrence /
Incident Report’ form and administered by both Operations and Quality Assurance
Department. All occurrence reports that have technical or maintenance related event shall
be investigated in liaison with the Safety / Quality Assurance Manager and Maintenance
Section.
Completed Occurrence / Incident reports raised by operations shall be copied to the

respective customers, with where required maintenance action taken.
Quarterly Safety reports are also sent to the GCAA
7.3.4 Multi-Purpose Report Form

Ref: MME/MOE Section 2.18(5)
Suggestions for Improvements can be submitted either verbally to any of the
management personnel or by the use of the Multi-Purpose Report Form.
Any issues regarding safety can be reported using either the Multi-Purpose Report Form,
the Confidential Safety Report Form or verbally to any management personnel, the
Quality Manager or the Safety manager.
7.3.5 Mandatory Occurrence / Defect Report

The UAE GCAA has mandated a limited number of occurrences that require reporting.
Aerogulf has its own MOR scheme that embraces those occurrences mandated by
GCAA. In order that confidentiality is protected, neither the Company nor the Regulator
will disclose the name of any person submitting a report, or that of a person to whom it
relates unless required to do so by law, or unless the person concerned authorises the
disclosure. Should any safety follow-up action be necessary, the regulatory authority will
take all reasonable steps to avoid disclosing the identity of the reporter or of individuals
involved in the occurrence.
In the case of GCAA mandated reports, recommendation for the closure of a report must
be agreed with the regulatory authority. The authority and the reporter must be informed
of action taken once the incident is closed.
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7.3.6 Verbally
To the department supervisor, Safety / Quality Assurance Manager, Flight Safety Officer
or any of the management, confidentially is assured should any report be submitted to the
Safety department.
7.3.7 Load sheet

Can be used by pilots to record details of particular events such as delayed departures,
ATC delays etc. however on return to base an Occurrence/Incident/Accident Report shall
be raised, see 6.6.3
7.4 Monitoring and Tracking (Feedback)
Data for trend analysis is gathered from Safety Reports submitted which is entered in to
the database. Dependent on the nature of the occurrence / hazard the safety / QA
manager will assign ownership with action target dates. Information such as trends, risk
assessment, hazard analysis, investigations and follow-up’s are then more effectively
implemented. After final management review the report will be displayed on the safety
notice board. Any further action will be determined at the management meeting refer to
section 7.
7.5 Follow-up and Closure of Reports
Some reports can be closed on receipt e.g. late or delayed departures. If follow-up is
required, action will have been assigned to the appropriate department(s). The Safety /
Quality Assurance Manager will review responses and, if satisfactory, recommend closure
of the incident at the next Safety Review Board meeting. If responses are unsatisfactory
and do not address the problem, the incident must remain open for continuing review and
action as required.
7.6 Auditing
Ref: Quality Manual
Quality Procedure Manual, Procedure P 822, Internal Quality audits
7.6.1 Internal Audit Safety Plan (See Appendix 1)

Ref: Section 2.5 Safety Plan
Schedule – Safety / Quality Assurance manager establishes an internal audit / safety

plan and schedule See table 8-1 below, in accordance with Quality Procedure Manual
procedure P 822, Internal Quality Audits to ensure that activities and related results
comply with planned and regulatory requirements. Every activity and area is audited at
least once a year but can be carried out more frequently if required. Selected activities
are audited more frequently, depending on their importance and quality performance
history.
Scope – To ensure compliance with procedures audit scope must cover as a minimum
those procedures as defined within:
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a. Operations Manual / Op Spec for Operations department e.g. performance, flight
crew, training, documentation, dangerous goods, etc. and
b. MME/MOE and Engineering Procedure manuals for Maintenance department e.g.
documentation, AD’s, ASB’s, MEL, training, Logs, records, etc.
Refer to check lists within Quality Procedure Manual, Procedure P822 Internal Quality
audits for full audit scope and AMC 3.3035 item 4.6.1(a) thru (x).
Department Frequency
Quality Assurance 12 mths
Line 12 mths
Overhaul / NDT workshop 12 mths
Avionics workshop 12 mths
Material control – stores 12 mths
Third Party 12 mths
Safety equipment 12 mths
Technical Records 12 mths
Machine shop 12 mths
Operations Department 12 mths
Contract Review 12 mths
Vendors 12 mths
Air BP T-181 records 12 mths
Flight Safety & security 12 mths
Away from base A/R
Table 8-1
7.6.2 Internal auditor: qualification, responsibility and experience
Internal auditor qualifications as a minimum are that they must have attended an
approved Internal Audit course and a Safety Management System course and have an
aviation background as either an engineer or pilot. They must also be familiar with the
area being audited, and must be independent of the audited activities. They are
responsible for preparing and conducting the audit in accordance with the Quality
Procedure Manual.
Selection of auditors and preparation for the audit are explained in procedure P 822,
Internal Quality Audits. Auditors may be the Safety / Quality Assurance Manager, Flight
Safety Officer or Assistant quality Assurance Manager, dependent on the area under
audit. As a guide engineering will usually be audited by the Safety / Quality Assurance
Manager and/or Assistant Quality Assurance Manager and Operations by the Safety /
Quality Assurance Manager and/or Flight Safety Officer.
7.6.3 Conducting the Audit
Conducting the audit; evidence is collected by observing activities, interviewing

personnel, and examining records for indications of whether the audited activities comply
with the requirements of the documented quality system, Safety system, regulatory
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requirements, department and customer procedure’s, and whether the safety system is
effective. Nonconforming conditions are documented and recorded using the audit report.
Audits are conducted in a way that minimizes disruption of the audited activities. Records
/ documents used to assist in the audit are:
• previous audit reports,
• Review of safety / hazard reports
• Review of occurrence reports
• Review any trends as reported within the Unscheduled Maintenance Report
system (UMR)
• reviewing applicable standards and procedures,
• analyzing quality records,
• establishing and reviewing questionnaires / feedback reports,
• checklists
7.6.4 Remedial Action and Follow-up
When nonconforming conditions / safety hazards are identified, the person responsible for
the affected area or activity is requested to propose a remedial action in the action
column on the ‘Internal Audit Report’. The report is then returned to the Quality
Department within seven days from receipt.
Implementation and effectiveness of the remedial action are verified by a follow-up audit.
However, if remedial action is not carried out as stated in the action column of the report
or the remedial action has not really addressed the non-conformance; then a ‘Major Non-
conformance’ is raised using the ‘Multi-Purpose report’ requiring immediate action.
7.6.5 Reporting / pooling of reports
When the auditing cycle is completed all the Internal Audit Reports are completed and
analyzed. They are submitted to the Director of Operations, Engineering Manager and the
Accountable Manager and if required are presented at the next management evaluation
review meeting.
The completed reports including all third party audit reports are retained and filed by the
Safety / Quality Assurance Manager who will carry out follow-up investigations to ensure
close-out and that final reports have been submitted to customers if required.
Aerogulf as owner / operators do not pool audit reports with other organisations other
than with the GCAA and contracted customers (e.g. Dubai Petroleum, Dugas, Shell, etc).
7.6.6 Audits by Third Party / Regulatory Authority
All communications with the auditor is through the Accountable manager who also
delegates a senior manager within Aerogulf to compile a feedback report, this is
submitted as soon as possible after the audit to assure the auditor that the report is being
actioned including remedial actions for any non-conformance.
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7.7 Management Review
7.7.1 Aerogulf Safety Committee

