Introduction To Safety Management System (SMS) : Flight Standards and Industry Roles

Introduction to Federal Aviation
Administration
Safety Management
System (SMS)
Flight Standards and

Industry Roles
Presented By: Flight Standards Service
Federal Aviation SL-1

Administration
Downloaded from www.avhf.com
Agenda
•Overview
•Safety Fundamentals & Case for SMS
•SMS Fundamentals - Overview
•Policy Component
•Safety Risk Management Component
•Safety Assurance Component
•Safety Promotion Component
•Standards, Tools and Implementation

Administration
Federal Aviation
Administration
Overview

Administration
What SMS is not and what it is…
What it isn’t: What it is:
A substitute for Compliance is integral
compliance to safety management
A substitute for An effective interface for

oversight safety management
A replacement for SMS completes the
system safety systems approach
A requirement for a A set of decision making

new department processes for senior and
line management

Administration
What is safety?
• Freedom from harm (Dictionary def’n.)
• Safety is not equivalent to risk free (U.S.
Supreme Court, 1980)
• “Risk management” is a more practical term than
“safety.” (Jerome Lederer ~1928)
• Carelessness and overconfidence are more
dangerous than deliberately accepted risk
(Wilbur Wright, 1901)
• Practical safety is risk management

Administration
Definition of Safety
“Safety is the state in which the risk of harm

to persons or property is reduced to, and
maintained at or below, an acceptable level
through a continuing process of hazard
identification and risk management”
ICAO Doc 9859

Administration
3- Minute SMS Introduction Video
Example Safety Promotion Video

Administration
Safety Management Systems
“SMS”
A systemic approach to managing safety,
including the necessary organizational
structures, accountabilities, policies and
procedures.
ICAO Doc. 9859

Administration
SMS Purpose and Methods
• Safety management systems provide a
systematic way to control risk and to
provide assurance that those risk controls
are effective
• The SMS gives the certificate holder a

formal means of meeting statutory safety
requirements (title 49) and the FAA a means
of evaluating management capability

Administration
System Safety
• "The application of special technical and
managerial skills in a systematic, forward
looking manner to identify and control hazards
throughout the life cycle of a project, program,
or activity" (Roland & Moriarty, 1990)
• Traditional approach concentrates on technical
• SMS adds emphasis on management elements

Administration
SMS, ATOS, SAS, and QMS
Does SMS =ATOS=SAS? Does SMS = QMS?
• SMS • Same principles but
– Management system different objectives
– Only service provider can • QMS Objective
manage – Customer satisfaction
• ATOS • SMS Objective
– Oversight system – Aviation safety
– Used to meet regulator
responsibilities
• SAS
– Safety Assurance System
– FAA-Future-State system
safety oversight across
14CFR parts (121, 135, 145)

Administration
ICAO Annex 6
• “From 1 January, 2009,
States shall require, as part
of their safety programme,
that an operator implement
a safety management
system acceptable to the
State of the Operator…”
• The U.S. has filed a
difference with ICAO
• Currently, there are no FAA
authorized procedures to
accept of approve Service
Providers’ SMS’s

Administration
ICAO: State’s “safety
programme”
• Definition:
– An integrated set of regulations and activities aimed
at improving safety.
– Includes SMS requirements for aviation service
providers
• The AVSSMS is the U.S. safety program
– FAA Oversight
• Regulations, Standards & Policy
• Assurance (ex; Certification, Surveillance, etc.)
– Service Provider SMS Requirements

Administration
ICAO •Annex 6
State Safety
Programme (SSP)
•ICAO Doc 9859: Safety
Management Manual (SMM)
SSP Framework SMS Framework
FAA Aviation Safety •Order 8000.369; FAA SMS Guidance

(AVS) Safety
Program=AVS SMS
•VS8000.367; Requirements Doc
Internal External
(FAA SMS) (Service Provider
SMS)
Flight Standards •AC 120-92; SMS Standard

•Developmental Guidance
AVS LOB’s
SSP & FAA Air Operators’/

Oversight Service
Providers’ SMS

Administration
Clarifying the “3 R’s”:
FAA’s Safety Roles, Responsibilities

Management
(Oversight)
and Relationships:
(SAS)
•FAA
•Service Providers
Operator’s Safety
Management Operational
System Process
(External SMS)

Administration
Federal Aviation
Administration
Safety
Fundamentals
&
Case for SMS

Administration
What is the Fundamental Objective of
a Business Organization?
To achieve its
production objectives!

Administration
The Business Case
• Aviation organization management requires
managing many business processes.
• Safety management is a core business

function just as financial management, HR
management, etc.
• This constitutes a management challenge.

Administration
Protection and Production
• Safety Requirements
– Title 49 USC…44702 “…the duty of an air
carrier to provide service at the highest level
of safety in the public interest”
• Economic Requirements
– [Proposed operation must be] “…consistent
with public convenience and necessity”
– [Company must be] “…fit, willing and able to
provide the service proposed”

Administration
Safety Space
Protection Bankruptcy
Financial
Management
Unrocked Boat
Safety
Management Catastrophe
Production
Life of the system
Administration
Safety Management System
• Infuses safety into all parts of the system
– People
– Tools Management levels
– Procedures
– Materials
– Equipment
– Software
Protection Production
• To maintain the balance of production and

protection
Administration
Accidents and Incidents Cost!
Direct costs Indirect costs
• Loss of aircraft • Loss of use of equipment
• Injuries to or death of • Loss of staff
flight crewmembers, – Involved in accident issues
passengers – Lower productivity
• Insurance deductibles • Investigation & clean-up
• Costs not covered by • Legal claims
insurance • Fines
• Misplaced/stranded
passengers
• Negative media exposure

