Form: Version:

MS.FORM.012 1.0
Audit Report
No: Date: Page/No.
SAF001Ex 22.12.2021. 4/4

Organisational Unite: M-NAV

Audit type: External

Model: Periodical
Audit subject: Safety Management System (EC_2011R1035)

Тим за проверу
1. Audit Team leader: Igor Došljak
2. Team member: Sergej Raca

Participants: 1. Leonora Shala, Head of Quality/Safety section

2. Jasminka Gočeva, Head of Safety Quality Security Department

Report
1. Entry meeting (introduction)
At the introductory meeting, the goal and scope of the Audit was presented (as stated in the Audit
announcement, e-mail of 15.12.2021), necessary activities (Responces and evidence in accordance with
the prepared questionnaire) and the timetable of the Audit. It is indicated that the Audit plan included
verification of compliance with regulatory requirements aligning the scope of the requirements
EC_2011R1035. Requirements for ATM/ANS providers and the safety oversight thereof aligning Safety
Management Systems (SMS) requirements in Commission Implementing Regulation (EU) No 1035/2011
to ANNEX II - General organization common requirements for the provision of
ATM/ANS/Part-ATM/ANS.OR) framework.
The SMATSA Team presented a questionnaire to be conducted.
2. Verification activities
During the inspection, based on the answers received and the evidence presented, the following was
found:

M-NAV manages the following services that belong to the parts of the functional System which has
impact on safety: ATS, AIS, MET and CNS.
Within the implemented Safety Management System (SMS), M-NAV has developed procedures for
managing the safety of its services, which are described in the document Safety Management Manual
(SMM), approved by the competent aviation authority - Civil Aviation Agency authority of the Republic of
North Macedonia - CAA).

The Safety Management Manual (SMM) based on the presentation by M-NAV has the following content:

1. Safety Policy
2. Safety Accountabilities and Responsibilities
3. SMS Organizational Structure, including a Safety Manager
4. Safety planning, in terms of established safety performance targets and SMS enhancement
plan
5. Safety reporting and investigation
6. Safety performance monitoring and measurement
7. Safety Surveys
8. Safety Documentation, including safety standards and procedures
9. Competency
10. Risk Management, including hazard identification, risk assessment and mitigation
11. Safety interfaces
12. Continuous (Safety) improvement
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13. Safety promotion and lesson dissemination

The document Safety Policy (Safety Policy…. Name and label) shows the commitment to safety
improvement, proactive approach to safety management, as well as safety responsibility, safety priority
and safety objective. The Safety Policy document, approved and accepted by the management, is
prominently displayed and is available to all M NAV employees.

 Safety responsibility is processed through several documents: Safety Policy, Organizational

structure, Rulebook on organization and systematization of jobs and procedure + NAME AND
MARK.
 The main safety objective of the M-NAV (Safety Objecive), to reduce the contribution of air traffic
services to the risk of an air accident as much as possible, is set out in the Safety Policy and
SMM.
 Within SMM, M-NAV has developed procedures for managing the safety of its services when
introducing new functional Systems (CHG MGM PROC). During the verification of the
introduction of changes in the functional system, as a sample, two documents of the Safety Case
for VHF replacement and the introduction of the Free Route concept were provided.
Based on these two documents, the process of introducing changes in the functional system
based on the prescribed documentation was presented. The analysis of hazards and potential
risks is performed on the basis of the "SAM" methodology and the defined classification scheme
of risks. The Safety department monitors trends defined by safety objectives through Audit
reports, inspection reports, reports, reports on the monitoring reports for equipment and systems,
analysis of occurrences and recommendations).
The process is based on a cycle from initial planning and definition to decommissioning, through
maintenance and withdrawal from operational work. The process consists of initial reporting to
the regulator (ACV), by forming a working group for a given change, creating a “brainstorming
session”, identifying hazards and otherwise creating a Safety Case (SC). Every change is
checked in the next Audit by the regulator.

Hazard detection and risk assessment is performed in a systematic way (Change Management and Risk
Classification Ver.1.0). During the Audit, two changes in the functional system were presented (state the
exact names of VOR DME Ohrid and______) through which the stated findings were determined.

M-NAV establishes links with all stakeholders that may affect safety through contracts/ agreements with
the Ministry of the Interior, the Army, the Airport Company, as well as a memorandum of understanding
with the neighboring ANSP through the LOA and SLA.

Criticality of certain services is defined on the basis of the document Procedure for External Services
V.2.0; Date 02/26/2019 (Chapter 5.3.3 Identification of external services and their criticality). Lists of
external stakeholders are updated once a year and approved by the board.

 The document Accountability and Responsibilities (NAME AND MARK) defines the function of
Accountable Manager, defines competencies and responsibilities and defines the Safety
Committee (safety and quality managers participate in the work), safety group (Senior officers
and department heads participate in the work as an external experts as needed). Training is
defined for each position, i.e. defined each completed course the employee must have. The
functions of the Managing Board, the President of the Managing Board, and the Executive
Directors of the Sector have been defined. Also, in M-NAV there is a document that defines the
job catalog (systematization of jobs) and clearly defines the organizational structure.