Aerogulf Services shall have a Safety Committee, which will address all facets of safety.
The Accountable manager will act as chairman for the committee. The other members of
the committee will be senior management from Aerogulf; the committee will be made up:
a. Accountable manager
b. Director of Operations
c. Chief Pilot
d. Engineering Manager
e. Safety / Quality Assurance Manager
f. Flight Safety Officer
g. Security Manager
h. Ground Operations Manager
The committee are tasked to:

a) Hold monthly minuted safety meetings.
b) Develop a proactive safety programme.
c) Publicise safety information.
d) Involve all members of the staff in safety initiatives developed by the
committee.
e) Circulate safety literature from external sources.
f) Maintain the HSE Notice Board.
g) Make recommendations to the directors for Safety related training.
h) Investigate all HSE related accidents and incidents.
i) Monitor the near misses, first aid uses, and incidents seeking to identify
trends and weaknesses, which then should be targeted for resolution.
j) Carry out internal audits of each facet of the organisation. The Quality
Procedures Manual details the schedule for carrying out internal audits.
7.7.2 DP / Dugas Safety Committee
As for Aerogulf Safety Committee but with the inclusion of DP / Dugas representatives
dealing with issues relevant to their operation with Aerogulf.
The actions of the Aerogulf Safety Committee will not alter the workings of the DP /
Dugas Safety Committee.
7.7.3 Safety Review Board (SRB)

The Aerogulf Safety / Quality Assurance Manager assess ‘safety performance’ through
the Occurrence reports and Safety Hazard reports raised within Aerogulf’s operations and
maintenance department’s (the ‘Gap Analysis’ in section 7.10 will also be included when
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carried out every two years). This is presented at the Safety Review Board meeting where
the overall performance can be measured and if required action can be assigned with
action dates. This is recorded on the minutes which are then attached to the Safety
Review Board performance chart and then forwarded to the GCAA Operations
Department in Abu Dhabi.
7.8 Non-Punitive Reporting and Just-Culture Discipline

It is fundamental to the purpose of a reporting scheme that it is ‘Non-Punitive’, and the
substance of reports should be disseminated in the interests of safety only.
The evidence from numerous aviation accidents and incidents has shown that the lack of
management control and human factors are detrimental to the safe operation of aircraft.
The management of safety is not just the responsibility of management however; it is
management that has to introduce the necessary procedures to ensure a positive cultural
environment and safe practices. The best performers internationally use formal Safety
Management Systems to produce significant and permanent improvements in safety. It is
also important to develop a ‘just culture’ that encourages openness and trust between
Management and the work force. For example, all employees should feel able to report
incidents and events without the fear of unwarranted retribution. Reporting situations,
events and practices that compromise safety should become a priority for all employees.
Aerogulf promotes ‘Non-Punitive reporting’ through the use of internal Safety / Hazard
Reports, Multi-Purpose Report Forms, verbally, etc. A ‘Just Culture Disciplinary’ policy will
result in action only being taken if it is found to be as a result of gross negligence or wilful
deliberate destruction of company property, safety of assets and personnel. The following
diagram shows the Aerogulf Just Culture model.
Aerogulf Services ‘Just Culture’ Discipline Model
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7.9 GAP Analysis (Appendix 2)

In order to identify gaps within the existing resources and defences against hazards,
Aerogulf conducts a ‘Gap’ analysis; to identify where additional resources, facilities or
even additional safety arrangements to maintain the safety management system.
Refer to Appendix 2 for the Aerogulf ‘Gap Analysis’ check list. This has been modelled on
the ‘National Safety Council’ check list as used by the International Helicopter Safety
Committee.
To ensure that the Safety Management System functions to the standards as defined
within this ISMS Manual, the Gap Analysis check list is included within the Safety Audit
Plan; to be carried out every two years or whenever there is a Management of Change.
The Gap Analysis check list is in the form of two columns:
1. The first column is to establish a base line for the ISMS through eighteen Primary
Considerations with ‘yes / no’ questions and current Aerogulf status.
2. The second column can now be used to ‘Plan’ and set goals to implement where
required the necessary actions to fill gaps within the safety system. This can then
be presented to the safety committee at the safety review board meetings (section
7.8.3).
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8.0 EMERGENCY RESPONSE PLANNING

8.1 Coordination
The senior company representative must coordinate and control with all company and
outside agents (as listed above in section 8.1), all necessary action until relieved by a
superior. Seniority for this purpose is as follows:
• Aerogulf Duty Officer
• Accountable manager
• Assistant Accountable manager
• Personnel Manager
• Director of Operations
• Chief Pilot
• Engineering Manager
• Safety / Quality Assurance Manager
8.2 Designation of Emergency Authority

Refer to Appendix 3, Helicopter Emergency Response Plan (Form AGS/OPS/033) for
telephone number of contacts and flow chart for emergency action. Following list
details the emergency authority and their responsibilities:
• GCAA, Chief of Regulations and Investigations; responsible for the
coordination and control of the accident site, and the subsequent investigation.
• DCAA, Airport Safety and Crisis Management – Aviation Unit; responsible for
incidents within the Airport.
• Dubai Police, responsible for investigation of all accidents that result in injury
or death.
• Customer HSE Manager, will coordinate emergency response as required for
their offshore facility, support personnel and equipment e.g. rescue boats.
• Aerogulf Duty Officer, will coordinate with above authority and customer until
such times as mobilisation of senior management, at which time the
Accountable manager or Assistant Accountable manager will assume
responsibility.
• Accountable manager / Assistant Accountable manager, will assume
responsibility as point of contact for company with all departments and
authorities. He may delegate certain tasks to individuals as appropriate to their
position.
• Director of Operations / Chief Pilot, to coordinate additional aircraft, pilots
and crew to assist initially and post event.
• Personnel Manager to arrange as required coordination with families and
employees.
• Engineering Manager, to assist as required in technical matters pertaining to
aircraft and equipment, engineers for assistance, tools and equipment as
required.
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• Safety / Quality Assurance Manager, to remain as point of contact with
regulatory authority. If required will impound all documents and manuals as
required for regulatory authority. All documents and manuals to be recorded
before removal.
8.3 Transition from Normal to Emergency Operations