Administration
R a m p D a m a g e H a s B ig P r ic e
T a g F o r A ir lin e s
A ile r o n & T a b A s s e m b ly $ 1 8 3 ,5 4 5
O u tb o a r d F la p A s s e m b ly
$ 2 5 5 ,8 4 5
P a r ts p r ic e s o n ly
E le v a to r
In b o a r d F la p
A s s e m b ly
A s s e m b ly $ 2 2 4 ,8 7 2
$ 2 6 4 ,7 0 8
C a r g o D o o r $ 5 8 ,3 2 7
M a in E n tr y D o o r
$ 1 7 1 ,2 2 0
L .E . S la t A s s e m b ly
$ 5 2 ,8 6 3
R a d o m e $ 1 9 ,7 1 2
W in g tip A s s e m b ly $ 2 8 ,8 7 2
T A T P ro b e S id e c o w l
$ 6 ,5 8 3 $ 1 6 1 ,4 0 7
A O A V a n e P ito t S ta tic P r o b e In le t C o w l $ 3 2 9 ,2 0 3 8
$ 4 ,3 0 0 $ 5 ,1 5 7 In le t C o w l S e g m e n t $ 5 ,1 5 1

Administration
Income lost
Event Direct Indirect
Catering truck hits airplane $17,000 $230,000
Jetway hits airplane $50,000 $600,000
Landing event $1,900,000 $4,800,000
Source: USAir/America West Airlines

Administration
Accidents Cost Small Operators, Too
Claim Flight Training Fixed Wing Air Helicopter

Operation Taxi Operation Air Taxi
Forced landing $150,000 $300,000 $900,000
(aircraft destroyed)
Propeller makes $20,000 $30,000 $150,000

contact with object
on ground
Hangar Rash $5,000 $10,000 $35,000
Flight cancellation $500-1,400 $3-5,000 $8-10,000

per day

Administration
… Technical Factors
Human Factors1949 British Comet
Organizational Factors
1954 Boeing

Administration
Traditional approach – Preventing accidents
• Focus on outcomes (causes)
• Unsafe acts by operational personnel
• Attach blame/punish for failures to “perform safely”
• Address identified safety concern exclusively
Identifies:
WHAT? WHO? WHEN?
But not always discloses :

WHY? HOW?

Administration
Human Error and Operations
• Human error: a contributing

factor in most aviation
occurrences.
• Even competent personnel
commit errors.
• Errors are a normal
component of any system
where humans and
technology interact.

Administration
Context and outcomes
Causes and
consequences
of operational
errors are not
linear in their
magnitude
Source: ICAO SMM

Administration
Types of Errors (Active Failures)
• Perception Errors
– “I didn’t see it,” or “I didn’t notice the difference…”
• Memory Lapses
– “I forgot to do it…”
• Slips
– “I didn’t mean to do that…”
• Wrong Assumption
– “I assumed that the situation was different…”
Alan Hobbs, ATSB (2008)

Administration
Errors (cont.)
• Technical Misunderstandings
– “I tried to do it right but I didn’t understand
what I had to do…”
• Procedure Violations
– “Nobody follows that procedure here….”
– “We can’t get the job done if we do all that…”

Administration
Organizational Accidents
Organizational processes
Workplace Latent
conditions conditions
Active
Defenses
failures

Administration
Organizational Culture
Values
National Culture Professional Norms
Psychological
•Laws/Regulations
•Industry Standards
System/
Environment
Behavioral Outcomes
•Industry Norms Practices

•Business Relations
•Markets

Administration
Safety Management Strategies
Reactive Proactive Predictive
(Past) (Present) (Future)
Actively seeks the

Responds to Analyzes
identification of
events that have system
hazardous
already processes and
conditions
happened, such as environment to
through the analysis
incidents and identify potential
of the organization’s
accidents future problems
processes

Administration
Federal Aviation
Administration
SMS
Fundamentals

Administration
SMS Concepts
• Applying Risk Management
• Assuring Safety Risk
Controls
• Oversight of Design and
Performance of Systems
– Design Assurance
• Using Assessment tools
– Performance Assurance
• Using Assessment tools

Administration
SMS Concepts: Risk Management
• Understanding the
system and environment
• Identifying hazardous
conditions
• Assessing risk
• Applying risk controls

Administration
SMS Concepts: Assurance
• Assurance: “something
that gives confidence”1
• Quality assurance: “...
focused on providing
confidence that quality
requirements are being
met”2
• Likewise, Safety
Assurance relates to 1
Black’s Law Dictionary
safety requirements 2
ISO 9000-2000

Administration
SMS Components (“Pillars”)
Policy:
(Structure)
Risk Safety
Mgmt. Assurance
Safety Promotion:
(Culture)

Administration
The 4 SMS Components Policy
(Structure)
Risk Safety
Management Assurance
Safety
Promotion
1. Policy
• All management systems must define
policies, procedures, and organizational
structures to accomplish their goals.
• Policy establishes the structure of the SMS.

Administration
(Structure)
Risk Safety
Safety
Promotion
2. Safety Risk Management.

• A formal system of hazard identification,
analysis and risk management is essential
in controlling risk to acceptable levels.

Administration
(Structure)
Risk Safety
Safety
Promotion
3. Safety Assurance.
• Once controls are identified, the SMS must
assure they are continuously practiced and
continue to be effective in a changing
environment.

Administration
(Structure)
Risk Safety
Safety
Promotion
4. Safety Promotion.
• The organization must promote safety as a

core value with practices that support a
positive safety culture.

Administration
Safety Risk Management (SRM) and Safety Assurance (SA) Workflow
SRM SA
Description
System System & Context
Description Operation
Data Specific
Hazard
Acquisition
Ident
& Process Information
Risk Analysis Analysis

Analysis (RCA)
Risk System Assessment

Assmt Assmt
Action:
Risk Corrective
Control Action
Problem
Resolution
Administration
Design Performance
Oversight and SMS
FAA
Oversight Program Protection Production
Management
Technical Program Requirements
FAA’s Safety •Systems
Management •Subsystems
DA PA (Oversight) •Elements
(SAS)
Surveillance
S
S Operator’s Safety Public:
R
A Management Operational Users
M System Process
Cert C.O.S.

