Safety Management Manual (SMM)

1 Doc 9859 AN/474 Third Edition 2012 International Civil Aviation Organization Safety Management Manual (SMM) Notice to Users This document is an unedited advance version of an ICAO publication as approved, in principle, by the Secretary General, which is made available for convenience. The final edited version may still undergo alterations in the process of editing. Consequently, ICAO accepts no responsibility or liability of any kind should the final text of this publication be at variance with that appearing here. Third edition 2012 ICAO 2012 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, without prior permission in writing from the International Civil Aviation Organization.

2 1 AMENDMENTS Amendments are announced in the supplements to the Catalogue of ICAO Publications; the Catalogue and its supplements are available on the ICAO website at The space below is provided to keep a record of such amendments. AMENDMENTS CORRIGENDA No. Date Entered by No. Date Entered by 2 Intentionally Left Blank 3 Contents AMENDMENTS 1 Contents 3 ACRONYMS AND ABBREVIATIONS 8 OVERVIEW OF THE Manual 10 DEFINITIONS 11 CHAPTER 1 - Safety Management FUNDAMENTALS 12 THE CONCEPT OF Safety 12 THE EVOLUTION OF Safety 12 ACCIDENT CAUSATION 13 PEOPLE.

3 CONTEXT AND Safety 17 ERRORS AND VIOLATIONS 19 Safety CULTURE 21 THE Management DILEMMA 24 CHANGE Management 25 INTEGRATION OF Management SYSTEMS 26 Safety REPORTING AND INVESTIGATION 27 Safety DATA COLLECTION AND ANALYSIS 29 HAZARDS 34 Safety RISK 36 Safety RISK Management 40 Safety INDICATORS AND PERFORMANCE MONITORING 41 PRESCRIPTIVE AND PERFORMANCE-BASED REQUIREMENTS 42 Appendix 1 - Hazard Prioritization Procedure (Illustration) 46 Appendix 2 Safety Risk Mitigation Worksheet (Illustration) 47 Appendix 3 Organization Safety Culture/ Risk Profile Assessment 52 CHAPTER 2 - ICAO Safety Management SARPs 58 Introduction to ICAO Safety Management SARPs 58 State Safety Management Requirements 58 4 Service Providers Safety Management Requirements 60 New Annex on Safety Management 61 Chapter 3 STATE Safety PROGRAMME (SSP)

4 63 INTRODUCTION TO SSP 63 SSP FRAMEWORK 63 STATE Safety POLICY AND OBJECTIVES 64 1-1 State Safety legislative framework 64 1-2 State Safety responsibilities and accountabilities 65 1-3 Accident and incident investigation 65 1-4 Enforcement policy 66 STATE Safety RISK Management 66 2-1 Safety requirements for the service provider s SMS 66 2-2 Agreement on the service provider s Safety performance 67 STATE Safety ASSURANCE 67 3-1 Safety oversight 67 3-2 Safety data collection, analysis and exchange 68 3-3 Safety -data-driven targeting of oversight of areas of greater concern or need 69 STATE Safety PROMOTION 70 4-1 Internal training, communication and dissemination of Safety information 70 4-2 External training, communication and dissemination of Safety information 70 SSP IMPLEMENTATION PLANNING 70 Regulatory System Description 71 SSP Gap Analysis 71 SSP Implementation Plan 71 Safety Indicators & Acceptable level of Safety performance 71 SSP IMPLEMENTATION - PHASED APPROACH 73 PHASE I 74 PHASE II 76 PHASE III 78 PHASE IV 79 5 Appendix 1 to Chapter 3 82 Guidance on SSP Gap Analysis and Implementation Plan 82 Appendix 2 to Chapter 3 89 Guidance on a State Safety Policy Statement 89 Appendix 3 to Chapter 3 91 Guidance on State Enforcement Policy 91 Appendix 4 to Chapter 3 94 Guidance on State Enforcement Procedures in an SSP-SMS Environment 94 Appendix 5 to Chapter 3 96 State SMS Regulation (Example) 96 Appendix 6 to Chapter 3 98 Safety Indicators & ALoSP (Examples)

5 98 Appendix 7 to Chapter 3 108 SMS Acceptance/ Assesssment (Example) 108 Appendix 8 to Chapter 3 118 Accident and Incident Notification and Reporting Guidance 118 Appendix 9 to Chapter 3 126 Safety Information Protection 126 Appendix 10 to Chapter 3 129 SSP Document/ Manual Contents (Example) 129 Appendix 11 to Chapter 3 131 State Voluntary and Confidential Reporting System 131 Appendix 12 to Chapter 3 134 State Mandatory Reporting Procedure 134 CHAPTER 4 - Safety Management SYSTEM (SMS) 139 INTRODUCTION TO SMS 139 SCOPE 139 SMS FRAMEWORK 139 Safety POLICY AND OBJECTIVES 140 Management COMMITMENT AND RESPONSIBILITY 141 6 Safety ACCOUNTABILITY 143 APPOINTMENT OF KEY Safety PERSONNEL 145 COORDINATION OF EMERGENCY RESPONSE PLANNING 147 SMS DOCUMENTATION 148 Safety RISK Management 149 HAZARD IDENTIFICATION 150 RISK ASSESSMENT AND MITIGATION 152 Safety ASSURANCE 155 Safety PERFORMANCE MONITORING AND MEASUREMENT 156 THE Management OF CHANGE 157 CONTINUOUS IMPROVEMENT OF THE SMS 158 Safety PROMOTION 159 TRAINING AND EDUCATION 159 Safety COMMUNICATION 160 SMS IMPLEMENTATION PLANNING 161 SYSTEM DESCRIPTION 161 INTEGRATION OF Management SYSTEMS 161 GAP ANALYSIS 163 SMS IMPLEMENTATION PLAN 163 Safety PERFORMANCE