Normal day to day operations shall continue upto a declaration of an emergency.
Whereby the Accountable manager, or Director of Operations will, dependant on
the circumstances of the Emergency call for either:
• An immediate cessation of Operations until further notice, in order that the
cause of the emergency can be determined.
• Additional aircraft and crew made available to assist the emergency
services and / or to assist with the GCAA and Police.
• Continuation of Operations, but restricted away from areas that may
potentially conflict with the emergency services.
• Duty Officer, upon notification of an emergency to notify immediately all
management as detailed at section 8.2 below. And to remain in contact
with customers management.
• Accountable manager shall designate those management personnel to
attend to the next of kin and shall also be the point of contact with the
customer, authorities and press.
• Full implementation of the Emergency Response Plan as per section 8.1
dependant on the nature of the emergency.
8.4 Return to Normal Operations

The Accountable manager shall determine the recommencement of operations based
on the nature of the emergency, its outcome and if required approval from the
customer and regulatory authority, and in liaison with Director of Operations and
Engineering Manager.
The circumstances may be such that personnel will require counselling and support in
particular the next of kin. This will have a major influence on the operation and
therefore the decision will be dependant on the general feeling and morale.
Technical reasons may also have an affect on the recommencement, with aircraft
grounded until the authorities give their approval.
When the decision is taken the Accountable manager and / or his designate shall
arrange department meetings in order to clarify the situation, take questions and to
give a restart date. Operations will then recommence with all personnel carrying out
their respective duties.
Senior management as detailed at section 8.2 shall monitor the company at all levels
to ensure that personnel are performing their duties safely and without distraction.
That all concerns are noted and follow-up actions where required are assigned and
carried out. All reports to the Accountable manager.
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8.5 Emergency Response Plan (Appendix 3)
Aerogulf maintains an emergency response plan that details the actions to be taken
should an aircraft fail to call in or arrive at its destination on time. This document is
held separately as a controlled document and is located throughout the company
within every office in the Emergency Action Plan.
The Emergency Response Plan is maintained up to date and is exercised at least

once per year in liaison with the customers’ senior management / Head of HSE to
ensure that the response works effectively in practice. Records of the exercises are
maintained and together with any noted shortfalls, raised as remedial Actions at either
customer Safety Meetings and / or Company Management Review Board quarterly
meetings. The nature of the exercise can take the form of aircraft calling in an ETA for
a platform, and then returning to base to monitor the response. The intention is to see
if the various radio rooms / operators are actually monitoring the flight and know what
to do in the event there is an emergency. The ERP can be pre agreed with the
customer to target a specific area of concern and may take place as often as required.
8.6 Accident / Incident Investigation Procedures

Whenever an accident or an incident occurs, an Occurrence / incident report form and
a GCAA Mandatory Occurrence and Defect Report (MODR) is raised if it was an
accident or an occurrence that may have jeopardised the safety of the aircraft or
personnel, refer to GCAA Airworthiness Notices for actual definition. These are
reported directly to the Quality Assurance Department for updating of the central data
base. The report is also faxed immediately to the customer. With the MODR (if
required, sent to the GCAA within 72 hours).
An accident as defined within GCAA Airworthiness Notice will result in the GCAA
conducting an investigation either independently or with the assistance of an external
authority e.g. NTSB, AAIB, etc.
Likewise the customer may also implement an investigation as per their contract using
an external auditing organisation with the final report presented to Aerogulf and the
customer for corrective action.
The Accountable Manager together with advice from the Management team will
decide if an investigation is warranted for incidents / occurrences that do not directly
affect a customer or fall under a classification requiring GCAA intervention. The
designated investigator in this case will usually be the Safety / Quality Assurance
Manager and / or Flight Safety Officer possibly along with other members of the
management team who will respond directly back to the Accountable Manager /
Management Team.
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The norm is that all accidents and occurrence’s e.g. failure to comply with procedures,
personal injuries, damage to aircraft or property will be investigated. Occurrences and
incidents will not be investigated if they are for weather related or simple defect
rectifications requiring replacement of components or LRU’s (Line Replacement
Unit’s). Defect trend analysis is carried out as per the Unscheduled Maintenance
Report (UMR) system as defined within the MME/MOE.
The company safety policy is non-punitive and supports a just and learning approach
that doesn’t seek to apportion blame as its primary thrust. It is recognised that human
error can occur, in such cases blame and subsequent punishment will not be delivered
as the resolution to the problem, but this will not absolve all those involved, directly or
indirectly, from accepting the responsibility for their part. However, where appropriate,
in cases of gross negligence or deliberate violation, appropriate disciplinary action will
be taken.
Investigation reports will be presented to the Accountable Manager, The Safety /

Quality Assurance Manager will hold a file copy for control in Quality Department.
Records of any investigations and any subsequent follow-up action will be reported
and reviewed through the monthly management meetings.
8.7 Accident Investigation and Reporting

Initial steps to be taken:
To ensure the risks are reduced and the incidents are fully investigated, the
Accountable Manager shall detail a suitable nominee to:
a) Go to the scene of accident or dangerous occurrence promptly.
b) Ensure injured persons are protected and treated.
c) Call for medical assistance (Dial 2161999), if appropriate.
d) Take steps to make the area Safe. If practical, avoid disturbing the
scene of the accident until an investigation is carried out (this is a legal
obligation in event of a fatality).
e) If safe, enter the area and endeavour to determine the cause of the
accident.
f) Speak to witnesses to determine what happened and obtain written

statements if possible. Ensure witnesses stay at the scene or obtain
details by which they can be contacted.
g) Notify the Accountable manager and police in the event of a fatality.
h) In the event of a notifiable dangerous occurrence or major injury, notify

the appropriate authority by telephone, within 24 hours.
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i) Ensure that the area is safe before allowing employees to recommence
work.
ii) Complete Occurrence Report (Form No: AGS/OPS/004) and submit to

either the Safety / Quality Assurance Manager or Flight Safety Officer.
iii) If the injury was as a result of contact with an agent and requires hospital
treatment give copy of Material Safety Data Sheet for presentation to
Doctor.
In the case of an incident to an aircraft, the reporting procedure to be followed is

detailed in the Operations Manual. A MODR (Mandatory Occurrence Defect Report
– AWN No. 20) must be completed and submitted within 72 hours to the GCAA. This
will be raised either by the personnel involved in the incident or by the Safety / Quality
Assurance Manager, one copy will be retained with a copy faxed to the GCAA. The
procedure for reporting other accidents is shown below. In all cases the Accountable
manager, or in his absence, the Directors must be informed.
8.7.1 Aircraft Recovery post Accident
Prior to the removal of any items permission must be obtained from the GCAA, the
Police and the owners of the site. The following gives an oversight into the removal
procedure and hazards likely to be encountered, for further details the following
reference material must be read.
A company employee must be on site to assist in the recovery process, they must
have access to all relevant manufacturers’ manuals. They are responsible for liaising
with the authority and the company. They are not permitted to disclose any information
without prior approval from Aerogulf management.
• Jet A1 Material Safety Data Sheet (MSDS)