Administration
1 National Aviation System Level
2 Service Provider/Organizational Level
3 Individual (Airman/Aircraft) Level

Administration
Policy: QMS
Regs./Policy FAA FAA Strategic
SRM() SA(S) Analysis
1
2
DA PA SAS
FAA
SA
Public
S Users
CH S
R
SRM A SMS
M
3 Education & Awareness

FAA of Risk (GA) FAA
SA Designee SP
System
Airmen & Aircraft Federal Aviation SL-47
Administration
AVS SMS = FAA Safety Programme
FAA Internal SMS External SMS

(SSP & Oversight)
Flight Standards Air Operators/

Service Providers
Policy
Policy
Safety Risk
Management FAA Act 44702 CFR’s (aka FAR’s) Safety Risk
Management
Safety
Assurance Field Divisions (Oversight) Safety
Assurance
Design Assurance (Certification,
Safety Safety
Promotion Prgrm. Apprvl./Accept., Cert. Mgt) Promotion
SAS
Performance Assurance (Surveil., Plus)

Administration
Provides a systematic way to:
1. Identify hazards and control risk
2. Provide assurance that risk controls are effective
Policy
(Structure)
Safety Risk Safety

Safety Promotion
(Culture)

Administration
Federal Aviation
Administration
SMS Details:
Policy
Component

Administration
SMS Policy
• Establishes management commitment and

objectives – what the management wants
• Sets up framework of organizational
structures, accountabilities, plans,
procedures, and controls to meet objectives

Administration
Management Responsibility
• Managers should manage safety in the same
way that they manage other areas of the
business
• Safety management involves judgment,
assessing priorities, and making decisions –
like all management decision making

Administration
Top Management Involvement
Top management stimulates a healthy safety
environment
• Visible, personal involvement of top
management
• Setting safety goals and objectives as
policy
• Allocation of resources to meet safety goals
• Clear communication
AC 120-92, App. 1

Administration
Objectives of the Policy Component
Top Management will:
• Implement an integrated, comprehensive
SMS for entire organization
• Define a safety policy and set safety
objectives
• Define roles, responsibilities, and authorities
throughout the organization
• Appoint a member of management to
implement and maintain the SMS

Administration
Policy: Other Responsibilities
• Emergency response
– Develop and implement procedures
to respond to accidents and incidents
• Control of Documents and Records:

– Have a clearly defined document maintenance
process
– Implement and maintain a safety management plan

Administration
Safety Policy Requirements:
• Commitment to:
– Implement an SMS
– Continually improve safety
– Manage safety risk
– Comply with statutory & regulatory requirements
• Establish clear standards of acceptable
behavior
• Documented
• Communicated
• Periodically reviewed

Administration
Organizational Structure
• Top management with ultimate authority and
responsibility
• Top management requirement to provide
resources
• Defined lines of supervision and control
• Defined safety responsibilities for all employees
• Designated management official to ensure
effectiveness of SMS (e.g. DOS)

Administration
Accountability Defined
Accountability = Obligation or willingness to

account for one’s actions
A SMS shall clearly define lines of safety

accountability throughout the provider organization,
including direct accountability for safety on the part
of senior management.
ICAO Doc. 9859

Administration
Accountability vs. Liability
• SMS promotes an environment that stimulates

open reporting
• This includes and active involvement of all
personnel, starting with top management in
safety problem-solving
• Barring negligence or deliberate disregard for
safety, SMS does not promote blame for error

Administration
Management Functions
Managers must be actively and personally
involved in:
• Planning: Setting clear goals, guidelines,
standards, and timelines for safety
• Organizing: Providing clear lines of
management and supervisory responsibility,
control and communication
• Directing: Allocation of resources needed
for accomplishment of safety goals
• Controlling: Personal involvement in
assurance of safety goals and objectives
Administration
System Attributes
Processes must have safety requirements built
into their design.
a) Responsibility: accountable for quality of

activities
b) Authority: power to accomplish required activities
c) Procedures: clear instructions for members of the
organization
d) Controls: supervisory controls on processes to
ensure activities produce the correct outputs

Administration
System Attributes
In addition, there are process measures and
interfaces.
e) Process Measures: measurement of both
processes & their products
f) Interfaces: Recognizing interrelationships
between individuals and organizations within the
company as well as with contractors, vendors,
customers, and other organizations

Administration
System Attributes in Management
• The six attributes are the essence

of management:
– Planning: Procedures
– Organizing: Procedures, Responsibilities & Interfaces
– Directing: Responsibilities & Authority
– Controlling: Process Measures & Controls
• Now also documented in the ICAO SMM

Administration
SMS Documentation
• System documentation conveys

management expectations and work
instructions to employees
• May be a stand-alone manual or
integrated into existing documentation
systems

Administration
Federal Aviation
Administration
SMS Details:
Data
Quality

Administration
Decision Making:
Data, Analysis, and Assessment
• Reports (Facts): what exists or is happening
now
• Inferences (Interpretations)
– What’s likely to happen in the future, based on
what’s happening now
– Conclusions based on facts
• Judgments: value, quality assessments
(e.g. good, bad, acceptable, unacceptable)
of what is or will exist or happen
Administration
Example:
• Facts (Conditions):
– Duty day is 14 hours
– Flight schedule is 8 hours
– Flights have 10 legs, 10 IFR approaches
– Flights are legal (within regs.)
• Inference (Hazard):
– Crew fatigue will probably result
• Inference (Risk analysis):
– Likelihood of crew errors will increase
• Judgment (Risk Assessment):
– Unacceptable risk

Administration
Attributes of Data and Measures
• Validity:
– Does the data/measure address the subject
desired?
– Does it only address the subject desired?
– How completely does it cover the subject desired?
• Reliability:
– Are data points about the same thing comparable?
– Are data points collected by different observers
comparable?
Training and careful
Data and measures must be reliable to be preparation of tools can
valid but reliable data is not always valid increase reliability of data

Administration
Federal Aviation
Administration
SMS Details:
Safety Risk
Management
Component

Administration
Definitions
Safety management systems provide a
systematic way to control risk and to provide
assurance that those risk controls are effective.
Safety Risk Management is a formal system of

hazard identification, analysis and risk management
essential in controlling risk to acceptable levels.