 Training and competence of employees to perform the tasks they perform is the subject of the
procedure for determining competence (MNV-850-407 Staff Competence Assurance Procedure
and safety training plan, V.2.0; Date 07.03.2019). To carry out specific activities such as
occurrence analyses and verification, employees must have completed appropriate courses
(AOI, Safety Survey,…).
 The procedure for drafting and managing documents/documentation is prescribed by the SMS
procedure and the document management procedure (NAME AND MARK). Safety levels are
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defined through the document МНВ-850-406 Safety performance monitoring and measurement;
V.3.0; Date 22.02.2019 based on where safety goals are defined on an annual basis through:
(a) Leading indicators
(b) Lagging indicators
(c) Precursor events
(d) Differing levels of safety performance monitoring

In addition to the elements of the five-year Strategic Business Plan (approved by the Government of the
Republic of Northern Macedonia and the M-NAV Steering Committee), the findings from the Audit and
Survey reports are also used as input data. Safety objectives, adopted annually by top managers are
reviewed semi-annually (sector managers - tactical level) and quarterly (operational level - every 3
months) based on reports from organizational units.

 Based on the Safety Survey reports, evidence is collected on the state of the functional system.
Based on the results, corrective measures are analyzed by the Safety Group or the Safety
Committee and officially distributed to the relevant sectors. The procedure for conducting the
Safety Survey is prescribed in the document Safety Survey and Internal Audits; V.2.0; Date
02/22/2019 The Safety Survey is conducted in accordance with the approved annual plan.
 Based on the procedure for reporting and analyzing events, procedures for mandatory and
voluntary/anonymous reporting of events are defined. Mandatory reporting of events is done
through the shift manager, and anonymously in accordance with the procedure defined (check if
there)
 on page 8 of the procedure for reporting and analysis of occurrences (SPECIFY THE NAME
AND MARK OF THE PROCEDURE). Preliminary findings of the occurrence analysis are
distributed within 72 hours, followed by a final report. Based on the analysis report,
recommendations and corrective measures are defined, which are adopted by the safety group
and distributed to the appropriate addresses. The RAT methodology is used to classify the
severity of events.
 Feedback from the event research process is conducted/submitted in accordance with point
2.3.4 of the procedure.
 Promotion and lesson dissemination is done in order to inform employees about the findings or
recommendations of good practice within the M-NAV. In the past year, three safety bulletins
were issued, and notifications are made via the internal network (intranet) as well as by
distribution of minutes from the Safety Committee. In addition to the mentioned ways, the impact
on improving safety is also done through trainings (TRM) and operational briefings.

Reviewed documentation:
- МНВ-850-408 Change management and assessment of ATM changes; V.1.1; Date 22.02.2019
- МНВ-850-406 Safety performance monitoring and measurement; V.3.0; Date 22.02.2019
- MNV-850-417 Safety Record Management V.2.0; Date 22.02.2019
- MNV-850-418 Safety promotion (lesson dissemination and safety improvement); V.2.0; Date
22.02.2019
- MNV-850-420 Plan za obuka za safety V.2.0; Date 07.03.2019
- MNV-850-416 Safety Survey and Internal Audits; V.2.0; Date 22.02.2019
- MNV-850-412 Procedura za nadvoreshni servisi, V.2.0; Date 26.02.2019
- MNV-850-412.01 Одобрена листа на над сервиси 2019
- MNV-850-420 Plan za obuka za safety, V.2.0; Date 07.03.2019
- MNV-850-407 Staff Competence Assurance Procedure and safety training plan, V.2.0; Date
07.03.2019
3. Findings
No findings identified
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4. Opservations

 There is no procedure for the adoption of a new external entity if it occurres;

 There is no predefined period when it is necessary to refresh knowledge in certain areas as proof
of competence;
 M-NAV does not have a prescribed procedure or specified requirement for continuous training of
non-operational staff;
 Monitoring safety levels is hampered by the lack of a unified monitoring system. (M-NAV does
not have a table of identified risks whose manifestations would be monitored on the basis of
information obtained from the procedures for reporting and investigating events, external and
internal checks and other available sources on the occurrence of events, problems and / or
irregularities). hazard identification when introducing changes to the functional system).

5. Closing meeting

Preliminary findings were presented at the final meeting and it was agreed that the audit report be
prepared in the form used by SMATSA doo for its internal audits, as well as that the report be prepared in
English.

It was also stated, taking into account that this type of verification has not been done so far and that the
competencies between service providers on this issue have not been clearly defined, that MNAV has no
obligation (it is a matter of good will) to provide feedback on reported discrepancies and observations.

Audit leader: Igor Došljak

Team Member
_________________________________________

Aproval of report: Leonora Shala