• Air Accidents Investigation Branch – Aircraft Accidents; Guidance for the Police
and Emergency Services (www.aaib.gov.uk)
8.7.2 Bio Hazards.
Personal Protective Equipment (Gloves, masks, eye protection and full length apron)
must be worn in the event of contact with human remains. Hazards such as hepatitis
and Aids / HIV are a very serious risk.
Photographic evidence of any human remains are to be taken prior to removal, then
sealed into plastic bags which in turn must be marked with the exact location that they
were found and collected in to a body bag. Removal will be determined by the Police.
Additional cleaning material such as bleach and disinfectant sprays are to be used
when vacating the site and all protective clothing is to be bagged and marked as bio
hazard for incineration. If at any time personal contamination is suspected medical
advice is to be obtained immediately.
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8.7.3 Fuselage and personal belongings
Fuselage: Dependant on the size (in excess of 25 Kgs), heat damage and condition of
the fuselage assistance may be required in the form of a crane.
Personal belongings: must be treated as evidence and retained, these are to be

bagged and identified from where they were found.
At all time PPE must be worn to avoid ingestion of dust and ash (mask and eye
protection) and the possibility of cuts / crushing (gloves, hard hat and safety shoes).
Removed parts must be labelled with location of the part from where it was found.
8.7.4 Material hazards:
• Hydraulic fluid Aeroshell 4

• Jet A-1 Turbine fuel.
• Oil and grease
• Air condition refrigerant (206)
• Fibre glass (212 tail boom fairing)
• Float inflation cylinder (212 nose compartment), (206 rear baggage
compartment or lower fuselage)
• Float bottle operating cartridge (212 nose compartment)
• Engine fire extinguishers cylinders x2 (212, to rear of both engines)
• Engine fire extinguishers operating cartridges x2 each cylinder, total x4 (212,
to rear of both engines)
• Cabin fire extinguishers x2 (212), x1 (206), in cockpit area
• Life jackets upto 15, integral gas operating cylinders
• Life rafts x2 (212 cabin) x1 (206 cockpit floor or rear bag hold), integral gas
operating cylinders.
• Lead Acid / Nicad Battery (nose compartment)
• Magnesium alloy (transmission / gearbox)
• Cargo, possibly dangerous goods e.g. radioactive material, bio hazards, etc.
8.8 Personal Accident.
The procedure for reporting an accident or incident is the same as that used for first
aid injuries, using the Work Related ‘Personal’ Accident Report’. In the case of
fatalities, serious injuries or high value damage accidents the reporting will be within
24 hours. Copies of the completed Form should be distributed to:
a) Safety / Quality Assurance Manager
b) Flight Safety Officer
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The Aerogulf requirement for reporting injuries and accidents is for the protection of
the employee and the Company, and a record must be retained by the Company.
These records may be required as evidence in any subsequent legal proceedings
affecting the staff, third parties and the Company. By maintaining such records the
Company also benefits by being able to target areas for process improvement. On
completion this report is submitted to the Accountable Manager for review and
closure.
8.9 Vehicular Accident; Company Cars.
Such accidents will be reported to the Accountable manager. The driver should
contact Aerogulf by phone on 2200331, on or by the next working day following the
accident. The driver if possible, is also to submit to the company the copy of the
accident form as issued by the Police, whether this is the RED or the GREEN form. In
either case the driver will be expected to write a report for submission to the
Accountable manager describing the nature of the accident, etc.
8.10 Vehicular Accident; Non-Company Cars
Any accident including those causing injury incurred by Aerogulf staff whilst in their
own car should also be reported via the Focal Points, the personnel manager or to
Operations. This is also especially important if the car is on the Group insurance
scheme and will assist in the early settlement with the Insurance Company.
8.11 Sickness and First Aid Reporting
Generally any First Aid trained staff will attend any staff member who is sick, or injured
whilst at work. However, if required medical assistance can be sought from the Dubai
Police Air Wing medics.
First Aid Kit’s are located in Stores, Overhaul workshop and Avionics workshop. Minor
personal injuries are to be recorded in the book contained within the First Aid kit; this
in turn will be checked monthly by the QA department.
It is incumbent on all staff to report in by phone if they are sick and unable to work.
This must be carried out through their immediate supervisors or through the Personnel
Manager. In addition any injuries incurred while on company business shall be
recorded, irrespective of whether they are working outside normal working hours or
working away from the Aerogulf facility.
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8.12 Near Miss or Potentially Hazardous Situation
The intent of reporting near misses or other hazardous situations, is to give due focus
to the management, and allow them the opportunity to manage the hazard or reduce
the risk. The process of improvement needs the support of all staff; therefore it is up
to each employee to feed back any such problem of which he becomes aware. To
assist in this complete either a Safety report or a Multi-purpose Report and submit to
the Focal Points who will record the information and instigate an investigation. If
confirmed, action will be set in motion to deal with the problem(s). The Focal Point will
ensure that these are reported to the Accountable Manager and that the individual is
given feedback on the planned action and expected resolution.
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9.0 Management of Change (MoC)
9.1 Procedures
The management of change is critical to all of Aerogulf, either when:
• a new type of aircraft is scheduled to enter service;
• a new area of operation is about to start,
• a change to procedures that may affect the safety of personnel, etc.
Each part of the MoC procedure can be defined as a business process and each process
has a process owner, unless otherwise specified this will be the department manager /
supervisor for the part of the business in which the process is primarily performed. When
change is required to the procedures, practices or standards applied for the completion of
any process that has been identified as being as safety critical to the company operations
then that change must be managed into place by the appropriate manager / supervisor.
This requires active management to ensure the staff understand and have appropriate
knowledge of the change and its implications to the operation. Change management
requirements are formally recognised through their inclusion in Safety Meeting agenda,
focussed safety meetings or training requirements.
9.2 Introduction (Appendix 4)