Administration
Levels of Risk Management
• Process Risk Management
– Policy (What)
– Procedure (How)
– Controls
• Operational Risk Management

– Operational Control (Flight/Task/Mission)
– Crew/Team (Real time decision making)

Administration
System Description System
Description
Hazard
What is System & Task Analysis? Identification
• It is a system design function. Risk

• It is a predictive method of hazard identification. Analysis
• It is the foundation for sound safety analysis. Risk

Assmt
When is it used? Risk

Control
• Used during implementation phases of SMS.
• Used in conjunction with all operational changes.
Who uses System & Task Analysis?:

• Personnel within the organization who form an appropriately
diverse team:
– Stakeholders
ICAO Doc. 9859
– Subject Matter Experts

Administration
SRM System Description
System
Description Facts
Processes
Hazard
Identification Activities Workplace Conditions:
e.g. • Equipment
• Information (Procedures)
System • Facilities
Risk
Analysis Factors & • Phys. Envir.
Attributes • Other Proc. (Interfaces)
Variable • Training
Human • Supv./Mgmt. (Controls)
Risk
Performance • ….
Assmt
Risk
Control

Administration
Typical Workplace Conditions
• Equipment: Human-Machine Interface,

Facilities
• Operators: Individual performance
• Crew/team performance
• Organizational culture
• Company/regulator factors
Strauch, Barry (2004). Investigating Human Error

Administration
Process (System) Attributes
• Responsibility
• Authority
• Procedures
• Controls
• Process
Measures
• Interfaces

Administration
Conditions Related to Error
• Time pressure
• Procedures and documentation
• Teamwork/documentation
• Shift turnovers/crew briefings
• Group norms
• Fatigue management (shifts/circadian problems)

Administration
Conditions Related to Error (cont.)
• Lack of System Knowledge

• Equipment/facilities
• Human-machine interface (e.g. design for
maintainability)

Administration
Activities and Conditions: Deicing
Activities/Tasks and Actors Workplace Conditions
What and Who System and Environment
Select type of fluid Day/Night

(Check holdover time) Precipitation/cold
Position at Aircraft Employee demographics
Communicate with crew
Apply Fluid
Depart Ramp Area

Administration
Hazard Identification System
Description
Hazard
Identification
A hazard is any real or potential
condition… Risk
Analysis
Risk
that can result in injury, illness, or death Assmt
to people; damage to, or loss of, a Risk

Control
system (hardware or software),
equipment, or property;
and/or damage to the
operating environment.
ICAO Doc. 9859

Administration
SRM Hazard Identification
from Workplace Conditions
System
Description
Processes
Hazard Activities Workplace Conditions:

Identification
e.g. • Equipment
Risk Factors & • Phys. Envir.
Analysis Attributes • Other Proc. (Interfaces)
• Training
• Supv./Mgmt. (Controls)
Risk • ….
Assmt
Deficient Conditions
impacting activities =
Risk Variable
Control
Inference Performance Hazards
Causing… Resulting in…
Active Failures Consequences

Administration
Risk Analysis System
Description
Hazard
Identification
 Important to distinguish between: Risk

Analysis
 Hazard – a condition
Risk
Assmt
 Consequence – result
Risk
 Risk – likelihood & severity of the Control
consequence
 Analyzing risk involves the consideration
of both the likelihood and the severity of
any adverse consequences. ICAO Doc. 9859

Administration
SRM From Hazard to Risk
System
Description Deficient Conditions
impacting activities =
Variable
Hazards
Hazard
Performance
Identification
Causing… Resulting in…
Risk Active Failures Consequences

Analysis
Risk L ikelihood S everity

Assmt
Risk
Risk
Control
Judgment
Risk

Administration
Failures and Consequences
Active failures Potential Consequences
Direct results of conditions (e.g. accident/incident severity)
Take-off accidents due to

Incorrect Fluid Type
ice
Hold-over time too long
Incomplete deicing

Administration
Risk Analysis
Risk is the composite of the predicted likelihood or
probability and the severity of each possible
consequence of each identified hazard.
Hazard Intolerable
Active Failure Tolerable
Acceptable
Consequence
Probability Severity Risk Level
Adapted from ICAO Doc. 9859

Administration
Risk Assessment
Risk assessment determines the level of risk to use in
making a bottom line decision.
Risk Risk Severity

System Likelihood Catastrophi Hazardo Major Minor Negligible
Description c us
C D E
A B
Frequent 5 5A 5B 5C 5D 5E
Hazard
Identification
Occasional 4 4A 4B 4C 4D 4E
Risk Remote 3 3A 3B 3C 3D 3E
Analysis
Improbable 2 2A 2B 2C 2D 2E
Risk Extremely 1 1A 1B 1C 1D 1E
Assmt improbable
Risk
Control A risk matrix is a tool used for risk assessment. It can vary in
form yet it accomplishes the same purpose.