6 INDICATORS 163 PHASED IMPLEMENTATION APPROACH 164 PHASE I 167 PHASE II 168 PHASE III 169 PHASE IV 170 Appendix 1 - SAMPLE JOB DESCRIPTION FOR A Safety MANAGER 173 Appendix 2 - GUIDANCE ON SMS GAP ANALYSIS AND IMPLEMENTATION PLAN 176 Appendix 3 - GUIDANCE FOR THE DEVELOPMENT OF A SMS Manual 185 Appendix 4 - EMERGENCY RESPONSE PLANNING 191 Appendix 5 - RELATED ICAO GUIDANCE MATERIAL 195 7 Appendix 6 Safety PERFORMANCE INDICATORS (EXAMPLES) 197 Appendix 7 - VOLUNTARY & CONFIDENTIAL REPORTING SYSTEM 206 Appendix 8 - ELECTRONIC SIGNATURE 209 8 ACRONYMS AND ABBREVIATIONS ADREP Accident/incident data reporting (ICAO) AEP Aerodrome emergency plan AIRPROX Aircraft proximity ALARP As low as reasonably practicable ALoSP Acceptable level of Safety performance AMJ Advisory material joint AMO Approved maintenance organization AOC Air operator certificate ASDE Airport surface detection equipment ASR Air Safety report ATC Air traffic control ATCO Air traffic controller ATM Air traffic Management ATS Air traffic service(s)

7 CAA Civil aviation authority CDA Constant descent arrivals CEO Chief executive officer CFIT Controlled flight into terrain CIP Commercially important person Cir Circular CMC Crisis Management centre CRDA Converging runway display aid CRM Crew resource Management CVR Cockpit voice recorder DME Distance measuring equipment Doc Document ERP Emergency response plan FDA Flight data analysis FDM Flight data monitoring FDR Flight data recorder FOD Foreign object (debris) damage ft Feet GPS Global positioning system ILS Instrument landing system IMC Instrument meteorological conditions ISO International Organization for Standardization kg Kilogram(s) LOFT Line-oriented flight training LOSA Line operations Safety audit 9 m Metre(s) MDA Minimum descent altitude MEL Minimum equipment list MOR Mandatory occurrence report MRM Maintenance resource Management NM Nautical mile(s) OJT On-the-job training OSHE Occupational Safety , Health & Environment OHSMS Occupational Health & Safety Management system PC Personal computer QA Quality assurance QC Quality control QMS Quality Management system RVSM Reduced vertical separation minimum SA Safety assurance SAG Safety action group SARPs Standards and Recommended Practices (ICAO) SDCPS Safety data collection and processing systems SeMS Security Management System SHEL Software/Hardware/Environment/Liveware SMM Safety Management Manual SMS Safety Management system(s)

8 SMSM Safety Management systems Manual SOPs Standard operating procedures SRB Safety review board SRM Safety risk Management SSP State Safety programme TLH Top level hazard TRM Team resource Management USOAP Universal Safety Oversight Audit Programme (ICAO) VIP Very important person VMC Visual meteorological conditions VOR Very high frequency omnidirectional range 10 OVERVIEW OF THE Manual GENERAL This third edition of the ICAO Safety Management Manual (SMM) (Doc 9859) supersedes the second edition, published in 2009, in its entirety. It also supersedes the ICAO Accident Prevention Manual (Doc 9422), which is obsolete. This Manual is intended to provide States with guidance for the development and implementation of a State Safety programme (SSP), in accordance with the International Standards and Recommended Practices (SARPs) contained in Annex 1 Personnel Licensing, Annex 6 Operation of Aircraft, Annex 8 Airworthiness of Aircraft, Annex 11 Air Traffic Services, Annex 13 Aircraft Accident and Incident Investigation and Annex 14 Aerodromes, Volume I Aerodrome Design and Operations.

9 It should be noted that SSP provisions will be incorporated into Annex 19, which is under development at the time this revision was published. This Manual also provides guidance material for establishment of Safety Management Systems (SMS) requirements by States as well as for SMS development and implementation by affected product and service providers. It should be noted this SMM is intended to be used in conjunction with other appropriate guidance materials which can be useful for complementing or enhancing the concepts or guidance within this document. Note: In the context of Safety Management , the term service provider or product and service provider refers to any organization providing aviation products and/ or services.

10 The term thus encompasses approved training organizations that are exposed to Safety risks during the provision of their services, aircraft operators, approved maintainance organizations, organizations responsible for type design and/or manufacture of aircraft, air traffic service providers and certified aerodromes. STRUCTURE Chapter 1 presents the fundamental Safety Management concepts and processes. Chapter 2 provides a compilation of the ICAO Safety Management SARPs contained in Annexes 1, 6, 8, 11, 13 and 14. Finally, Chapters 3 and 4 outline a progressive approach to the development, implementation and maintenance of SSP and SMS. The last two chapters also contain appendices which provide practical guidance and illustrations. OBJECTIVES The objective of this Manual is to provide States and product and service providers with: a) an overview of Safety Management fundamentals; b) a summary of ICAO Standards and Recommended Practices (SARPs) on Safety Management contained in Annexes 1, 6, 8, 11, 13 and 14; c) guidance for States on how to develop and implement an SSP in compliance with the relevant ICAO SARPs; including a harmonized regulatory framework for the oversight of product and service providers SMS; and d) guidance for product and service providers on SMS development, implementation and maintenance.