This section provides an overview of the MOC process and describes those involved in the
implementation of this process using the ‘Management of Change’ form (AGS/QA/043).
The 5 Steps:
1. SCREEN 2. REVIEW
Proposed Def ine Proposed Ev aluate Proposed
Change Change Change
4. IMPLEMENT
3. APPROVE Build the Change,
Authorize Change and Document,
Communicate and
Train.
5. CLOSE Start Up
Change is Ready to
Start Up.
Change
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9.3 Role description
• Initiator - Any person who identifies the need for a change and begins the MOC
process.
• Operations Leadership - The supervisors or managers who are responsible for
the operation of the location.
• Department Manager(s) - Individual(s) responsible for the location where the
change is being considered, e.g. Accountable manager, Director of Operations,
Engineering Manager, Chief Pilot and LAE’s.
• Reviewers Those knowledgeable in the particular field or area of expertise that are
requested to comment on a particular change.
• Approver The Accountable Manager (or his designate)
• Owner(s) The person(s) accountable for the operation, maintenance, surveillance
or modification of the equipment, system or process.
• Implementation Resources Those called on to implement the change by
contributing to the completion of the work in their area of expertise and/or providing
assigned documentation, training and communication.
9.4 Step 1: Screen
9.4.1 Overview
In this Step, a proposed change is initiated and then screened to determine if it
1) is desirable and justified,
2) meets the definition of a change that requires an MOC, and
3) has sufficient detail for the reviewers to reasonably understand the purpose, scope
and context.
Note: The MOC Process shall not be used merely to float ideas for comments beyond the
Asset.
9.4.2 Temporary Changes

Temporary changes shall be indicated on the form, including the date of initiation and date
when the change will be returned to original condition. At the end of the approved time limit,
the temporary change shall either be returned to its original condition or a permanent MOC
shall be submitted and approved.
Temporary changes shall not be closed out unless the system is returned to its pre-change
condition or a permanent MOC has been submitted and approved.
9.4.3 Initiator Actions

The table indicates the actions to be performed by the Initiator.
1) Commence the MOC process by starting to fill out the MOC form.
2) Complete all of the form fields that are known. Include the equipment affected by the
change, location of the change, and a description of the proposed change.
3) Submit the MOC request to Operations Leadership.
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9.4.4 Operations Leadership Actions

The table indicates the actions to be performed by Operations Leadership upon receipt of
the MOC form from the Initiator.
1) Screen each MOC request to determine if the change is desirable and justified.
Cancel the change if it does not meet this criterion.
2) Screen each MOC request to determine whether it meets the screening criteria. If
the change does not meet the screening criteria, then cancel the change and archive
the MOC form.
3) Revise the MOC form inputs as required for clarity and completeness, and complete
any remaining fields in the Step 1: Screen section of the form.
4) Assign the Owner(s) who will be responsible for the operation, maintenance,
surveillance or modification of the equipment, system or process.
5) Assign the Department manager(s) who will be responsible for providing
engineering or other technical support to the location or facility where the change is
being considered.
6) The Accountable Manager will have final approval of the change.
7) In the Step 2: Review section of the form, designate the types of reviews required
to assess the change, the Due Date, and assign the Reviewers (by name).
Additional review types/Reviewers may be added to the form as necessary. A
Reviewer shall, as a minimum, be knowledgeable in the particular field or area of
expertise that he or she is requested to comment for a particular change. The
Reviewers of a proposed change shall include:
Representative(s) from both Operations and Maintenance
Representative(s) from HSE or other competent personnel to evaluate the HSE impact, and
8) Determine any documentation changes or new document requirements that may
result from the proposed change. In the Step 4: Implement section of the form,
select the documents and assign an Implementation Resource and Due Date for
each item selected. Additional documents may be added to the form as necessary.
9) Determine the Communications and Training Requirements and identify which
functional group(s) – Operations, Maintenance or HSE - should provide the
necessary communication and training. In the Step 4: Implement section of the
form, select each required training functional group, Due Date and Resource
Name(s).
10) Submit the form to the Department Manager.
9.4.5 Department Manager Actions

The table indicates the actions to be performed by the Department Manager upon receipt of
the MOC form from Operations Leadership.
1) Review the entire MOC form from a technical standpoint, and modify or improve any
information provided on the form.
2) Review, and modify as necessary, the list of Reviewers so that the list conforms to
the reviewer requirements that are described in the Operations Leadership Actions
above. Ensure that the MOC form has sufficient detail for the reviewers to
reasonably understand the purpose, scope and context.
3) Submit the form to the Reviewers for comments.
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9.5 Step 2: Review
9.5.1 Overview
In this Step, the change is evaluated, and any issues involving the proposed change are
identified and documented. Examples of issues to be raised are HSE consequences and
risks, design deficiencies, documentation needs, communications and training
requirements.
9.5.2 Reviewer Actions

The table indicates the actions to be performed by each Reviewer upon receipt of the MOC
form from the Department Manager.
1) Review all aspects of the form, including any comments available in the form from
other Reviewers.
2) Seek clarification on ambiguous or vague wording that causes doubt as to the
intended change, review or implementation.
3) Assess the need for any additional mitigation for identified health, safety, or
environmental hazards.
4) Recommend further review by different specialties, engineering disciplines, or
consultation when, in the opinion of the reviewer, additional review would enhance
the assessment of the MOC.
5) Document all comments and recommendations in the Reviewer Comments field
provided on the form. The review comments shall be meaningful, and may include
attachments if necessary to support the comments. Reviewers should identify any
HSE issues or concerns from their review. As appropriate, the Reviewer’s
comments should identify:
The impact of the change;
Who additionally should review the Form;
What additional information is required; and
What additional documentation is required?
6) Submit the form back to the Department Manager.
9.5.3 Department Manager(s) Actions

The table indicates the actions to be performed by the Department Manager once the MOC
form has been returned from the Reviewers, or if the MOC form has been returned from the
Approver with an indication of “Review Not Adequate”.
1) Reconcile any conflicts, inconsistencies, questions or ambiguities raised by the
Reviewers or Approver.
2) Determine whether the review scope and comments received are now adequate.
If. . . Then. . .
Further review is required Provide comments in the Department
Manager comments field, consider adding
Reviewers for further evaluation, and
resubmit the form to the Reviewers.
All Review issues have Submit the MOC form to the Approver.
been addressed
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9.6 Step 3: Approve
9.6.1 Overview
In this Step, a determination is made as to whether the MOC is Approved or Cancelled or if
further review is required.
9.6.2 Approver (Accountable Manager) Actions

The table indicates the actions to be performed by the Accountable Manager once the
MOC form has been received from the Department Manager.
1) Review the MOC form and associated documentation. In particular:
• Determine that plans are in place to adequately address HSE concerns raised
within the MOC.
• Ensure that design and operability issues either are addressed or will be
addressed.
• Determine whether an adequate review of the change has been conducted.
2) Once satisfied that all relevant aspects of the proposed change are understood,
make one of the following decisions regarding the change:
Decision Action
Approve Approving the MOC signifies that:
Reviews have been completed by skilled personnel from
required groups,
The scope and impact of the change are understood;
Identified hazards have been suitably addressed;
Required Implementation work processes are adequately
identified and can begin (e.g. detailed design, physical
work, etc.).
Submit the form to the Implementation Resources.