Administration
Risk Control = Risk Mitigation System
Description
Hazard
A major component of any safety system Identification
is the defenses (controls) put in place to Risk

Analysis
protect people, property or the
Risk
environment. Assmt
Risk
Control
These defenses are used to reduce the

likelihood or severity of the
consequences associated with any
given hazard or condition. ICAO Doc. 9859

Administration
SRM Risk Control/Mitigation
System
Description
Processes
Activities Workplace Conditions:

Hazard
Identification • Equipment
e.g.
Factors & • Phys. Envir.
Risk
Analysis
Attributes • Other Proc. (Interfaces)
Variable • Training
Human • Supv./Mgmt. (Controls)
Performance • ….
Risk
Assmt
Risk
Control Risk Controls

Administration
Risk Control System
Description
Order of Precedence: Hazard

Identification
1. Modify the system (design hazard out) Risk

Analysis
2. Physical guards or barriers Risk

Assmt
3. Warnings or alert signal Risk

Control
4. Administrative controls
• Procedures
• Training

Administration
Federal Aviation
Administration
SMS Details:
Safety Assurance
Component

Administration
SMS Concepts: Assurance
• Assurance: “something
that gives confidence”1
• Quality assurance: “...
focused on providing
confidence that quality
requirements are being
met”2
• Likewise, Safety
Assurance relates to 1
Black’s Law Dictionary
safety requirements 2
ISO 9000-2000

Administration
SM Strategies – Intervention Levels & Tools
Safety management levels
h
Baseline performance le
Hig Mid
d Low
O pPredictive “Practical drift”
er a Proactive Reactive
tio n
al p
erfo
System r m Organization Accident
anc Surveys
Analysis e Audits ASRS and incident
Design reports
Assessment
Performance SDR
Assessment
Highly efficient Very efficient Efficient Insufficient
Desirable management
levels

Administration
Safety Assurance Functions:
• Collect and analyze information to
determine that process requirements are
continuously being met.
• Assess performance and effectiveness
of risk controls.
• Works in partnership with Risk
Management.
AC 120-92

Administration
S.A. is similar to Q.A.
• QA focuses on product conformity & customer

satisfaction on a continuous basis.
• SA ensures that risk controls, once designed and

put to place, perform in a way that continue to
meet their safety objectives.
• Integration of management systems may be

beneficial.
AC 120-92

Administration
S.A. & Q.A.:
“Once controls are in place, quality
management techniques can be used to
provide a structured process for ensuring
that they achieve their intended objectives
and, where they fall short, to improve them.”
AC 120-92

Administration
System Operation
System
Operation
Data
Acquisition
& Process
Written documentation to describe: Analysis
System
Who, What, When, Where, Why, How Assmt
Preventive/
The system operation includes:

Corrective
Action
1) Monitoring of risk controls during operations;

2) System description, including risk controls
added during SRM which form the basis for
SA functions such as audits and analysis.
AC 120-92

Administration
Data Acquisition & Process
System
Operation
Data
Acquisition
& Process
Information Sources Analysis
1. Continuous Monitoring System

Assmt
2. Internal Audits Preventive/

Corrective
Action
3. Internal Evaluation
4. External Audits
5. Investigations
6. Employee Reporting Systems
AC 120-92

Administration
Continuous Monitoring
System
Operation
Data
Acquisition
Where SRM and SA interface - risk controls

& Process
Analysis
Line managers of operational departments: System

Assmt
Preventive/
• Accomplish continuous monitoring of

Corrective
Action
day-to-day activities & processes

• Have direct responsibility for process
control
• Must ensure that processes in their
areas function as designed.

Administration
Continuous Monitoring
- Operational Data Sources
• Flight dispatch records
• Flight schedules
• Financial data
• Crew schedules and records
• Warranty return reports
• Aircraft discrepancy reports
• Flight cancellation and delay
reports
Administration
Internal Audits
System
Operation
Data
Acquisition
The day-to-day responsibility for safety & Process
management rests with those who “own” the Analysis
technical processes. System

Assmt
Preventive/
Corrective
This is where: Action
• deficiencies in processes contribute to

risk
• audits provide feedback to process
owners
• direct supervisory control and resource
allocation can help to maintain
effectiveness of risk controls

Administration
Internal Audits Continued System
Operation
Data
Acquisition
• Performed by each department.

& Process
Analysis
• Department Director/Manager is responsible. System

Assmt
• Regularly scheduled Preventive/

Corrective
Action
• Include contractors & vendors

• Determine:
– Conformity with safety risk controls
– Performance of safety risk controls
– Performance to meet business objectives
• Deficiencies always get action! AC 120-92

Administration
Internal Evaluation System
Operation
Data
Acquisition
& Process
• Performed by a functionally independent Analysis
person or organization (e.g. QA, Safety)

System
Assmt
• A process-oriented control function Preventive/

Corrective
Action
• Backs up the internal audit function

• Uses sampling to validate SA processes

Administration
External Audits
System
Operation
Data
Acquisition
& Process
Analysis
Conducted by: System

Assmt
• Code-share partners Preventive/

Corrective
Action
• Industry organizations (e.g. C.A.S.E.)

• Third parties: consultants
• The regulator (FAA) = “Safety Oversight”

Administration
Safety investigations
System
Operation
Data
Acquisition
• For continuity – put the event behind us

& Process
Analysis
– To put losses behind

System
– To reassert trust and faith in the system Assmt
Preventive/
– To resume normal activities Corrective

Action
– To fulfil political purposes
• For improved system reliability

– To learn about system vulnerability
– To develop strategies for change
– To prioritize investment of resources

Administration
Employee Reporting
System
Operation
Data
Acquisition
• Employee safety reporting & feedback & Process
system is required.
Analysis
System
Assmt
• Must provide confidentiality. Preventive/
Corrective
Action
• Employees must be encouraged to use

the system.
• Data may identify emerging hazards.
• Data must be included in analysis.
AC 120-92, App. 1

Administration
Analysis System
Operation
Data
• To be useful, information must be

Acquisition
& Process
made understandable.
Analysis
System
Assmt
• Analysis is used to determine Preventive/

Corrective
effectiveness of: Action
1. Risk controls in the organization’s

operational processes, and
2. the SMS.
AC 120-92

Administration
Types of analysis System
Operation
Data
Acquisition
• Against criteria/objectives & Process
Analysis
• Compared to norms
System
Assmt
• Patterns from multiple data points Preventive/

Corrective
Action
• Trends over time

– “Trends” is one of the most misused term in
analysis
– Must have stable, reliable measures at each
time sample for a valid trend

Administration
Attributes of Data and Measures
• Validity:
– Does the data/measure address the subject
desired?
– Does it only address the subject desired?
– How completely does it cover the subject desired?
• Reliability:
– Are data points about the same thing comparable?
– Are data points collected by different observers
comparable?
Training and careful
Data and measures must be reliable to be preparation of tools can
valid but reliable data is not always valid increase reliability of data

Administration
System Assessment System
Operation
• Are objectives being met? (“Happy loop”)

Data
Acquisition
& Process
• Risk controls failing due to: Analysis
– Lack of supervision System

Assmt
– Lack of resources Preventive/

Corrective
– Lack of training Action
– Poor job aids

• New Hazard/failed Risk Controls
(redesign - back to SRM)
• Prioritize according to safety criticality
(triage)

Administration
Preventive/Corrective Actions
System
Operation
• Revised policies Data

Acquisition
& Process
• New procedures Analysis
System
• Equipment changes Assmt
Preventive/
Corrective
• Enhanced training
Action
• Schedule changes
• Assignment of responsible persons

Administration
Management Review
Top management will conduct regular
reviews of the SMS, including:
• The outputs of SRM & SA
• Lessons learned
• Need for changes

Administration
Continuous Improvement
The organization shall continuously improve
the effectiveness of the SMS through:
• Safety and Quality Policies
• Safety Objectives
• Audit & Evaluations
• Analysis of Data
• Corrective and Preventive Actions
• Management Reviews AC 120-92

Administration
Federal Aviation
Administration
SMS Details:
Safety
Promotion
Component

Administration
Promotion: Definition
Safety promotion = a combination of:
• Safety Culture,
• Training and
• Knowledge Sharing
activities that support the implementation and
operation of SMS in an organization
Organizations must promote safety as a

core value with practices that support a
positive safety culture. AC 120-92, App. 1

Administration
Culture
Management Employees
Communication
Informed: People understand the hazards & risks
Learning: The company learns from mistakes. Staff are

updated on safety issues by management.
Just: Employees know what is acceptable

& unacceptable behavior.
Reporting: All personnel freely share critical safety

information.
AC 120-92

Administration
What gets communicated upward?
4% Problems known to
top management
middle
management
supervisors

rank and file MX
personnel
Source: Yoshida, Shuichi,
2nd Intl Quality
Symposium, 1989
Administration
To Support a Sound Safety Culture:
1. Senior management commitment
2. Senior management visibility
3. Safety accountability framework
4. Safety policy, goals, objectives, standards, and
performance
5. Effective employee safety reporting system
6. Safety information system
7. Resource commitment
Administration
Training and Communication!
• Employees must understand the SMS
• Employees benefit from safety lessons learned
• Explain why particular actions are taken
• Develop awareness of hazards
• Foster open reporting of safety concerns
• Initial and ongoing training
Example Safety Promotion Video

Administration
Personnel Competencies and SMS
Training
• Identification of competency requirements
• Selection and hiring criteria and standards
• Training
• Skill competency
– Initial training
– Recurrent training
– Continuous communication

Administration
ISD Processes SMS Processes
SRM: System/ Task
Analyze Description & Analysis
•Safety Critical Job Tasks
•Competencies (KSA’s, etc)
•Target audience characteristics
Design •Training Tasks

•Qualification Standards (SRM risk Control)
•Courseware
•Medium
Develop •Lessons, Exercises, Activities
•Tests, Evaluations
SA: Monitoring
Implement •Training Delivery
•Records
•Testing/Qualifying
SA: Assessment
Evaluate •Student Evaluation/critique
•Instructor Critique
•OJT & performance observations

Administration
Commitment to SMS
•Documents alone will not
guarantee development of
a positive safety culture.
•Employees must see evidence of
management commitment to SMS.
Management Attitudes & Actions =

the most important factor.
ICAO Doc. 9859

Administration
Federal Aviation
Administration
SMS Guidance,
Tools and
Implementation

Administration
SMS Guidance and Tools
• ICAO Doc 9859: Safety Management Manual (SMM)

• FAA Order 8000.369: FAA SMS Guidance
• Order VS 8000.367: AVS Requirements Document
• SMS Standard: AC 120-92 Appendix 1
• Voluntary Implementation Guidance (Multiple Docs)

Administration
ICAO and FAA SMS Framework
Elements:
3.1 Safety Performance Monitoring & Measurement
• Elements:
Process 3.1.1 Continuous monitoring
Policy • 2.1 Hazard
Elements:
Process identification
3.1.2 Internal audits byand analysisdepts.
operational
(Structure) • Process 3.1.3 Internal
Process
1.1 Safety 2.1.1
Policy evaluation
System and task analysis
• Process 3.1.4 External auditing of the SMS
1.2 Process 2.1.2
Management
Elements: Hazard identification
Commitment & Accountabilities
• Process 3.1.5 Investigation
2.2
1.3Risk
4.1Key assessment
Safety Personnel
Competencies andTraining
and control
• Process 3.1.6 Employee reporting and feedback syst.
Safety Risk • 1.4 Process
Emergency
Process
Process 3.1.7 2.2.1
4.1.1
Analysis Analyze
Preparedness safety
Personnel
of data and risk
Response
requirements
Safety
Management • ProcessProcess
1.5 SMS Process
3.1.8 2.2.2
System4.1.2Assess
Documentation safety
and
Training
assessment risk
Records
Assurance
• 4.2 Process
Process 2.2.3 Control
3.1.9 Preventive/corrective
Communication safety
actionrisk
and Awareness
• Process 3.1.10 Management review
3.2 Management of Change
Safety Promotion 3.3 Continual Improvement
(Culture)