Cancel State the reasons for canceling the MOC in the
Approver Comments field, and archive the MOC form.
Further Provide comments about the review in the Approver
Review Comments field. Submit the form back to the
Required Department Manager.
9.7 Step 4: Implement
9.7.1 Overview
In this Step, detailed documentation, communication, training, and actual work are
conducted to bring about the change.
From the standpoint of the MOC form, two sets of requirements shall be tracked:
Documentation Requirements;
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Communication and Training Requirements.
9.7.2 Pre-Startup Safety Review

As part of the implementation, a pre-startup safety review (PSSR) shall be conducted.
The Pre-Startup Safety Review (PSSR) serves to verify that the change is complete and
that the facility and operating personnel are prepared to incorporate or activate the change.
The PSSR includes:

• Verification that necessary Implementation, Training, and Communication
activities are complete, and
• As appropriate, a walk-through by Operations Leadership.
9.7.3 Starting up a Change prior to completion of implementation

In certain circumstances, it may be acceptable to start up a change prior to completion of
all implementation tasks, when meeting the following conditions:
1. The implementation step is sufficiently complete to allow a safe startup and safe
operation of the change;
2. If a PSSR is required, it shall be done prior to startup;
The decision about whether to start up prior to completion of implementation is made by the
Owner.
9.7.4 Implementation on Resource Actions

The table indicates the actions to be performed by each Implementation Resource when an
approved change has been received from the Approver.
Action
1 Provide assigned documentation, training and communication.
2 Contribute to the completion of the implementation work.
3 When the assigned implementation task(s) are complete,
indicate as such on the MOC form.
4 Submit MOC form to the Owner.
9.7.5 Owner Actions

The table indicates the actions to be performed by the Owner when an approved change
has been received from the Approver.
Action
1 Monitor the implementation process to determine when
implementation is sufficiently complete, and all hazards are
sufficiently mitigated to allow startup of the change prior to the
completion of all tasks.
2 Ensure that a Pre-Startup Safety Review (PSSR) is
conducted, if required, to evaluate the change, and address
any findings from the PSSR.
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3 Authorize start up of the change, and document the
authorization on the MOC form.
9.7.6 Approver Actions

The Approver may stop the change after Implementation has begun. The table indicates
the actions to be performed by the Approver if the MOC needs to be cancelled after
implementation has begun.
Action
1 Cancel the change and notify the Implementation Resources
of the cancellation. Consider whether any completed
implementation tasks may need to be changed back to pre-
change status.
2 Archive the MOC form.
9.8 Step 5: Close
9.8.1 Overview
In this Step, the change is closed because implementation is complete.
9.8.2 Owner Actions

The table indicates the actions to be performed by the Owner after receiving indication from
all Implementation Resources that implementation is complete.
Action
1 Verify that all documentation, communication and training
requirements in Step 4: Implementation of the form are completed
and documented in the form.
2 Verify that the work or activity necessary for the change to take
place is complete.
3 Verify that the Pre-Startup Safety Review (PSSR) has been
performed, if required.
4 Signify closure on the MOC form.
5 Archive the MOC form.
REV: 0 DATE: 27-05-09 PAGE: 9-7

10 SAFETY PROMOTION
10.1 Safety Training

Ref: Operations Manual
MMOE Part 3
MMOE - ‘Certifying Staff and Personal Authorisation’ folder.
Training folders
Procedure P 621, Training and Awareness
10.1.1 Safety Personnel training

The Accountable Manager shall attend Safety Awareness training as a minimum in order
to better understand the safety objectives, safety policy, SMS roles and responsibilities
and the interrelationship of Safety and Quality.
The Safety / Quality Assurance Manager and Safety Officer within Aerogulf shall both
come from an aviation background with experience on the maintenance and operation of
the aircraft to which they must maintain quality and safety oversight.
In addition they will be conversant with the regulations, have attended formal recognised
audit training and prior to assuming their position will have attended a Safety Management
System course as a minimum.
10.1.2 Employee Training
The Director of Training (Operations) and Safety / Quality Assurance Manager

(Engineering) also establish, maintain and implement a Training Needs Analysis(TNA)
which specifies details of the training to be carried out in each department sufficient to
permit effective implementation of the Quality and Safety System including compliance of
regulatory, customer and Aerogulf requirements.
Training includes initial and recurrent training to cover quality and safety as per Aerogulf,
Regulatory and Manufacturer requirements; this can be carried out in-house.
The scope of the training carried out is dependant on the individuals’ involvement in the
Safety Management System and is carried out as part of Operations crew CRM training
and for engineering department personnel at specific training establishments, at
manufacturer’s facility, biennially and in-house.
The effectiveness of the training is evaluated based on the Course Feedback from the
employee who received the training and/or on the performance of the employee prior and
after the training. Records of these evaluations are documented and maintained.
Management to identify gaps in the training schedule, frequency of training and recurrent
training, periodically reviews training records as part of the Management Review process
and quarterly manpower meetings.
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10.2 Competence and Awareness
Ref: MMOE
Other measures include the availability of clear and precise instructions, procedures,
flowcharts, etc. for activities that do not require specific training, e.g. Engineering
Procedures Manual, Operations Manual, etc.
Appropriate records of the employee's education, training, skills and experience are kept
in the employee's personal file.
The awareness of employees regarding the importance of their activities and their
contribution in achieving quality or safety objectives is established through induction
training at the beginning of their employment or when they assume new responsibilities,
which covers initial human factors, quality, safety, security and regulatory issues.
10.3 Safety Awareness
The Safety / Quality Assurance Manager will provide awareness training for all employees
either as part of the recurrent training programme and in particular at the regular monthly
meetings of pilots and engineering employees.
As detailed within section 7, the minutes of these meetings are displayed for all
employees to enable active feedback and involvement. Additionally through Read and
sign / Initial safety information can be communicated directly to those that need to know
giving reasons why actions have been taken, changes to procedures and generic safety
and quality information.
Ultimately any changes will be adopted permanently within the relevant manuals.
The Safety Notice boards in Operations and Engineering are also used to communicate
safety and quality issues. Safety letters and bulletins as issued by the various authorities
worldwide are also displayed giving details of related issues, and in particular helicopter
offshore operations.
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APPENDIX
Appendix
1 Safety Plan
2 GAP Analysis
3 Emergency Response Plan
4 Management of Change
5 Job Safety Analysis
6 Risk Assessment
Safety Program Activities 2009
January February March April May June July August September October November December Remarks
1 GCAA Ops audit
2 Shell Audit Eng meeting Eng meeting
3 Shell Audit Dugas Eng meeting Eng meeting Shell audit report compliance by 03/08/09 & 03/02/10
4 Eng Meeting Eng meeting
5 DP Audit Eng meeting
6 DP Audit
7 DP Audit Eng meeting
8 Dugas o/s Dugas o/s Dugas o/s
9 Dugas o/s
10
11 Dugas o/s Dugas o/s
14 Dugas o/s
15
16 Pilot Meeting
17
18 Dugas Meeting
19
20
21 Pilot Meeting Pilot Meeting
22 Pilot Meeting DP / SRB
23 DP / SRB DP/SRB
24 DP DP
25 Dugas Meeting DP
26 DP DP Dugas Meeting DP
27 DP
28 Dugas Meeting DP
29 DP/SRB
30 GCAA Report
31 GCAA Report GCAA Report GCAA Report
Dugas o/s - Attend Dugas monthly offshore safety meeting