Administration
Administration
Start Inputs: 2.0(B)(2)(a),(b) & (d)
2.1 Hazard
SRM •New System
•System Change Identification
System •New Operational Procedure
Analysis & Analysis
(Design) 2.1.1
2.1.2
Hazard
Ident Inputs: 2.0(B)(2)(c)
From SA: 3.1.8(B)(3)
Risk
2.2 Risk
Analysis 2.2.1
Assessment
& Control
2.2.2
Risk
Outputs: To SA 3.0(B)(1)(b)
Assmt
Evaluate
Controls
2.2.3(B) Risk
(2) & (3) Control 2.2.3

Administration
SA 3.1 Safety
Performance
Inputs:
From SRM 2.2.2(B)
System
Operation
Per 2.1.1 including Monitoring
Risk Controls per 3.1.3
& 2.2.3 (B)(2)(b) and Measurement
To SA:
3.0(B)(1)(b) 3.1.1 Continuous Monitoring
Data
Acquisition 3.1.2 Internal Audits
3.1.3 Internal Evaluation
& Process
* 3.1.4 External Evaluation
3.1.5 Investigations
3.1.6 Employee Reporting
Analysis
3.1.7 Analysis of Data How is this going to be
analyzed? By whom?
System 3.1.8 System Assessment

Outputs: 3.1.8(B)(3) Assmt 3.1.10 Management Review
To SRM 2.0(B)(2)(c)
Preventive/
Corrective
Action
3.1.9
* Note: Each data source should be traceable
through analysis (3.1.7(B)(1)), assessment and
Corrective Action (3.1.9(B)(1) where necessary.

Administration
External Internal
Decision by Previous Process
Organization
Inputs Interface – (I)
Process
Controls (C) Responsibility (R)
•Procedural •Accountable for
Activities
•Supervision process output
•Assurance Authority (A)
Processes Empowered to:
Procedures (P) •Make key
decisions
•Alter process
Outputs
•Deliverable – Performance Measures (PM)
•Destination – Interface (I)

Administration
Each Element/Process has a
Performance Objective that
defines the expected outcome
of the process.
Design expectations are then
defined that outline characteristics
of a well
Inputs designed
tell us where the process.
process
These are organized in terms of the
starts:
Management
six decision Responsibility
•Aattributes. on the part of the tells us:
•Who is accountable for process
company
Each • completion
process
The has
output a(Responsibility)
ofnumber of
a previous
Finally, the “Bottom Line Assessment” takes us
Every
activities process
–objective
•Who has
theis“things an output.
peopleto:
empowered do”There are two
back to process
the (Interface)
– will/does the process
aspects
(Procedures) to outputs:
Make key decisions in the
achieve its intended outcome? (Affirmation)
•Evidence of accomplishment
process (Authority) (Process
Measures) Alter or deviate from the
process
•Destination of (Authority)
the output (Interfaces)
Some critical processes also have
Federal Controls
Aviation SL-131
Administration
SMS Implementation
• Should follow a Phased
Approach
• The processes underlying the
four components will be
modularized
• “Growth” or “increasing
maturity” will then be
emphasized for each process
and the system as a whole

Administration
SMS Voluntary Implementation: Pilot
Projects
• Pilot Project activities commenced in 2007
• Voluntary SMS development
• AFS combined effort
• Objectives are to Develop:
– Implementation strategies,
– Oversight interfaces, and
– Gain experience for FAA and Service Providers

Administration
SMS Implementation Process
Continuous
4 Improvement
Proactive
3 Processes
Reactive
2 Processes
Planning &
1 Organization
Orientation &
0 Commitment

Administration
Who’s Involved in Implementation?
• The Operator/Service Provider
• The Certificate Management

Organization (CMO, FSDO, CHDO)
• The SMS Standardization and Assistance

Team (STAT)

Administration
SMS Transition Assistance Team (STAT)
• Provides Standardization and Assistance to
operators and CMT’s in voluntary SMS projects
• Under direction of AFS SMS Program Office (PO)
– Team members currently from:
• SMS PO
• FAASTeam
• HQ Policy Divisions
• All activities coordinated with appropriate certificate
oversight offices

Administration
Focus Group (SMSFG)
Voluntary implementation user’s group
• Provides a two-way communications

mechanism between SMS PO and
participants in voluntary implementation
• Provides a forum for knowledge sharing

among participants

Administration
Level 1: Planning & Organization
Charting the Course
• Preliminary Gap Analysis: Evaluating
existing processes, programs, and
practices for safety management
• Develop Safety Policy
• Develop Implementation Plan
• Organizing for Implementation
Administration
Level 1 - Meetings
Session 1 is a 2-day event
• Day 1- STAT Briefing:
– SMS Tutorial – 4-Hr. In-Depth Overview
– In-depth walk-through of the Framework & Assurance Guide
– Preliminary Audit/Gap Analysis Tool
– Detailed Audit/Gap Analysis Tools
• Day 2 - Service Provider & CMT jointly Perform
Preliminary Gap Analysis
– Schedule Operator’s Detailed Gap Analysis
– The operator may require 4 to 6 months to complete the
detailed gap analysis. STAT and CMT will be available on call
while the operator is performing this task.

Administration
Level 1 - Expectations
• Service Provider/Certificate Holder
– Sessions 1
• Complete preliminary gap analysis
– Session 2
• Completed detailed gap analysis utilizing the detailed audit/gap
analysis tools
• Brief gap analysis results
• Brief gaps and how they will be addressed
• Provide evidence of conformity
– Session 3
• Present implementation plan
• Complete the required documents
• Meet the requirements of the exit criteria for this phase
• Provide process inputs to the STAT

Administration
Level 1 - Expectations
Oversight Organization
– Review and utilize audit/gap analysis tools
– Attend audit/gap analysis meetings with the operator
– Participate in meetings with the STAT and operator
– Review the operator’s implementation plan and other
documents
– Discuss the requirements of the exit criteria for this
phase with the operator and STAT
– Provide input to the STAT regarding the SMS
implementation, documents and audit tools

Administration
Level 2: Reactive Processes
Basic Risk Management
• Setting up the information infrastructure and processes
• Going after known problems: Reactive Hazard
Identification
• Designing and implementing risk controls
• Non-punitive voluntary employee reporting system
• Documentation
• Training
– Training commensurate with this level of
implementation phase maturity

Administration
Level 3: Proactive Processes
Looking Ahead
• System and task analysis of the
operational (production) systems
• Proactive Hazard identification
• Updating:
– Risk controls
– Documentation
• Additional specialist training

Administration
Level 4: Continuous Improvement
Continued Assurance
• Mature safety assurance process
– Analysis of data
– System performance assessment
– Corrective/Preventive action: Maintaining the
controls
– Identifying new and emerging hazards
• Management Reviews: Formal involvement
• Documentation & Training as required

Administration
SMS Studies and Analysis
Continuous
4 Improvement
Phase 2:
Proactive
Experience 3 Processes
Reactive
2 Processes
Planning &
1 Organization
Phase 1:
Orientation & Readiness
0 Commitment

Administration
Organizations

Administration
AFS SMS Program Office (PO)
Authorized by Order FS1100.1A:
– AFS SMS Policy
– Focal point for SMS rulemaking
– Oversight and coordination of voluntary SMS
implementation and testing
– Integration with oversight systems
– Policy, guidance, and tool development
– Training and outreach development and coordination

Administration
FAASTeam (FAA Safety Team)
• Participate in STAT team efforts
• Conduct outreach sessions for CMTs and
service providers
• Assist SMS PO in development of:
– Guidance material
– Promotional Material
– Development and Delivery of Training
– Promotional web presence for SMS

Administration
SMS Transition Assistance Team (STAT)
• Provides Standardization and Assistance to
operators and CMT’s in voluntary SMS projects
• Under direction of AFS SMS Program Office (PO)
– Team members currently from:
• SMS PO
• FAASTeam
• HQ Policy Divisions
• All activities coordinated with appropriate certificate
oversight offices

Administration
MITRE Corporation Involvement
• MITRE is a Federally-Funded Research and

Development Corporation (FFRDC)
• MITRE assists the AFS SMS PO in:
– SMS Pilot Project (SMSPP) activities
– Studies and analysis to support development of
SMS implementation and oversight strategies

Administration
Federal Aviation
Administration
Summary

Administration
Provides a systematic way to:
1. Identify hazards and control risk
2. Provide assurance that risk controls are effective
Policy
(Structure)
Safety Risk Safety

Safety Promotion
(Culture)

Administration
Roles, Responsibilities & Relationships
AVS SMS = FAA Safety Programme (SSP)
FAA Internal SMS External SMS

(SSP & Oversight)
Flight Standards Air Operators/

Service Providers
Safety Policy
Safety Policy
Safety Risk
Management FAA Act 44702 CFR’s (aka FAR’s)
Safety Risk
Management
Safety
Assurance Field Divisions (Oversight) Safety
Assurance
Design Assurance (Certification,
Safety Safety
Promotion Prgrm. Apprvl./Accept., Cert. Mgt) Promotion
SAS
Performance Assurance (Surveil., Plus)

Administration
Provides
1. Increased Safety
2. International Harmonization
3. Improved Organizational
Effectiveness

Administration
“Carelessness and overconfidence are more
dangerous than deliberately accepted risk”
Wilbur Wright, 1901
Contact:
SMS Program Office Manager
Don Arendt, Ph.D.
(703) 661-0516
don.arendt@faa.gov
Wilbur Wright gliding, 1901

Photographs: Library of Congress

Administration

Introduction To Safety Management System (SMS) : Flight Standards and Industry Roles

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Introduction to Federal Aviation

Flight Standards and

Presented By: Flight Standards Service

Federal Aviation SL-1

Federal Aviation SL-2

Federal Aviation SL-3

A substitute for An effective interface for

A requirement for a A set of decision making

Federal Aviation SL-4

Federal Aviation SL-5

“Safety is the state in which the risk of harm

ICAO Doc 9859

Federal Aviation SL-6

Example Safety Promotion Video

Federal Aviation SL-7

Federal Aviation SL-8

• The SMS gives the certificate holder a

Federal Aviation SL-9

• Traditional approach concentrates on technical

• SMS adds emphasis on management elements

Federal Aviation SL-10

Federal Aviation SL-11

Federal Aviation SL-12

Federal Aviation SL-13

SSP Framework SMS Framework

FAA Aviation Safety •Order 8000.369; FAA SMS Guidance

Flight Standards •AC 120-92; SMS Standard

SSP & FAA Air Operators’/

Federal Aviation SL-14

FAA’s Safety Roles, Responsibilities

Federal Aviation SL-15

Federal Aviation SL-16

Federal Aviation SL-17

• Safety management is a core business

• This constitutes a management challenge.

Federal Aviation SL-18

Federal Aviation SL-19

• To maintain the balance of production and

Federal Aviation SL-22

Federal Aviation SL-23

Jetway hits airplane $50,000 $600,000

Landing event $1,900,000 $4,800,000

Source: USAir/America West Airlines

Federal Aviation SL-24

Claim Flight Training Fixed Wing Air Helicopter

Propeller makes $20,000 $30,000 $150,000

Flight cancellation $500-1,400 $3-5,000 $8-10,000

Federal Aviation SL-25

Human Factors1949 British Comet

Federal Aviation SL-26

But not always discloses :

Federal Aviation SL-27

• Human error: a contributing

Federal Aviation SL-28

Source: ICAO SMM

Federal Aviation SL-29

Federal Aviation SL-30