Dugas Meeting - Quarterly Onshore Dugas Safety Meeting
GCAA Report - Quarterly summary to GCAA
DP- Monthly DP Safety Meeting
SRB - Quarterly Safety Review Board meeting
SAFETY MANAGEMENT SYSTEM
GAP ANALYSIS
Establish baseline Plan
Primary considerations YES NO Current status Set Goals
1 Does the corporate culture 

promote and support safety
(and health) efforts?
2 Is management committed to and 
supportive of safety efforts?
3 Are employees involved in safety 
efforts?
Are these steps followed for 
implementing a successful
safety management system?
• Provide management
commitment and
leadership
• Assess (establish a baseline)
• Plan (set goals,
strategies, and tactics)
• Implement strategies and
tactics
• Review and adjust
5 Does the safety management 
system give equal consideration
to the administrative,
operational/technical, and
cultural/behavioral issues of
safety?
6 Is the safety management 
system integrated throughout
the company?
7 Is the safety management 
system proactive and
preventive?
8 Has a clearly stated safety 
policy been established and
communicated to all
employees?
9 Are safety program goals and 
objectives defined?
10 Is senior management 
visibly involved?
11 Are employees involved in safety 
program planning and
implementation?
12 Is assistance provided to 
managers and supervisors so
they understand their
responsibilities?
AGS/QA/045 Rev 0 1 Date: 22-09-09

SAFETY MANAGEMENT SYSTEM
GAP ANALYSIS
Establish baseline Plan

Primary considerations YES NO Current status Set Goals
13 Are resources provided to 

responsible personnel?
14 Are there periodic reviews of off- 
the- job programs, projects, and
activities to determine their
effectiveness in achieving goals
and objectives?
15 Are statistical analyses used to 
identify causes of off-the-job
injuries, illnesses and property
damage?
16 Is safety training provided to all 
employees?
17 Do you take an active role in 
building management
commitment?
18 Are the following safety areas 
included in the Safety
Management System?
• Hazard recognition,
evaluation and control
(HEMP / Risk
Assessment)
• Occurrence / Incident
reporting
• Job Safety Analysis
• Employee involvement
• Safety training
• Safety communication
• Safety Meetings
• Industrial hygiene
• Hazard communication
• Ergonomics
• Personal protective
equipment (PPE)
• Record keeping
• Emergency action
planning (ERP)
• Safety induction
• Managing safety efforts
John Scott-Laws Robert Denehy

Safety / Quality Accountable Manager
Assurance Manager
Date: Date:
AGS/QA/045 Rev 0 2 Date: 22-09-09

Appendix 3 HELICOPTER EMERGENCY RESPONSE PLAN

Ref: Form AGS/OPS/033
REV: 0 DATE: 27-05-09 APPENDIX 3 PAGE: 0-1

Management of Change
Step 1 SCREEN Initiators to complete as many fields as possible in this section, then submit the form to
Management. Fields to be verified and remaining fields to be completed by nominated
manager and / or Engineering Manager / Director of Operations.
Initiator: Origination Date: MOC #:
Operations Leadership:
Area: Facility: Location:
Type of Change:
Duration of Change:
Permanent
Temporary From: To
Start Date End Date
Equipment, System or Department
select one from the categories below
Helicopters Effected Tech records
Maintenance 145 Waste Handling
Stores Administration
Sheetmetal wokshop Operations
Machineshop
Avionics
Safety Equipment
Overhaul workshop
NDT workshop Other (specify)
Paint shop
Helicopter ramp
Hangar
Description of Change:
Attach supporting documents
Reason for Change:
Attach supporting documents
Proposed Start-up Date:
Roles:
To be Assigned by Management
Owner: Department Manager: Approver:
The person accountable for the Individual responsible dependant on Accountable Manager
operation, maintenance, surveillance or where the change is being considered.
modification of the equipment, system or
process.
AGS/QA/043 Rev: 0 DATE: 14-07-09 Page 1 of 3

Step 2 REVIEW
The fields below to be completed by nominated manager The fields below to be completed by the Reviewers
Select all that Reviewer Reviewer Comments Review Complete
Review Type apply Assigned (Attach supporting documents)
Due Date Initials Date
Flight Safety/ HSE Impact
Director of Operations
Chief Pilot
Director of Training
Engineering Manager
Quality / Safety Control
Security Manager
Chief Pilot
Ground Ops Manager
Accounts
Other 1 (specify):
Other 2 (specify):
Other 3 (specify):
This section to be completed by the Accountable Manager.
Step 3 APPROVE
Cancel MOC Yes / No Review Not Adequate Approved
Return the form to the Engineering Forward form to the Implementation Resources.
Archive the MOC Form. Manager / Director of Operations to
resolve.
Comments:
Signature: Date:

Step 4 IMPLEMENT
The fields below to be completed by nominated manager The fields below to be completed by the
implementation resources.
Select all that Resource Assigned Completed
apply
Item Due Date Name Initials Date
Documentation Requirements
General Arrangement/Plot Plan
Process & Instrumentation Diagram
Hazards Analysis Documentation
Material Safety Data Sheet (MSDS)
Regulatory Submittals (GCAA)
Design Codes & Standards Utilized
Specifications Utilized
Equipment Data
Procedures – Operating
Procedures – Maintenance
Fire Fighting & Safety Equipment
Plan
Safe Work Plan
Pre-startup Safety Review
Training Material
CAR OPS (Sub-part K & L)?
Other (specify):
Other {specify):
Other (specify):
Communications and Training Requirements
Communication and Training –
Operations/Pilots
Communication and Training -
Maintenance
Communication and Training - HSE
Other (specify):
Cancel After Implementation has Started Approver Signature:

MOC Canceled
Date:
Reason for Cancellation:
Authorize Early Startup Owner Signature:

The implementation step is sufficiently complete to allow a
safe startup and safe operation of the change, and the Pre-
startup Safety Review (PSSR) has been completed, if required. Date:
Step 5 CLOSE This section to be completed by the Owner
MOC Canceled Owner Signature:

Reason for Cancellation:
Work Complete, Change Managed to ALARP
Date:

JOB SAFETY ANALYSIS
Area: Scope of Work:
Date: Supervisor: Team Lead:

Do not deviate from scope of work. If change is required – STOP – regroup – discuss – then proceed with the work.
Required personal protective equipment:
Other PPE requirements:
Work Procedure/Guideline Ref No: Permit No:
BASIC JOB STEPS POTENTIAL ACCIDENT OR ACTIONS TO REDUCE RISK RESPONSIBLE PERSON
HAZARD
Attendees:
Form No: AGS/QA/042 Rev. 0 DATE: 18-05-09

JOB SAFETY ANALYSIS
Hazard Management Hazard Identification

Can all personnel in the group answer YES to the following questions: Will the work involve:
• Have all the significant hazards involved with the work been identified? • the use of lifting equipment?
• is separate lifting plan available/required?
• Have control measures been identified for these hazards? • working near objects which may move?
• use of ground power, AC / DC?
• Have the people responsible for implementing these control measure been identified?
• manual handling – moving objects . loads?
• Are these control measures in place? • working in tight or confined space?
• working at height?
• Has the method of communication been agreed and tested? • working near areas which could cause personnel
to slip, trip or fall?
• Is everyone aware of what everyone else is doing at the work site? • using portable electrical equipment?
• Does everyone know that any changes to the work plan have to be communicated to • working with equipment or connections under
pressure – Ground Test rig?
everyone involved in the work?
• working dangerous goods and substances
• Does everyone know that any new people joining the work party must be given a full and hazardous to health?
thorough handover? • working in areas with poor lighting or high
noise levels
• Is the immediate area free of any conflicting work? • personnel who are new to the company or each
other
• rotating equipment
If the answer to any one these question is NO, then the safety of people is at risk
If so, the work may be hazardous and care should be taken to ensure that work is done
safely.
Remember everyone is responsible for:
Using the correct tools for the job
being aware of the hazards around them and remaining vigilant to changes
using the correct PPE for the job
Making themselves aware of and working to the requirements of HSE / ISMS system,
The Supervisor should confirm the understanding of the group by asking open questions on Maintenance Manual, Procedures, Risk Assessment knowledge what action to take in an
the above point emergency
Form No: AGS/QA/042 Rev. 0 DATE: 18-05-09

RISK ASSESSMENT
Use for Safety, Hazards and

Risk Assessments
Ref. No.
Hazardous Event:
Base / Location: Type of Harm:

Section/Department: Injury
Work Activity: Damage to
environment
Employees at risk:
Others who may be at risk:
Assessor Name: Signature:
Date of Assessment: Review date:
INITIAL ASSESSMENT:
DOES THE EXISTING ARRANGEMENTS OR CONTROLS TO THE HAZARD EXIST? YES □
NO □
Detail the controls in place:
IF SO, ARE THEY EFFECTIVE? YES □

NO □
N/A □
IF ADDITIONAL CONTROL MEASURES ARE REQUIRED, CAN THEY BE IMPLEMENTED YES □
IMMEDIATELY NO □
IF NO, SUMMARISE ACTION PLAN BELOW
Action required: Target Date Action by: Completed by
(Name & Date)
Date for full implementation of control measures:

Assessment accepted by: (relevant manager):
Title:
Date:
AGS/QA/044 Rev 0 1 Date: 22-09-09

RISK ASSESSMENT
RISK ASSESSMENT
RAM RAM
Hazards/Risks Additional control Residual Risk
(A to E)
Increasing Likelihood
Consequences (PEAR)
Severity (0 to 5)
Risk Rating (H, M, L)

measures required* Rating
(High,
Medium
or Low)
* Including existing physical preventative measures (e.g. interlocks, guards, mechanical controls etc.)
AGS/QA/044 Rev 0 2 Date: 22-09-09

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COPY No 6004-k

REV: 0 DATE: 27-05-09 PAGE: 0-1

0.1 TABLE OF CONTENTS

SECTION 1.0 SCOPE OF SMS 1-1

SECTION 2.0 SAFETY POLICY AND STRATEGIC OBJECTIVES 2-1

SECTION 3.0 SAFETY ACCOUNTABILITIES 3-1

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3.6 Informed Involvement 3-7

SECTION 4.0 KEY SAFETY PERSONNEL 4-1

SECTION 5.0 DOCUMENTATION CONTROL 5-1

SECTION 6.0 HAZARD IDENTIFICATION AND RISK MANAGEMENT 6-1

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application of the RAM

SECTION 7.0 SAFETY PERFORMANCE MONITORING 7-1

SECTION 8.0 EMERGENCY RESPONSE PLANNING 8-1

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8.7 Accident Investigation and Reporting 8-4

SECTION 9 MANAGEMENT OF CHANGE (MoC) 9-1

SECTION 10 SAFETY PROMOTION 10-1

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APPENDIX Index Reference

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0.2 LIST OF REVISIONS

Rev. Date Sign Nature of revision

0 27-05-09 JSL ISSUE

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0.3 LIST OF EFFECTIVE PAGES

Section 0- 3-8 Rev 0 7-7 Rev 0

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0.4 DISTRIBUTION LIST

No: 6004-a Master Copy Safety / Quality Assurance Manager

No: 6004-b Accountable Manager

No: 6004-c Director of Operations / Flight Safety Officer

No: 6004-d Engineering Manager

No: 6004-e Chief Pilot / Security Manager

No: 6004-f Director of Training (Operations)

No: 6004-g Administration Manager

No: 6004-h Flight Operations

No. 6004-i Engineering Line Office

No. 6004-j Assistant Accountable manager

No. 6004-k GCAA

No. 6004-l Ground Operations Manager

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0.5 Index and Revision Status

0.6 System Interaction - Associated Manuals

0.7 Manual Source Material

0.8 Operational Environment

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0.9 Abbreviations and Definitions

AAIB Air Accidents Investigation Branch (UK)

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systems of work to be ignored or otherwise be unofficially

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barriers, e.g. maintenance failure, due to explosion or fire,

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Responsibilities Those duties which describe the purpose of what an individual

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Safety Is the state in which risk is reduced to, and maintained at

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regarded as another dimension of probability.